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THE

STETHOSCOPE,

VIRGINIA MEDICAL GAZETTE

MONTHLY JOURNAL

JtlcMcitu ani tl)£ Collateral Sriences.

EDITED BY

P. CLAIBORNE GOOCH, A. M., M. D.

ONE OF THE SECRETARIES OF THE AMERICAN MEDICAL ASSOCIATION, AND SECRETARY

OF THE MEDICAL SOCIETY OF VIRGINIA— FELLOW OF THE PATHOLOGICAL

SOCIETY OF MONTREAL AND OF THE PARISIAN MEDICAL

SOCIETY, ETC.

'Medicine is enriched "by facts only." — Bboussais.

VOL, I.

RICHMOND :

PRINTED BY RITCHIES & DUNNAVANT.

1851.

ft

52

THIS VOLUME CONTAINS ORIGINAL PAPERS FROM THE FOLLOWING

CONTRIBUTORS:

L. B. Anderson, M. D.

G. W. Ashby, M. D.

James Bolton, M. D.

John J. Boswell, M. D.

W. S. Bowyer, M. D.

D. W. Brodnax, M. D.

J. N. Broocks, M. D.

Wm. M. Broocks, M. D.

Wm. Browne, M. D., Pres't Med.

Society Fredericksburg. P. H. Cabell, M. D. Robt. G. Cabell, M. D. J. H. Claiborne, M. D. G. Lane Corbin, M. D. J. B. Davies, M. D. F. H. Deane, M. D. Thos. Dunn, M. D. J. R. Elsome, M. D. D. S. Evans, M. D. W. B. Evans, M. D. J. M. Gait, M. D., Phys, and Supt.

Eastern Lunatic Asylum. T. J. Garden, M. D. S. C. Gholson, M. D. P. C. Gooch, M. D. P. H. Grigg, M. D. W. D. Haskins, M. D. R. W. Haxall, M. D. M. H. Houston, M. D. R. E. Jennings, M. D. R. G. Jennings, M. D.

C. P. Johnson, M. D., Prof. Anat. and Phys. Hamp. Sid. Med. Col.

W. F. Jones, M. D.

L. S. Joynes, M. D.

Joseph Laidley, Pharmaceutist.

Zachary Lewis, M. D.

Harvey Lindsly, M. D.

J. P. Little, M. D.

R. L. Madison, M. D.

J. C. Marcks, M. D.

O. F. Manson, M. D.

D. T. Martin, M. D.

W. D. Meriwether, M. D.

A. T. B. Merritt, M. D.

J. P. Mettauer, M. D., Prof. Med.

Sfc. Rand. Macon Med. College. C. R. Palmore, M. D. J. F. Peebles, M. D. Thomas Pollard, M. D. M. P. Scott, M. D. Albert Snead, M. D. J. Snyder, M. D. P. C. Spencer, M. D. J. J. Thweatt, M. D. J. W. H. Trugien, M. D. A. B. Tucker, M. D. T. J. Young, M. D. J. Wistar Walke, M. D. G. A. Wilson. M. D.

TH£

AND

Ho. 1.

RICHMOND, JANUARY 1851.

[Vol. I.

INTRODUCTION.

In embarking upon the arduous and responsible task of establishing and editing a monthly medical journal in Virginia, we deem it due to those upon whose pa- tronage and support we are dependent, to set forth our views and intentions at some length. The establishment of a medical press in Virginia has been a long- cherished desire of the whole profession. In 18-16, in convention assembled, the report of a committee urging the establishment of a journal was unanimously adopted ; but, from various causes, no one hitherto has volunteered to risk the la- bor and expense of the undertaking. In doing so ourselves, we naturally felt some doubts and misgivings as to the success of our enterprise. These, however, have been totally dispelled by the flattering and earnest assurances of assistance — (with- out which we feel incompetent to the task) — which we have already received from many of our zealous professional brethren, in every direction. It is proper to say, that our determination to assume the important post which we occupy dates no fur- ther back than the past month. In the short space of 30 days all the arrangements were to be made to put into operation a monthly publication. Arrangements with publishers — securing original matter and contributors, the making known our intention and obtaining subscribers — all to be done at once — were embarrassments which cannot be readily appreciated by the uninitiated. These disadvantages be- ing met, we found another source of perplexity, viz: the selection of a name ; and it being a matter of considerable moment, gave much concern. To choose one which would please everybody we knew was impossible, and to select one which would give satisfaction to the greatest number presented no little difficulty. We accordingly communed with many professional friends, of the best judgment and taste, both far and near, for aid ; and, after the most mature consultation about a matter of so little real importance, the Stethoscope was selected. As some have already criticised the election, it may be well to allege some reasons in its favor. There are so many "Journals," "Gazettes," "Recorders," "Examiners," and other similar titles already in circulation, that none of those seemed eligible. The aptness of a name after some important professional instrument, had been at- tested by the "Lancet," " Scalpel," &c. The " Stethoscope," then, Avas deem- ed particularly adapted, as the name of a work not devoted to any particular de- partment, but to medicine generally. It is an instrument used in each of the prac- tical divisions of our art, and is a valuable means for obtaining information —

Z INTRODUCTION.

such, may we hope, will be our Stethoscope. Its devotion to auscultation will he no more exclusive than is that of the "London Lancet" to venesection, or the " Scalpel" to dissections. So much for the name — it being satisfactory to us, we hope that it will not be the source of any sort of prejudice with others.

The objects of this journal scarcely need to be explained. We desire our pages to be the medium for drawing more closely the bonds of professional union, and for encouraging that esprit du corps among our brethren, which is so essential to their well being. We will labor in the advancement of medical science and its literature in Virginia and the South generally ; to aid in drawing into active use- fulness the great fund of information and talent which is now dormant; to collect and diffuse all the facts which medical science is rapidly developing, both in our own country and abroad; to suppress empiricism and charlatanry, both legitimate and illegitimate ; and to favor the protection and fostering of the science of me- dicine, by sound and effectual enactments of legislature, and to lend our mite in the " elevation of the science from the position of a trade to that of a noble profes- sion."

Much is to be done for the interests of medical men, now not only neglected entirely by law, but most shamefully oppressed. In the reform and the movement in favor of medicine, which it is hoped will soon be effected, we wish " to let the professional voice be heard on professional questions," and through an organ which will afford every facility for that interchange of investigation, experience and opinion among those engaged in active practice, which is so valuable in a progressive science — and which is as abundant and valuable in our own as in an}' other country. All agree that it is high time for the South to be building up itself and advancing its own institutions — its own medical schools and literature. To these ends will our energies be directed. We will be governed by those rules and principles laid down by the " American Medical Association," and oppose every innovation upon them. Having no party to favor — no sinister purposes to ad- vance, we will pursue steadily the course here laid down ; and though it may oc- casionally be our duty to take positions, and strive to establish them, in opposition to some of our brethren, we will ever be actuated by high and pure motives — will act promptly and decisively, according to the best lights before us — and in the discharge of the delicate duties incident to the editorial chair, to the best of our feeble ability, we hope to retain the friendship of all, and merit the enmity of none.

Being desirous of making our work interesting in all the branches, we invite practical communications upon the subjects of chemistry, pharmacy, botany, and every subject of medical interest, as well as of medicine and surgery. And, finally, as the work must surely die without support, we solicit the patronage of the pro- fession by their liberal subscription.

HAXALL ON UTERINE HAEMORRHAGE.

A few Remarks on the subject of Uterine Hemorrhage, limited to cases of Placenta Previa and those which occur subsequent to the completion of Labor.

BY ROBT. W. HAXALL, M. D.

Not intending to enter into an examination of the several modes by which it was attempted to explain the occurrence of flooding at the time of labor, I will merely remark, that it was clearly understood at an early period that the placenta might in some way or other be- come attached near to, or over the mouth of, the womb in such manner as to give rise to haemorrhage during its dilatation. Suffice it to say, that the first complete description of this kind of haemorrhage was furnished by R aederer in his Elementa artis Obstetricia, published about eighty 3rears ago.

Hemorrhage occurring in a case of placenta praevia, has been very properly denominated unavoidable; and it is so, because, to use the words of Prof. Naegele, " the very action which nature uses to bring the child into the world, is that by which she oftentimes destroys both it and its mother." In this sense it is clearly distinguishable from ac- cidental haemorrhage, which may happen at any period of gestation, and against which we have to contend in the common and ordinary forms of abortion.

The causes of placenta praevia are not, it must be admitted, fully understood. The most generally received opinion, I believe, is, that the semi-fluid condition of the decidua at this very early period of preg- nancy, does not always present a force sufficient to retain the ovum in the superior portion of the uterus. Hence it is that it has been supposed to glide down between the deciduous membrane and the uterine pari- etes, until finally arrested at the os internum. The manner of its ar- restation is seen to be different in different cases ; and we may sa,y, that in proportion to its direct implantation over the os internum, is the danger to be estimated by which both mother and child are threatened.

As just intimated, this central implantation may exist; at other times a portion only of placenta is observed to overhang the dilating os tincae ; and fortunate for the patient is it, when this complication exists in no greater degree.

The eruption of haemorrhage, in cases of placenta praevia, is confined to the latter months of gestation ; it is never perhaps noticed earlier than the sixth month ; much more frequently is it entirely unobserved until a month or six weeks before the period of accouchement, and this- is the case, for reasons which must suggest themselves to the minds of all.

The appearance of haermorrhage is sudden and unexpected — -unex- pected because the woman cannot recal to mind any act of impru- dence by which it might have been induced. It is more abundant than accidental haemorrhage ; and particularly is' it so, the nearer the patient has approached the period of parturition. Should1 she have two or three months, yet to go before reaching thfeterm, the flooding will not be so profuse ; but the probability is that a return of it will be

4 HAXALL ON UTERINE HEMORRHAGE.

experienced every twelve or fifteen days. There is also a very con- siderable difference in one respect, between accidental and unavoid- able haemorrhage ; in the latter, the eruption of blood shews itself during the 'presence of pain, for very obvious reasons, and diminishes when this subsides ; while in the former the reverse of this is found to be the case.

When the symptoms which I have here detailed exist, there is much reason to dread the existence of placenta praevia. A resort to the touch however will very frequently impart sufficient information to dispel our doubts ; not always however with entire accuracy, because the os tincae is at this stage of gestation so high up in the hollow of the sacrum as to render the touch somewhat obscure. It may, to be sure, be reached if the whole hand is introduced, and I would not hesitate thus to act, if I could not otherwise gain the desired information. By whatever method we may reach the os uteri, it will be found to be more bulky and much softer than in ordinary gestation, for the reason that its vessels are enlarged and distended, as are those of any other portion of the organ where the placenta may happen to be attached. When the finger penetrates the cervix, if there be a partial implanta- tion of the placenta, it will be felt overlapping one side, while upon the other we may recognize the distended membranes, and in all pro- bability be enabled to distinguish the presenting portion of the foetus. If the implantation be central, the finger comes in contact with a soft, spongy body, which is found to be attached throughout the whole cir- cumference of the os internum.

This diversity in the mode of the placental implantation will clear- ly explain to us the characters which belong to haemorrhage connected with this complication. It is unquestionably true that the most alarm- ing and profuse gushings of blood take place when the after-birth is centrally attached ; for every pain but serves to separate more and more the connection which exists between it and the womb. Under these circumstances, awful and appalling in the extreme, are we sometimes called upon to act ; and our action can admit of no delay ; for if the case be left to nature, the unhappy patient is sure to find a bloody grave ; — and how are we to act ? The ingenuity of the profession has devised several means, to which the intelligent accoucheur will imme- diately resort, according to the varying circumstances of the case — means which sometimes succeed, but which, it must be confessed, are too often inadequate to the end.

Where the placenta is but partially attached, the haemorrhage will not be so profuse, and the danger is consequently less. Should the uterine pains be sufficiently active, and the placenta overlap a small portion only of the os uteri, the case may demand but little interfer- ence ; for the bag of waters will more or less protrude through the gradually dilating os, and thus serve as a compress by which the flood- ing will be measurably commanded. If the presenting placenta cover a large portion of the os tincae, the tampon ma}7- in such a case be used with advantage, in order to afford time for its dilatation. Should the flooding however prostrate too much the powers of the patient, the finger may be passed through the unobstructed portion of the os tincae

HAXALL ON UTERINE HEMORRHAGE. 5

and the membranes ruptured. By this process we gain the advantage of causing the uterus to contract with more energy, and perhaps the greater one of bringing down the head immediately upon the mouth of the womb ; by which manoeuvre it is made to act the part of a com- press, and thus becomes instrumental in arresting the further flow of blood. As the pains cause the head to advance, the less becomes the danger ; and so soon as the delivery of the foetus takes place, in the generality of instances the placenta follows without delay. It is scarcely necessary to add, that the patient may require pretty active stimulation should the loss of blood have been considerable, as well as the use of ergot, should the pains not be sufficiently energetic.

Should haemorrhage supervene at any early period, whether the pla- centa be partially or centrally implanted, we ought to make no forcible effort to enter the os tinea?. All our endeavors should tend to mode- rate the flooding, and conduct the patient to the latest period of ges- tation. A contrary course would ensure the death of the child in all human probability ; nor would it redound to the well-being of the woman.

The remedy adapted to this condition of things, in the first place, is bleeding if the patient is feverish, with a quick and active pulse, as frequently happens ; the bowels should be emptied by an enema or laxative, and cold applications assiduously applied ; and should the uterine pains become at all expulsive or harrassing, they may be calmed by opiates and anodyne injections. The administration of lead and opium will also prove beneficial. At this period of gestation these measures will often be effectual without the aid of the tampon; indeed the tampon is objectionable at this stage, because its presence might become a source of irritation to the uterus, and thereby increase the activity of the expulsive efforts.

Let us now proceed to consider the case in which the placenta is centrally attached ; and I need not remark, that here the most alarm- ing difficulties are presented. At every recurrence of pain the hae- morrhage is increased necessarily, and without the most prompt and well-directed action the patient inevitably succumbs.

The main object to be attained is to rid the womb of its contents with as much despatch as may be consistent with the safety of the woman; and how shall this be done ? The method uniformly adopted heretofore, was to turn the child and deliver by the feet. But ano- ther measure has been recently practised, to which I shall frequently call the attention of the reader.

The os tincae however may not be sufficiently dilated to admit of the introduction of the hand, and all are agreed that no forcible entry should be attempted. To introduce the hand it must either be dilated or dilatable ; in which latter case a very moderate effort will be sufficient to accomplish our purpose. But suppose that neither con- dition exists ; every returning pain increases the haemorrhage, and if it be not checked the most disastrous results are to be feared. Under these circumstances it is that the tampon is capable of exercising the most beneficial and saving influence ; until the os tineas is sufficiently dilated to admit the hand, we must plug the vagina as speedily as pos- sible. By this method the flooding is greatly checked, if not entire-

6 HAXALL ON UTERINE HAEMORRHAGE.

ly arrested ; and during the subsequent dilatation of the os tinea?, which is not at all impeded by the presence of the plug, the haemorrhage is held in check. And here permit me to say a word or two as to the manner in which the vagina should be plugged. One or even two large sponges will not be sufficient for the purpose; the vagina should be completely filled and distended ; and to accomplish this in the most effectual manner, several small pieces of sponge not larger than half the fist should be successively introduced. After accomplishing this, a bandage moderately tight should encircle the body, and the T bandage finally applied. I have had the fullest evidence of the utilit}7- of such a plan. Under its action the os tineas will continue to dilate or become dilatable ; and when this desirable end is attained, we shall have obtained the only practicable condition in which turning can be readily accomplished.

How is this to be effected ? Are we forcibly to thrust the hand through the centre of the placental mass, search for the feet, and then proceed to deliver ? By no means ; and without reciting the various arguments against such a procedure, allow me to dismiss this part of the subject by quoting the language of the late Dr. Dewees : " This," he says, "should never be done; especially as it is impossible to assign one single good reason for the practice, and there are several very strong ones against it."

But how are we to proceed ? So soon as the hand can be introduced, it should be passed between the os tincae and the placenta, by in- sinuating the fingers carefully, one after the other, if no portion of it be detached ; if any part of its circumference, however, shall have been separated, it is at that point through which the hand will be more easily made to penetrate. When it shall have gained admission, the haemorrhage will at once materially diminish, if it be not entirely sub- dued, just because the arm will most effectually perform the office of a well-adjusted plug. We should now proceed in our search for the feet, endeavoring to retain the membranes entire until this part of the process shall have been accomplished. When we have succeeded in grasping one or both, they are gently to be brought down ; and if the patient be not in the extreme of prostration, we may begin to congratu- late ourselves upon the favorable termination of the case. Like the arm, when introduced, so does the body of the child, as it advances, play the part of a most effectual plug. So soon as the child is deli- vered, the tonic contraction of the womb succeeds as in ordinary cases, and the placenta, the great cause of all the mischief, is speedily thrown into the vagina.

In looking over the history of obstetrical medicine, we shall find many cases recorded where the delivery of the placenta preceded the birth of the child ; these were necessarily cases of placenta prasvia. In many of these both mother and child have fallen victims ; the child, I may remark, invariably did — but in some few, the life of the parent was preserved. These facts have been known to the profession for years, but it is only within a comparatively recent period that they have been scrutinized with a scientific eye, and made available in a practical point of view.

HAXALL OX UTERINE HEMORRHAGE. 7

In those cases in which the life of the mother has been preserved, the somewhat astonishing fact was observed that the haemorrhage had very much diminished, and in some instances entirely ceased, so soon as the placenta was expelled. Dr. Collins relates a case in which the placenta had been delivered eighteen hours before the birth of the child, and the mother did well.

Reasoning upon these ascertained facts, the idea occurred to two eminent members of the profession, Dr. Simpsonof Edinburgh and Dr. Radford of Manchester in England, (and who, by the by, disputed the point of priority,) that a separation and abduction of the placenta, in cases particularly where this was centrally attached, would be the speediest means of bringing about a cessation of the haemorrhage. This plan has frequently been adopted of late years by both, and, they tell us, with a success which fully equals their expectations. Success- ful cases are also recorded by other practitioners who have adopted their views.

Are the arguments sufficiently strong in support of this plan of pro- ceeding? This is a question which every man must decide for him- self, upon a careful review of the whole ground ; for it is certainly true that reasons may be adduced both for and against the validity of such a procedure. In Scotland and in England, where the gentlemen referred to severally reside, the profession appear to have taken sides, and many of the back numbers of the Lancet particularly, are crowded with communications on the subject. I shall not attempt to relate all that has been said on the one side and the other ; the reference I have given as to the sources of information, will be sufficient for those who feel any curiosity about the matter — I shall merely revert to this plan of Drs. Simpson and Radford, as one of the modes now adopted in the treatment of placenta praevia.

The great object to be attained by the prior delivery of the placen- ta, is the arrestation of the haemorrhage. To this conclusion no theo- retical reasoning would perhaps have led us. The occurrence of the fact itself was absolutely necessary to induce a positive belief in its existence. We are told by many who have adopted the practice that it is true, and I for one am willing to trust their authority, having no personal experience in the matter. The fact being established, it is not perha.ps very difficult to find a satisfactory explanation.

When a separation of the placenta takes place, the flooding must proceed from the large uterine vessels, the mouths of which are thus exposed ; and as the womb cannot take on its tonic contraction so long as its contents are unexpelled, the haemorrhage will necessarily conti- nue. If, however, the membranes be ruptured and the waters evacuat- ed, and in addition to this the placenta be extracted, uterine contrac- tion will supervene to a degree sufficient to check materially, if not wholly to arrest the flow of blood. With this end accomplished, al- though the life of the child is almost inevitably sacrificed, turning need not be resorted to unless there may chance to be a faulty presentation of the foetus.

Such then is the plan of Drs. Simpson and Radford, which, although it destroys, as I have just observed, the life of the child in a very large

8 HAXALL ON UTERINE HEMORRHAGE.

majority of instances, yet has the advantage of very frequently saving that of the mother. By a comparison of the two modes of practice, can we only arrive at positive conclusions with respect to the value of. each. If we adopt the generally received plan of proceeding, the life of the infant is sometimes, though not very often, saved, while that of the mother is too frequently sacrificed. By the method newly recom- mended, and which I have here endeavored to detail, a large per cent- age in the saving of maternal life is found to result; and if the rule, universally I believe adopted by the profession, that the life of the mother is of more value than that of the child, is still to hold good, the weight of argument would seem to incline to the practice of the prior removal of the placenta.

The manner of effecting this, we are told, is simple enough. When the os uteri is sufficiently dilated, the finger is to be passed between the uterine walls and the adherent placenta, and by gliding it around its whole circumference, the connection is thus severed. When this part of the process is finished, with the hand above the placenta, it is gent- ly pushed down into the vagina, from whence it may easily be removed.

I shall now say a few words in relation to those cases of haemorr- hage which supervene subsequent to parturition. This is a condition also of very great danger to the woman, and it has fallen to my lot to witness several severe cases of this variety of haemorrhage. I have seen the patient delivered without one disagreeable symptom manifest- ing itself, and when all bid fair speedily and safely to terminate. Soon, I have seen her complain of a sensation of sinking or faintness ; her lips become blanched, her ears ringing with disagreeable sounds, and her vision darkened and obscured. Her pulse hurries on with a fearful rapidity and with diminished force, until by and by it is no longer to be felt; a clammy moisture bedews the surface; the respira- tion is deep, prolonged or gasping; vomiting frequently ensues — and muttering delirium,, with wild and senseless tossing of the arms, but add still gloomier features to the horrors of the scene. When we turn our attention to the condition of the uterus, we shall find that it has failed to return to that state of tonic contraction which it ought to have assumed, and that haemorrhage to a greater or less amount, has been the result.

Inertia of the womb, if the placenta shall not have been detached in whole or in part, will not be productive of haemorrhage, because the large uterine and placental vessels still remain unexposed ; and I have seen this condition of things continue for hours. When, however, the placenta shall be wholly or partially separated, the interposition of art cannot be long delayed ; every effort must at once be put into requisition for the purpose of producing contraction of the womb ; for until this shall have been attained, it is idle to expect a cessation of the haemorrhage ; it is the only condition upon which we can rest the security of the patient; and fortunately for her, several available means are at the command of the accoucheur. Active friction should without dela}'' be made over the region of the uterus, and ergot promptly and largely administered. Cold applications may also be resorted to ; and if these remedies fail to produce contraction of the womb, and consequent ex-

HAXALL ON UTERINE HEMORRHAGE. iJ

pulsion of the secunclines, the hand should without hesitation be intro- duced, and the placenta removed. When this end is accomplished, the uterus almost always returns to its state of contraction.

But there is another and more serious complication than the one to which reference has just been given ; it is, the continuation of haemorr- hage after the extraction of the placenta. In this case the flooding may exist under two very different circumstances ; it is either appa- rent, deluging the patient's bed with blood, or it. may be concealed ; in which latter event it is retained within the womb.

In the case where the blood is retained, all the rational signs of haemorrhage, if I may so speak, and which have been named above, may take place ; and when we come to examine the condition of the womb we shall find it largely distended, reaching in some cases even above the unbilicus. The obstruction to the exit of blood is produced either by a contraction of the os tincae or by the presence of a pretty firm clot. So soon as this is removed, or the contraction of the os overcome, the blood pours out with a fearful rush. Contraction of the uterus very generally succeeds to this; and while perhaps we may be congratulating ourselves with the hope that it will remain permanent, the lapse of a few moments will convince us that we have again to contend with the same disagreeable symptoms. This alternate con- traction and dilatation of the uterus, I have witnessed in one case as many as three times ; and it is not difficult to believe that under such circumstances the patient is often brought to the brink of the grave.

The first thing to be done, when haemorrhage supervenes, whether apparent or concealed, is to proceed diligently with frictions over the region of the womb. If this should not cause it to contract, the appli- cation of cold may be resorted to, and the plan recommended by Dr. Gooch will often be found very available. Cold water should be poured from a pitcher or teapot elevated some foot or more above the body of the patient. Injections of cold water into the womb have also been advised, but having succeeded by other means, I have never employed them. Velpeau's plan of placing a mustard plaster between the sca- pulae, the action of which he candidly confesses he does not under- stand, but as to the efficacy of which he speaks with much certainty, may also be tried ; nor should the administration of ergot be omitted. The application of the child to the breast should not be disregarded, for the sympathy existing between the mammae and the uterus will not unfrequently ensure its contraction. Failing in all these measures, the practitioner should boldly but cautiously pass his hand within the uterus, and having turned out all the clots, with the other hand placed upon the abdomen, and thus embracing as it were this organ between the two, he should institute such an amount of irritation as to produce its contraction. While this is taking place he will find his hand gra- dually pushed from its position within the womb, until it finally reaches the vagina. A bandage reaching from pubes to sternum should be ap- plied, taking care to place a thick and firm compress immediately over the womb.

In the case now under consideration, the tampon is not only useless but even objectionable; for it would be the means of converting an

10 THWEATT ON DIARRHCEA AND DYSENTERY.

open into a concealed haemorrhage. In conclusion, I will merely re- mark, that active stimulants are frequently demanded during the pro- gress of the treatment; and when the haemorrhage has ceased and the s}Tstem re-acted, a bland and nutritious diet will become necessan7.

On the use of the Nitrate of Silver in certain forms of Dysentery in Adults and Diarrhoea in Children, with cases and remarJcs.

BY J. J. THWEATT, M. D., PETERSBURG, VA.

My object in this paper is to call the especial attention of the profes- sion to the therapeutic action of the nitrate of silver in certain patho- logical conditions of the intestinal mucous membrane. The experi- ments that have been made with this medicine on the continent of Eu- rope, conclusively shew that its action on the mucous membranes generally is of a particular or specific character. The attention of many able pathologists has been directed to the object of ascertaining the precise morbid states, to the removal of which it should be ad- ministered. Upon this point, there is much diversity of opinion ; with some, the existence of the inflammatory element is no contra-indicaiion to its use ; while others maintain, that, when inflammation is present, it should be withheld or used with extreme caution. My experience with this agent, which has been pretty extensive, convinces me, that in diseases of the mucous membranes, where the inflammatory action seems high, the employment of the nitrate of silver is attended with prejudicial effects ; and I am moreover convinced, after an attentive- perusal of the authors who have written upon the subject, that much of this contrariety of sentiment is to be attributed to the confounding of the terms of irritation and inflammation. In my opinion there is a marked distinction between the two pathological conditions, and that this distinction should be kept prominently in view b}r the practitioner who contemplates employing the nitrate of silver. In the one state he will find its action eminently curative, in the other highly injurious. In the one state the nitrate of silver acts like a charm, removing everv symptom — in the other, it acts like a poison, aggravating all of the symptoms ; in the one it is a placebo — in the other it is an active irri- tant.

With these general remarks upon the pathological action of the ni- trate of silver, we will proceed to its application in dysentery and di- arrhoea of marked forms.

During the summer months, and particularly after heavy rains, d}rs- entery in some form prevails to considerable extent in the suburbs of our towns and the surrounding counties. In the years 1846-7-9, 1 was called to attend many cases of this disease ; one form, from its fre- quency and obstinacy, attracted particularly my attention. The follow- ing phenomena characterized it : The person would be seized, after an exposure to the heat of the sun, with an intense desire to have an eva- cuation, accompanied with a disagreeable itching about the anal region ; on going to stool and passing a small quantity of mucus, he would ex- perience relief; this however was but momentary, for in about half an

THWEATT ON DIARRHCEA AND DYSENTERY. 11

hour, he would be again seized with the same symptoms. The con- stitution at first is but slightly affected. There is no fever — pulse calm — skin in a perspirable condition — no thirst — no headache — the upper portion of the digestive organs remaining in their normal condi- tion— no anorexia — no nausea — no enlargement of liver or spleen — no tenderness on pressure ; the patients complaining of nothing but great tenesmus, itching and soreness around the anus. The quantity of the discharge rarely exceeded half an ounce — often no more than a drachm was evacuated at a time. The discharge consisted entirely of mucous, tinged more or less with blood. The above symptoms would continue, with very little diminution or aggravation, for some four or five days, when a new train of phenomena would make its appearance. The patient complained of great debility, want of sleep and appetite — the mind became irritable and fretful, pulse more excitable, especially as night approached ; in some cases anemia came on — still there was no pain in the bowels except in the lower portion of the rectum, about an inch or two inches from the anus. The pain in this part was in some cases excruciating, particularly on examination with the fingers : the soreness around the anus was a great annoyance — the evacuations would remain the same, only increased in frequency. I have seen the patient go to stool twenty to thirty times during a day, and the dis- charges all put together would not amount to/our ounces. When first called to treat this affection, I employed the usual remedies, calomel and opium, gentle laxatives, anodyne injections and fomentations, leeches to the perineum — in some cases mercury was carried as far as ptyalism, in conjunction with flying blisters over the abdomen. The result of this treatment was unsatisfactory ; a mitigation of the symp- toms would follow, and sometimes the disease appeared entirely sub- dued, but in a short time all the symptoms would return ; for instance, the calomel would frequently bring copious bilious passages, and after the lapse of five or six hours, the same inclination to go to stool, fol- loweel by the same discharge, would ensue. The anodyne injections and fomentations would produce their grateful and soothing effects, but in a few hours their pleasing results would disappear; no benefit was derived in any case from the application of leeches.

The treatment proving so unsatisfactory, and the seat of the disease being evidently limited to the lower portion of the rectum, I came to the conclusion to direct my treatment to that point, and abandon all internal remedies except the mildest laxatives. The high encomiums which had been bestowed upon the nitrate of silver by continental writers, induced me to try its effects in this disease. I commenced by throwing up the rectum every three or four hours, two ounces of a so- lution containing five grains of the nitrate of silver to an ounce of dis- tilled water, adding a few drops of the tincture of opium. The first case in which I employed this treatment yielded in a few days. The treatment was fully carried out in all of the subsequent cases, and with the most beneficial results ; in a few cases the dose was increased to ten grains, but generally five grains to the ounce was of sufficient strength. I have selected the following case to illustrate the treatment :

August, 1848, Mr. C, aged 25, of a strong constitution, general

12 THWEATT ON DIARRHCEA AND DYSENTERY.

health good, after exposure to the heat of the sun, was seized about six o'clock in the afternoon with a great inclination to go to stool, ac- companied with itching about the anus — on going to stool, he would evacuate a small quantity of mucus mixed with blood, which afforded relief; the inclination gradually increased, so that from six o'clock in the afternoon to nine in the morning he had been to stool twenty or thirty times. At nine o'clock I found him in the following condition : complaining of no pain, none was felt on pressure, skin moist, pulse slow and moderately full, tongue broad, moist, with a whitish coating, no derangement of the cerebal or digestive organs. On examination of the rectum by the introduction of the finger, he complained of pain, extending about two inches up the intestine ; the parts around the anus were swollen and acutely sensible to the touch. On inspection of the evacuations passed during the night, they were found to consist of mucous, slightly tinged with blood. Had two discharges while pre- sent, of the same kind, about a drachm at each evacuation, complains of itching around the anus — says the desire to have an evacuation re- turns every fifteen minutes ; prescribed the following enema :

&

Argenti. Nitrat. gr xxx Pul. Gum Arab. 3 j Tinct. Opii. gtts xij

Aq. Distill. 1 vj

M Fiat enema.

Two ounces to be thrown up the rectum every three hours — barley water for diet and drink — cold applications to the anus. Saw him again in six hours — had only three discharges — taken two injections ; says he feels much better — the inclination to go to stool diminished — ordered him a dose of oil with ten drops of the tinct. of opium. After the operation of the castor oil, to give an enema, and repeat it every three hours if necessary ; continue the cold applications ; same diet. Saw him again at 9 o'clock in the morning. Had slept well ; the oil had opei'ated twice, bringing faecal discharges ; used one injection ; had only one mucous and bloody passage. The tenesmus had almost disap- peared. Says he feels entirely relieved. Ordered an enema ; chicken water. Saw him in the afternoon. Had no evacuations — doing well in every particular. Left directions to use an enema, if the disease should return. Saw him again on the third day of his attack ; found him entirely relieved of every symptom of the disease, except sore- ness around the anus ; directed cold applications to be continued, and ceased my attendance, the cure being perfect.

Remarks. — We could cite many similar cases, but this one is suffi- cient to shew the nature of the disease, and its proper treatment. The question now occurs, "What is the pathology of this affection ? Is it an inflammation ? We must reply in the negative. There was no symptoms which usually attend the inflammatory action; and the treat- ment, which generally subdues inflammation, was nugatory and some- times aggravated the symptoms. The disease appeared to consist in

THWEATT ON DIARRHOEA AND DYSENTERY, 13

an irritation of the follicles of the mucous membrane of the rectum, attended with an undue secretory action. The action of the nitrate of silver in the case cited was that of a sedative ; it subdued the irrita- tion, arrested the undue secretion, and restored the parts to their nor- mal condition.

Diarrhcea.— The nitrate of silver has been lauded by many emi- nent physicians as a remedy in this disease ; but I think they have failed to point out clearly the cases in which it is most applicable. It is admitted, that diarrhcea is dependent on a variety of causes for its production- — its anatomical lesions are various and diversified in their character; its therapeutics must consequently be of a diversified cha- racter. In our climate a peculiar form of this disease is to be met with during the summer months ; it makes its appearance without pre- monition. The attention of parents or nurse is first excited by the frequent and sometimes copious evacuations — the physician is sent for — he finds no heat of skin, or head, or mouth, or abdomen ; no sick , stomach or vomiting — pulse calm and quiet — tongue clean and moist ? the child is apparently in excellent health- — its appetite is good — his sleep undisturbed, except by the passages. This state of things is however of short duration. The constitution becomes affected ; the child gets weaker and weaker — loses flesh- — instead of pursuing its usual gambols, is disposed to lie down — it becomes fretful — the exter- nal features undergo a marked change — the countenance is pale — skin corrugated and of low temperature — the pulse small and quick — ■ tongue contracted, but still free from fur — appetite fails — the secretions from the bowels become more and more frequent, and if not soon ar- rested, death ensues. In the dissections which we have made of this form of diarrhoea, nothing was discovered but a slight congestion of the mucous membrane of the small intestines ; no traces of inflamma- tory action were detected. The character of the evacuations is various, both with regard to quantity and quality ; in some they are natural, only more abundant and frequent, and less consistent ; in others they are small, mixed with mucous and of strong bilious appearance — in some green, in others dark or whitish. We have found no remedy so beneficial in this form of the disease as the nitrate of silver, as the following cases will shew :

June 8th, 184S. W., set. 19 months, has been subject to the bowel complaint for two weeks — 'much debilitated from the disease — coun- tenance pale — skin cool — tongue natural — pulse slightly irritable — ap- petite bad — no pain on pressure — no cerebral derangement, but is very restless and peevish. The discharges from the bowels were of a deep yellow color — no mucous or blood could be discovered. Prescribed a warm bath and a teaspoonful of the following mixture every four hours ;

Argent. Nitrat. gr ij Aq. Gummi. 1 iij Tinct. Opii. gtts xij

M Fiat mist.

14 THWEATT ON DIARRHCEA AND DYSENTERY".

June 7. Has had three operations from the bowels of more con- sistency, color more natural — appetite improved — had rested well — continued the mixture.

June 8. Had only one evacuation in twelve hours — that one of a healthy appearance. Looks better, had taken heartily of nourishment : suspended the mixture.

June 9. Had no return of the diarrhoea, condition improved in every respect. The child recovered without further medical aid.

June 18. Edward, infant, aet. 9 months, had diarrhoea for four or five days. Had taken calomel, Dover's powders, oil and chalk mixture. The effects of these medicines had been only temporary. The dis- charges would cease for a day and then return. When I saw the child it was free from fever, lively and playful, gums not swollen, having five or six passages during the day. They were green and slightly mixed with mucous. The abdominal perietes soft and flexible. No pain or sensibility on pressure. Tongue natural — no vomiting ; ordered the following mixture :

Argenti. Nitrat. gr j

Pulv. Gum. Arab. 3 j

Tinct. Opii. gtts vj

Aq. Distill. 1 iij

Fiat mist. Teaspoonful every three hours.

Saw the child in the afternoon. Had taken three teaspoonsful of the mixture. No passage after the first dose of the mixture. No fever ; had been sleeping. Ordered a tepid bath at bed time and a teaspoon- ful of the mixture and one early in the morning.

June 19. No passage through the night — had slept well — was playful and entirely free from fever. Ordered a dose of oil and a tea- spoonful of the mixture after the operation of the oil, to be repeated every four hours if necessary.

June 20. Had rested well during the nioht. No fever. One health v operation from the oil. Suspended the medicine, with directions to resume it if the disease returned. Saw the child on the 23rd. Had taken only one teaspoonful of the mixture. The passages were healthy. Stopped all medicine. The child enjoyed excellent health.

Remarks. — The action of the nitrate in these cases was prompt and efficient. It soothed the irritation of the mucous membrane ; gave tone to the general system — and acted as a sedative and tonic astrin- gent. The doses were small, from iV to aV of a grain. It has been recommended in larger doses. I will add that no doubt larger doses would be borne with safety.

lindsly's cases of mumps. 15

Tivo Cases of Mumps, with Metastasis to the Brain, both terminating fatally . — By Harvey Lindsly, M. D., late Professor of Pathology and Prac- tice of Medicine in the Columbian College, honorary member of the Rhode Island Medical Society, the New Jersey Historical Society, <8fc.

Cases of mumps with determination to the brain are so exceedingly rare that I do not recollect to have seen or read of more than three besides those referred to at the head of this article. Most of our popu- lar writers on the practice of medicine, though men of extensive ex- perience, have evidently never seen a case, while they still speak of it as of occasional occurrence. This is the fact with Good, Eberle, Wood, Dewees, Mcintosh, Watson, Tweedie, &c. ; and indeed the only author that now occurs to me, who speaks of this complication as having come under his own observation, is Dr. Dickson of Charleston, in his able and interesting work published a few years since.

In January 1849, a son of Gen. W., who at the time was a student of medicine and attending the lectures of the medical school in this city, was attacked with the mumps, and after a few days' illness died, as I was informed, from metastasis of the disease to the brain. I can- not give the particulars of this case, as the patient was not under my professional care. On the 1st day of February following, about a week after the death of this young man, I was requested to see his brother, (setat. 20,) a student of Princeton college, who was at home on a short visit to his friends. I found him laboring under a well de- veloped attack of mumps of the left side, the gland considerably swol- len and with some fever, though on the whole suffering but slightly, and feeling, as he remarked, very comfortable. The disease seemed to be taking its usual course, and if it had not been for the recent death in the family, would have excited little interest or observation. As it was, however, his friends felt some anxiety, and I was induced to attend the case more carefully than I should have thought necessary under ordinary circumstances. As precautionary measures, I directed pretty active purgatives, followed by diaphoretics, hot pediluvia, warm flannel to the swollen gland, &c, and watched very closely for any in- dications of disease of the brain. I could detect nothing of the sort however, and until the fifth day everything seemed to promise a fa- vorable termination. I examined my patient carefully twice a day, with reference to the condition of the testicles as well as the brain — but there was no apparent disturbance of the functions of the one, and no enlargement of the other. He was cheerful, slept naturally, and felt confident of a speedy recovery. Upon examining him, however, on the morning of the fifth day, my apprehensions were excited by finding that he was laboring under -priapism. I dreaded this symptom the more, as the disease seemed now to be taking the same turn that proved fatal in his brother's case. He was immediately ordered to be leeched freely at the base of the brain — a blister was applied to the nape of the neck, purgatives given and an active general antiphlogistic treatment adopted. At the same time additional professional advice was obtained. During the whole of this day, however, the priapism was the only indication we could detect of diseased brain.

16 PEEBLES ON THOMPSONIANISM.

On the next morning we were informed that he had been laboring under delirium the greater part of the night — had been restless and suffered much. These symptoms continued to increase in violence, convulsions came on, and in a few hours death closed the scene on the sixth day of the disease and the second after the appearance of the priapism.

A careful examination of the brain was made thirty hours after death, when decided marks of inflammation and congestion were found in the cerebellum, but none in the cerebrum.

Washington, Nov. 29th, 1850.

The Rise and Progress of Thomj)sonia?iism.

BY J. F. PEEBLES, M. D.

This is an indigenous production. Perhaps, on that account, we ought to approach it in a friendly spirit. Ours has been said to be *' the greatest people in creation." The writer is the last person in the world to underrate the national supremacy : but candor is an indis- pensable attribute of the historian. This compels us, in the very out- set, to declare that this, which is the most prominent specimen of our native medical delusions, proves that the attempts of our people in that line have, as yet, been awkward, bungling and extremely unre- fined. The right materials seem not to exist with us yet for excellence in these matters. How coarse and crude appears this torturing prac- tice of medicine, when compared with the refined idealisms of home- opathy and mesmerism ; even before the less elegant system of hydro- pathy, it sinks into insignificance — it has no protot37pe in the old world. It embodies a spirit which has no existence there, that of our restless, dauntless, active, western backwoodsmen, who even judge of their "physic" by the amount of labor it is capable of performing. It sprung from the necessities of this part of our population, and it em- bodies that which comports with the characteristics of their minds. — The man who is ripe for a belief in Thompsonianism would turn up his nose at homeopathy. The true nationality of its production is elucidated by its course ; it tends westward with the pioneers, leaving the east, where men, living upon their wealth and retired from business, have the time to be invalids, for the prevalence of the more luxurious and aristocratic systems of homeopathy and its kindred spirits.

Samuel Thompson, its founder, was born in the year 1769, in the town of Alstead, New Hampshire. His parents were among the first who settled in that region, then a wilderness ; they were poor, and supported themselves by the labor of their hands. The young Sa- muel, therefore, became early acquainted with manual labor ; and he tells us himself, in more than one place, that he had no fondness for it. Whatever genius he might have possessed, was certainly not soon discovered by his hard-working father, who, despite his aversion to it, and a lameness which much incapacitated him, kept his son steadily employed on the farm. This parental sternness, as has been often the case, was the making of the boy. It fixed his aversion to labor so in-

PEEBLES ON THOMPSONIANISM. 17

delibly, that he early began to turn about that he might devise some means of living without it. An opportunity was not long in present- ing itself. Being totally unprovided with physieians, the necessities of the rude settlers, scattered through that wild country, often led them to seek medical aid from any source it was profFered. In this way a sort of rude practice sprung up in the hands of old women and others, whose medicaments were gathered from the fields. Young Thomp- son was not slow to discover the necessities of the community, and with an eye always toward an escape from the drudgery of labor, he early joined these drug-gathering parties, and eagerly turned his atten- tion to the simple practice of the neighborhood. The expedient was a successful one ; his knowledge of the rude medicaments in common use became so perfect, that when only 8 years old he was dubbed " Doctor " by his neighbors, and was often called on to decide upon the properties of medicinal plants.

His acquirements, and the general belief in his great medical pro- mise, finally overcame the sternness of his father, and he tells us, that provided his services could have been spared from the farm, and had his education, which as yet consisted of only one month's schooling, been sufficient, he would, in his 16th year, have been sent to learn medicine under a certain root doctor of Westmoreland. This step, had it been carried out, might have been unfortunate for his subsequent celebrity as a doctor ; and if so, it would certainly have been fortunate for many a poor victim to his crude and remorseless system of practice. We have no idea of the medical knowledge of the root doctor in question, but we hold that, were he possessed of any experience in dis- ease, or any information about remedies, it would have been sufficient to have enabled him speedily to instil that in his pupil's mind, which would have thoroughly disgusted him with the career he was about entering upon. Our meaning can best be illustrated by a veritable in- cident. We once heard of a groom, who fancied he had a natural turn for surgery. After performing with the rudest implements, many mi- nor operations, a woman was finally brought him with a cancerous breast, which the most distinguished surgeons had declined amputat- ing, because the disease had extended itself to the glands of the axilla in such a manner, as to render the operation, not only useless, but immediately dangerous. It was a mere trifle to our groom. He re- moved it in a jiffy. It is true, the axillary artery was wounded and the haemorrhage was terrific ; yet, nothing daunted, he coolly seized the wounded vessels with a pair of ordinary pinchers well heated, and miracuously stopped the bleeding. The wound healed kindly, and the woman was soon sent home as well.

The result of this feat was the formation of a purse, by some be- nevolent persons, who, determining that such natural abilities should not be lost to the world, had resolved to afford the operator a regular medical education. Before his term was half out at the university, however, he returned home and quietly resumed his stable duties. — When asked for an explanation of this conduct, his reply was, that he bad become so shocked at his former foolhardiness, by what he had learned of medicine, that he was deterred from its further prosecution- 2

18 PEEBLES ON THOMPSONIANTSM.

That he then knew the danger of the knife, and henceforward, those who chose it might become surgeons; but as for himself, he never meant again to remove even a wart from the human body. Denied even the small chance of having the conceit taken out of him, which the root doctor might have afforded, our hero, we find, was left to pur- sue his labors on the farm and his medical studies at the same time. Without learning, without books, without a guide or example, it ap- pears, of any kind, this rude child of genius boldly knocked at the door of nature's great storehouse of knowledge, and he fancied that it was opened unto him. His history is a curious and not uninstructive ex- ample of the study of medicine denovo, without reference to what was hitherto known respecting it, occurring in our own times.

A contrast of his method with that of the most primitive medical enquirers of which we have any account, certainly proves an advance in the human mind, which is exceedingly interesting. Instead of ap- pealing to the gods or to the heavenly bodies ; instead of selecting remedies as was done b}r the earliest medical enquirers, according to a fancy, dictated by the shape, color, brillancy of substances, Thomp- son very philosophically, certainly, appealed directly to nature. He tasted and tried for himself; he experimented on his playmates and fellow-laborers with any thing that came in his way. We approve of this method of enquiry, and when we have said that, we have said all we can say in the praise of our hero.

The great storehouse of nature had been too sedulously and tho- roughly examined by men qualified for the work by the learning of ages, to leave any thing to be culled by so crude and ignorant an ob- server as Thompson. Yet, for all this, we can sjmipatbise with his belief in the originality of many of his discoveries. How was he, for instance, to know that the lobelia had been long known and used by physicians, when he was altogether unlettered had never seen a me- dical work, and had no acquaintance, with any man having any preten- sions to medical knowledge. The maintenance of this belief, when he was told better, is exactly what might have been expected of one so ignorant and uncultivated in every thing necessary to an enlighten- ed and civil man. Though utterly useless to science, the labors of Thompson brought him rich results in the way of conceit and self- sufficiency.

He soon began to look upon himself as a favored emissary of Heaven, sent to snatch his fellow-creatures from the clutches of the murderous faculty. Taking his own statements as authority, the man seems to have had but slight grounds for such a belief. The views which he took of disease would disgrace an enlightened New Zealander. We mar- vel how even he could have held such doctrines. It appears to us that the very powers of thought required to frame a theory at all of disease, ought to have ensured him against such manifest absurdities. He looked upon the human body as a great pot, to be boiled or refrigerated at pleasure. Disease he held to be something, endowed with a sort of life, which could only be killed out of the body by his " courses." To destroy this mis- chievous stranger was the end of his medication. He puked, steamed and stimulated ; that not answering, he puked, steamed and stimulated

PEEBLES ON THOMPSONIANISM. 19

again and again. His method of practice was exceedingly simple ; it was as plain as the building up and the putting out of a fire. He made no allowances for the vital properties of the body, but acted on it as though it were but inorganic matter. Heat, every one knows, vo- latilizes water : taking the hint, Thompson cured dropsy through an evaporation of the effusion, by raising the internal and external heat of the body. Such crudities fail to excite even our derision, and we turn from the further consideration of his mere theories with feelings of pit3r, blended with amazement, that such notions could have ever found advocates among a civilized people. Having fixed upon his " courses," to be employed alike in the treatment of all diseases, he set out on his great mission. It is due to the man to state that he prosecuted his plans with admirable energy. Indeed it is difficult to recognize the possession of so much perseverance associated in the same individual with so little intelligence. One would have supposed, at least, that the latter would gradually have been supplied, to some extent, by the exercise of the former quality. Not so with Dr. Thompson — he was too wise to learn; and he gained nothing by the contact with the world. His ignorance and self-sufficiencv encrusted

O J

him too securely to admit of the penetration of a single ray of know- ledge. He rivalled Paracelsus in the importance in which he held him- self: the professor of the much longed for philosopher's stone could not have been more arrogant. The brass of the man was inconceiv- able. Not content to preach his doctrines into the ears of the unenlight- ened in medicine, he bearded the lion in his very den. He -tells us that he called to have a conversation on medicine with Dr. Rush, and speaks of an interview with the elegant and accomplished Prof. Bar- ton of Philadelphia.

The smiles of physicians at his blunders he construed into envy of his success, and he seemed to be in perpetual trouble lest some one would seize and appropriate his discoveries. He carried the war into the enemy's country, and probably owed much of his popularity among the unenlightened to his attacks upon the faculty. It was lis that ori- ginated the prejudice against mineral medicines, still deeply rooted among the ignorant, and set the popular current in favor of vegetable or botanic remedies. Such was the character of Dr. Thompson. We dismiss its consideration with the assertion, that so much ignorance, self-conceit and daring energy were probably never before associated together in the same individual.

After many }rears spent in journeying about from place to place, healing the sick, the results of his medical investigations and dicove- ries, Dr. Thompson, to protect himself, as he says in his narrative from being robbed of all merit and emolument, ultimately embodied in a book, which he sold under the protection of a patent. His first patent, it appears from his narrative, was obtained in 1813. The early introduction of the system was attended with many annoyances. Dr. Thompson fairly suffered martyrdom for his strong faith in his discove- ries. We read in his book constantly of severe trials, arising chiefly from the ingratitude of his patients, the persecutions of the faculty, the faithlessness of his agents, and the general wickedness of mankind,

20 PEEBLES ON THOMPSONIANISM.

from the judges on the bench, who sat on his causes, down to the old women who had acted as nurses to his patients. His whole life, as he has most touchingly given it, is a satire on humanity: an instructive commentary on the injustice of the world ; marked, however, by the pleasing contrast afforded by his own meek endurance of evil, and steady adherence to the interests of his fellow-men. The Doctor seems to have encountered a perfect shoal of swindlers ; to have submitted his bantling to the world in most evil limes ; hence, he got but slight gains for all his troubles — received but little remuneration for his bene- fits to mankind.

His agents ran off, however, with immense sums obtained from the sale of rights, which, first to last, must have yielded a vast deal of money. The new doctrine gradually spread from New Hampshire into other states. Next to that giving it birth, Ohio, from the first, ap- pears to have afforded it the warmest reception. It was disseminated with the greatest zeal. The manner of its circulation was like that of a patented machine. Agents, armed with set phrases against the use of mineral poisons, and in favor of vegetable remedies, peddled the books through the country, and sold the right to their use in practice at twenty dollars per right. It steadily spread on, until it pervaded the whole country, including the Canadas. Every neighborhood was invaded, and in every neighborhood one or more individuals were to be met with, possessed of the requisite turn of mind necessary to constitute a Thompsonian doctor. An observer might soon have learnt to point out the individual in any given place likely to adopt the new calling. The varieties of the species are great, }7et admitting of classification. Your embryo Thompsonian doctor is considered in his neighborhood a smart man for his chance, although }Tet he has never been good for much. He is constantly astonishing his neighbors by his versatile mind. He is much wanting in veneration ; hence, old and established usages of every sort are frowned at by him. There is nothing which he be- lieves he cannot do; hence he is ever ready to attempt aiyvthing that comes to hand. He has no particular trade or business, yet he follows any that he fancies. Ten to one if he is not set up in some intricate trade, as watch-making, which he has never learnt. If not so, he as- pires higher. He may deal a little in law7 — generally he is only a preacher — in every thing he is essentially by nature a quack and pre- tender.

These are the men who readily take up this practice of medicine, making their neighborhoods ring awhile with their exploits, causing the old women to gape and wonder at the canker ejected, by the emetic weed, from stomachs hitherto held innocent of such abominations.

These are the men who deer}7 the faculty, who shudder at mineral remedies, and who see health alone in the vegetable kingdom. One such was asked in our presence of what was calomel made? Of cop- per and brass, was his confident reply, doubtlessty deriving the opinion from a fancied analogy between that ''awful" poison and the vene- mous look of the rust of these metals.

It took time — but, as we have said, the new practice has pervaded the whole country. We suppose fifty years must have elapsed from

PEEBLES ON THOMPSONIANISM. 21

its first promulgation before it became so generally diffused. Not only in its results, but in the manner of its invasion, does its progress resemble that of the cholera. It comes, and after a time departs; its residence in all places is temporary, and its return only at long intervals. After sweeping through a neighborhood, it will depart ; years after, when the memory of its freaks has become dimmed in the recollection of" the survivors, it will suddenly re-appear and vehemently assert its claims to popular favor. Although partly, it is not altogether in this way that it has been kept alive. Samuel Thompson, it seems to us, was honest in his belief about this practice. This is demonstrated by the artless manner he unfolded his doctrines. It is evident he meant them to rest exclusively on their own merits. He believed them himself, and he expected them to carry conviction to others. This was a frail reliance ; the creed had within itself the elements of its own speedy destruction. We affirm that, had its original spirit been maintained, had not its con- trol passed in a measure out of his hands, the system would have died with its founder. Long before his death, Thompson complained bitterly of the innovations of his disciples. These, more artful and long-sighted than himself, watched the popular mind. Money-making was their object; hence, to keep the delusion triumphant, they steadily propped it wherever it appeared to be giving way.

In this way only has it been kept from sinking. In late years but few, if any, of the true breed are to be met with. Thompsonianism, as Samuel Thompson taught it, has long been dead ; but out of its ashes there has arisen recently a more dangerous, because more imposing and disingenuous sect. We have now the Eclectics. These pre- tend to combine the excellencies, without the obnoxious parts of both systems of medicine, the "regular" and the Thompsonian. This has led to a new swarm of specious quacks, which overspread the land.

Cincinnati is their head-quarters ; from thence they emerge like lo- custs, to desolate the country. In many places they are now in the full tide of their prosperity. But they cannot last long; this medical monsoon will soon vanish ; then Thompsonianism will be forever dead. The system is completely worn out;' there is not enough of it left to hitch on another saving appendage. One word about the practical ope- ration of this system of medicine, and we are done with it. We have before alluded to the theories which guided Thompson in the applica- tion of his remedies. They are too absurd and ridiculous to be again referred to ; yet we candidly state that there was more in his proce- dures than he had the mind to appreciate. We mean that he was una- ble to perceive wherein his remedies were in certain cases salutary ; too ignorant to tell in what manner they might sometimes cut short an attack of disease. Need anything more be said to prove the utter recklessness and danger of this system of quackery? His remedies were powerful ; the;y produced the most violent and perturbating effects. In this way, in cases suitable, but limited in their number, their revo- lutionary tendencies might induce, although in a bungling and exceed- ingly uncertain manner, salutary changes. Applied without discrimi- nation, as it was in every disease, it could but lead constantly to the most criminal consequences. The people are slow to condemn

22 JONES' OPERATION FOR LOSS OF UNDER-LIP.

their petted systems ; yet Samuel Thompson, for all that, was several times brought to the bar of justice to answer the charge of murder, too palpably committed to escape the observation of the bystanders. Un- like some other delusions, all his blunders and crude experiments upon his patients have added nothing to the stock of medical knowledge. He had but glimpses of very few and unimportant therapeutical truths, such as the influence of sweating as a curative means, which truths have been long unfolded in the most satisfactory manner, and are known to the merest tyro in medicine. He could do nothing, with all his bungling and torturing procedures, which medical men do not hourly do by safer, simpler and less disgusting means. He developed no principle in medical practice which had not been known for ages, whilst his therapeutical additions, which were new, were utterly value- less. The whole delusion was but an unmitigated evil. In addition to its direct evil tendencies, it has indirectly been the cause of much mischief. Its spirit, and the manner of its introduction, tended to make the people rebel against medical authority. It diffused a contempt of study and learning, and excited a prejudice in the popular mind against physicians as a privileged class, who held unjustly a monopoly, which they used to oppress the people. The vaunted success of its heroes favored the idea, that any one with twenty dollars in his pocket could be a better doctor than the most scientific and learned physician. It fostered and maintained all the existing popular errors about drugs, and even originated many that were new. We repeat, therefore, that the whole delusion, from the first to the last, has been an unmitigated evil, and one not at all likely to reflect credit upon the intelligence of our people.

Deformity of the Mouth, caused by the use of Mercury, with loss of the greater portion of the Under-Lip, relieved by a Surgical Operation.

BY WALTER F. JONES, M. D., OF PETERSBURG, VA.

During the year 1845, 1 was requested to examine the case of a little boy from the county of Gloucester, Va., aged 14 years, who, it seems, had contracted a bilious remittent fever some six or seven years pre- viously, during the treatment of which, mercury had been employed by the attending physician, which resulted in the recovery of the pa- tient, followed by severe ptyalism and sloughing away of the under- lip. The patient exhibited the following appearance : The youth's ge- neral health seemed pretty good, but the deformity above referrred to consisted of the entire loss of the under-lip, save a very small teat- like remnant on the left side. The whole under surface, where the lip formerly adhered, from long-continued pressure, had become almost entirely cartilaginous, and was united firmly to the anterior portion of the inferior maxillary bone ; the tongue, with the sub-lingual glands, was much diseased and enlarged; also the sub-maxillary on one side. The patient could not articulate without the aid of a bandage, which served to prevent the tongue's protruding and the copious discharge

JONES OPERATION FOR LOSS OF UNDER-LIP.

23

of saliva. This bandage had been worn for several years, and from its continued pressure, served still more to paralyze the muscles upon which it acted. His voice was reduced to an indistinct guttural sound. Food could only be taken over the bandage, and had to be forced back by the finger to the posterior dorsum of the tongue, the latter having partially lost the power of aiding in the art of deglutition. All the teeth in the lower jaw had been destroyed as far back as the second molar. A the subjoined.

drawing from a cast of the original is exhibited in

After the necessary preparatory treatment in the presence of Drs. Peebles and Spencer of our city, I commenced the following operation: It became necessary in the first place to remove the cartilaginous adhe- sion which had formed and which has been described above. An in- cision from left to right was made with the scalpel, including the rem- nant of the lip to the left down to the periosteum. The bone itself was found sound and healthy, judging from the condition of the latter membrane, although the alveolar processes had been absorbed. After removing that portion which seemed devoid of all vitality, the dissec- tion was continued entirely around the chin and clown to the perios- teum, and the operation for hare-lip was performed, all the substance gained from under the chin being previously pushed up. In order to prevent adhesion from taking place to the gum, a small portion of zinc, of proper form, suggested by the shape of the decayed alveola?, and to supply their deficiency, was applied and worn during the whole treatment. Of course there was little or no haemorrhage, as only small branches of the facial artery were divided, which required only a small

24 JONES' OPERATION FOR LOSS OF UNDER-LIP.

twitch of the forceps to arrest the slight flow of blood. The bandage for fractured lower-jaw was then applied, which served to keep the substance under the chin in its desired position. After the operation the patient was comparatively comfortable, and only required an ano- dyne for the night, which was spent quietly. Nourishment was ad- ministered by means of a glass tube through an aperture afforded by the loss of an upper tooth. After the fourth da}* the bandage was re- moved, and the adhesion was already formed, needing only the appli- cation of a narrow strip of adhesive plaster between the sutures, and one below the second suture. The bandage was re-applied. It was ne- cessary to remove it every third or fourth day and adjust the zinc plate, if necessary. Our little patient continued well until about the fourth week, previously to which the adhesion had entirely formed, to all ap- pearances, and the needles had been removed. When about the com- mencement of the fifth week we observed a small dark spot which appeared immediately under the upper suture. In a few days a fever came on, and we began to fear sloughing ; but with close watching, nutritious diet mild tonics, and perfect rest, with an occasional ano- dyne, we began to see our little patient improve ; although the dark spot above alluded to continued to increase, leaving a narrow band between the upper extremities of the lip, and was not arrested until about the eighth week, notwithstanding the above general treatment and the oc- casional cautious application of lunar caustic. I may here add that the bandage was worn for several months, which afforded considerable comfort to the patient. Even at this stage he could speak quite dis- tinctly, and eat with comparative ease. The enlarged glands were greatly improved, and the tongue itself could be protruded with little or no inconvenience. The patient was allowed fresh air and nutritious diet ; and the opening on the lip was protected by a small portion of court plaster. After the expiration of six months from the first ope- ration his health had been entirely restored, and about the eigth month the second operation for hare-lip, employing only one suture, was per- formed, which in less than ten days had healed completely. It be- came necessary to apply a few false teeth upon a well formed artificial plate, corresponding with the deficient alveolae, which gave the lip its former natural appearance. In a few weeks he returned home entirely relieved from this distressing deformity. Drawing No. 2 will give a tolerably good idea of his appearance after the second operation..

BROWNE S ADDRESS.

25

[ We regret to send out such a caricature of the face as the second cut gives, but the lateness of the receipt of the cuts rendered it impossible to have a new one made. We hope an idea, at least, of the cure of the deformity will be given by- it and the description in the context. Editor.]

An Address delivered before the Medical Society of Fredericksburg.

BY WM. BROWNE, M. D., (PRESIDENT OF THE SOCIETY.)

I congratulate you, gentlemen, upon having at last completed the organization of the "Medical Society of Fredericksburg and the ad- joining Counties." I hope in all our proceedings we shall be guided by a spirit of conciliation and forbearance, which alone can render our intercourse agreeable and our action beneficial to ourselves and useful to the profession. We shall be frequently called on to exercise this forbearance in our remarks and criticisms on the reports of cases and professional essays which may be read before the society. But the characters of our members, happily, area satisfactory guaranty, that, in all our discussions, they will exercise a due regard for the feelings of each other, and render this caution superfluous.

On this occasion, it being our first meeting under our present organi- zation, I think it proper to submit a few remarks on one only of the numerous errors which have, for many years, been gradually extend- ing, and which, in this our day, prevail so generally. The error to

26 browne's address.

which I allude is, the strong propensity to catch at and adopt novelties, both in theory and in practice, without allowing sufficient time to test their claims to confidence, by reason and experience.

For the past half century, and especially during the last twenty years, revolution and progress have been stamped on every depart- ment and occupation of life. Even in the fixed sciences, the novel application of old and well-established principles has produced re- sults truly marvellous' and astounding. The general introduction of steam as a locomotive power has brought the inhabitants of our widely- extended country almost within the bounds of social intercourse, and by means of electricity we carry on friendly and business conversations, if such intercourse can properly be so called, with individuals thou- sands of miles from us. Schemes are also in progress, and will, in all likelihood, be ultimately accomplished, to bring the whole of Europe within conversational distance of us ; and it may be that some of the present generation may live to interchange greetings with their friends in England, France, Holland, German}^ and probably even in Rus- sia, in the space of a few short hours.

Mutation and progress are also stamped on our profession, and it re- quires vigilant care and close application to study to keep pace with their rapid strides. Our profession, however, is not a fixed science, and there are but few principles belonging to it that can be considered as determined. Progress and change here, then, must be carefully watched, that they lead us not into error. Our profession deals with the lives of our fellow- men, and our errors lead to death. Let us be careful, therefore, to avoid being led astray by the specious represen- tations and unsound deductions of over-sanguine members of our pro- fession, which too often come from men of high professional reputation, and which are scattered throughout the world in medical periodicals. There is a strong tendency in the present day, in all classes of societyr, to catch at novelty, and to build up ingenious theories and s}7stems, on the foundation of a few isolated facts, and these by no means satisfactorily substantiated, but, in truth, too often assumed. Our profession is by no means exempt from this prevailing bias. From this source has arisen homeopathy, frydropathy, Thompsonianism and other kindred medical fictions, which have obtained many proselytes, even from the ranks of the profession, and which are yet extensively engaged in the work of death, not only abroad, but throughout our own country ; and not onl} has it given rise to systems professing to be based on pathological data, but it has resuscitated from the ruins of Iry-gone superstitions, the miracles of monkish charms and relics, Prince Hohenlohe's prayers, Mesmer's hallucinations, and many others equally repugnant to reason and to sound sense. At a more recent date the semblance of deadi has been paraded on the stage, and ether and chloroform, the agents in this counterfeit representation of the extinction of vitality, have been hailed as among the choicest gifts from Heaven, which were, if not to deprive disease of its mortality, at least to procure exemption from all physical suffering, and to wreath in smiles the countenance of the most timid and delicate during the painful throes of parturition, and, what have heretofore been considered the agonies of the gravest surgical

browne's address. 27

operations, the very sight of which would cause the stoutest heart to tremble. That many have passed through this seeming death, with apparent impunity, we have abundant evidence, and I trust reliable, to shew ; that many, or indeed any, have been saved from real death, we have yet to learn. Sufficient time has not yet elapsed to enable us to learn whether dormant predispositions may not, in many instances, have been excited into life and vigor, which might have remained in- active for many years, if not for life, by the direct application of these potent agents to organs so important to life as the lungs. The evidence which has heretofore come to us has been, mostly, from the side of anaesthesia; an occasional lamentation, however, reaches us from the opposite quarter ; and late developments on the other side of the At- lantic are well calculated to excite alarm. The victims of this humane effort to mitigate suffering, have of late sadly increased, and the Lon- don Medical Gazette of the 7th of September 1S49, in a review of some treatises on anaesthesia in child-birth, closes with the following language, conveying a most solemn warning to all who use these agents to relieve the sufferings of labor :

" The trial has been made ; the claims of chloroform and ether, as employed in midwifery, have been tested. The result has been, that the little advantage gained by the many, and the great detriment sus- tained by the few, fully confirm the statements made by Mr. Gream and others, as to the dangers attending the use of these agents — at the same time justifying and strengthening the voice of alarm; so that it is now almost as rare an occurrence to meet with an obstetric practi- tioner in London, who would venture to chloroformise a patient in la- bor, as it was common, a few months ago, to meet with those who were daily making trial of this new charm for the relief of suffering. After the perusal of Mr. G ream's pamphlet, now before us, we feel that they in whose hands the experiment has not resulted in sincere, but unavailing regrets, have much cause to be thankful."

We have yet much to learn in relation to these important agents, before a correct opinion can be formed, either of the benefits or inju- ries which are likely to result from their use ; but the eagerness with which they were seized on, the extent to which their use has been carried, and the re-action which is already, to some extent, taking place, in regard to their introduction to general use, from the increased num- ber of fatal results, clearly point out the propriety of great caution in adopting novelties, and the necessity of carefully testing them before we give credence to the merits which their authors claim for them.

The number of specifics introduced into practice of late years, b}*- medical men of distinguished stations — the facility with which they have been adopted, and the rapidity with which they have passed out of notice, have their origin in the same source; and it is mortifying to see the members of a profession, who claim pre-eminence on account of liberal education and careful mental culture, so often led into this prevailing error, when they have been so often misled and disap- pointed. But a few years since a gentleman who occupied a. high rank in the profession, and who was physician to one of the most extensive hospitals in London, proclaimed, as the results of his own personal

28 beowne's address.

experience, that bi-carbonate of iron, in one or two drachm doses, amounted to a specific, almost, in tic doloroux. The same gentleman, about the same period, or perhaps a few years before, trumpeted fbtth kreosole as an infallible remedy in diabetes — one of the most fatal ma- ladies it has ever been my misfortune to treat. We all know with what avidity these remedies were adopted by many physicians in this country, particularly the first, as fortunately there occur more of those diseases in which iron was to prove specific, and how many feeble and delicate stomachs were crammed to overflowing with this earthy drug, luckily comparatively inert; and what has become of the anti- cipations so fondly cherished, that weapons were supplied to our hands, to disarm of their suffering and mortality, two at least of the enemies of our health, our comfort and our life? They have vanished into thin air, with the thousands which have preceded them; and, what is to be deplored, on account of distinguished talents, though sadly misapplied, their originator, still in search of some universal panacea, has wrecked his fame and reputation on the shoals of " Nickel and Mesmerism," and has become an exhibitor of the wonders of animal magnetism to the gaping nobles of England's metropolis in this the 1 9th century! How can we be surprised that individuals, uninstructed in our profession, and totally ignorant of our physical organization and of the functions and relative importance of the various and complicated organs of the human body, should seize with avidity on any of the nostrums, which in countless thousands are spread before them in newspapers, pam- phlets and almanacs, promising relief to "all the ills that flesh is heir to," and in too many instances recommended to public confidence by certificates from ministers of the Gospel, who "know not what they do" — and which, for the sake of suffering humanity, is deeply to be regretted — when members of the profession have so often been led to adopt medical prescriptions and plans of treatment in cases seriously involving life, on representations devoid of the necessary foundation to inspire judicious confidence? " Fashion in physic," has long been a reproach to the profession, from which, I regret to say, it is by no means exempt even at this day. How long it will remain so, must de- pend on the intelligence, the independence and honesty of its members. Nothing has a stronger tendency to increase and perpetuate such evils, as the introduction into the profession of young men of naturally sprightly talents, but of limited education, of little reading, and, of course, of defective judgment. Incapable of comprehending the che- mical changes which may take place from the introduction of incon- gruous materials into their prescriptions — unacquainted with the exten- sive and complex sympathies which exist between the various organs of the body, and the influence which remedies applied to one part, exercise through this medium on parts far removed from it, it is not to be wondered at that they should readily adopt remedies and modes of practice introduced to public notice by specious representations of their efficacy, and sustained by certificates of men of standing and reputation, but more ignorant of such matters even than themselves, and recommend and prescribe them with a confidence well calculated to beget a corresponding confidence in those to whom they are thus

JOHNSON S CASE OF TETANUS. 29

recommended. Among such persons we often find individuals pos- sessed of considerable astuteness, who know well the necessity, and practice it too with no little success, of supplying, by address and a confident manner, the defects of education and the want of knowledge. It is to be lamented too, that the public is more gullible on medical subjects than on any others, and too often invites the deceptions that are practised on it.

The formation of the " National Medical Association," with its va- rious ramifications extending throughout our country, by procuring a freer and fuller interchange of views, and bringing medical theories and facts to the test of close and strict examination and professional criticism, promises to do much towards ridding our profession of many of the evils and errors which encumber it. Its recommendations also to our public schools to raise the standard of medical education, which I am glad to see, has been favorably responded to by some of our leading institutions, will bring to its aid a most important adjunct in sustaining and forwarding the cause of humanity.

I have thus briefly alluded to this tendency to delusion in our pro- fession as a caution to all of us, against yielding a too ready credence to new systems, new theories and novel facts, and to the adoption of new remedies, more especially if in undue quantities they act as poi- sons, without a strict and critical examination of the foundation upon which their claims to confidence rest.

It is also highly important to avoid the opposite error, skepticism, which is equally, if not in a higher degree, injurious to the character and usefulness of our profession. In our search for what is true and useful, it would be well if both extremes could be avoided.

Proceedings of the Medical Society of Virginia — November Meeting 1850.

The society was called to order by Dr. R. W. Haxall, (president,) a large number of members and several visitors being present. After the disposal of some matters of business, there were presented letters of application for membership from several gentlemen, who were duly nominated. The subject of discussion for the evening, " Tetanus," was then called up by Dr. Carter P. Johnson, who said :

In presenting the report of the following case to the society, I would remark, that tetanus, as well as other spasmodic diseases, assumes a higher degree of interest at this time, in consequence of the investi- gations at present in progress in regard to the functions of the nervous system.

All writers agree in assigning the spinal marrow as the seat of tetanus ; or rather, in ascribing !o that portion of the nervous centres the emanation of the influence which is directly concerned in pro- ducing the spasmodic muscular aclion. The solution, therefore, of the iiutliology of this disease, must depend upon the proper compre- hension of the physiology of the spinal marrow.

Besides the mere office of conducting impressions and influences to

30 Johnson's case of tetanus.

and from the brain, the spinal marrow possesses the power of appre- ciating impressions conveyed to its grey matter, and of generating in- fluences which are conveyed from it by its exodic nerves, as was first proved by Procharca, and afterwards elaborately demonstrated by Marshall Hall.

When in its normal state, an impression conveyed to the spinal marrow by an exodic nerve, causes an influence to be generated which is reflected back merely through the corresponding exodic nerve, pro- ducing a motion in the muscle to which that nerve is distributed ; but if the natural excitability of the spinal marrow be exalted, the same impression conveyed to it will be responded to by a considerable por- tion of the organ, and will be reflected back by a large number of exodic nerves, producing a corresponding muscular contraction. Now if, when the excitability of the spinal marrow is thus exalted, }-ou have, at some peripheral portion of the body, a permanent source of irritation, such as a wound (particularly if in a state of high inflamma- tion) would afford, you will have, through the exodic nerve proceeding from this point, a constant series of impressions conveyed to the spinal marrow, and consequently a constant series of reflex influences con- veyed through the exodic nerves to the peripheral muscles, producing a constant state of spasm — or, in other words, tetanus.

Such I conceive to be the pathology of this disease, in whatever form it may present itself. Writers divide it into traumatic and idio- pathic ; but I am inclined to think, that if we could analyse strictly every case of idiopathic tetanus, so called, we should find its patho- logy to correspond with that of the traumatic variety, both being re- solved by the principles which I have just endeavored to explain. In every case of tetanus, I believe that you will, find an exalted condition of the function of the spinal marrow and a local point of irritation, be that point in the spinal marrow itself, or, as it most usually is, at some peri- pheral portion of the body.

These views are borne out by the case I am about to report. It would ordinarily be laid down as a case of idiopathic tetanus ; but that there was in this case a local point of irritation, I think is highly probable from its history, and that that point was the uterus, which had but the week before been the seat of a process well calculated to produce serious inflammatory action, I can scarcely doubt ; and if so, in what respect would this case differ from a case of ordinary trauma- tic tetanus.

On Sunday, September 15th, I was called, in consultation with Dr.

Wm. A. Patteson, to see Mrs. , of whose case I obtained from

Dr. Haxall, the attending physician, the following histoiy :

Mrs. is about 27 years of age ; has been married nine years,

and has borne four children. Her general health has been very good.

On Tuesda}T, 3d September, being about six weeks advanced in pregnancy, she experienced some pain in the loins, which was soon followed by haemorrhage. The occurrence of these symptoms she at- tributed to fright. During the day, Dr. Haxall saw her, but was not permitted to make an examination. Ordered acetate lead and opium, external application of cold — strict rest.

Johnson's case of tetanus. 31

Wednesday j 4. Haemorrhage continuing, an examination was in- sisted on, which disclosed the placenta presenting itself at os tineas, which was slightly dilated. Tampon was applied, strict rest enjoined, and all other remedies discontinued. No haemorrhage occurred after the application of the tampon.

Thursday, 5. Tampon being removed, a portion of the placenta came away. No additional haemorrhage. Tampon re-applied.

Friday, 6. Remainder of the foetal mass came away to-day, unac- companied by any haemorrhage. Tampon was discontinued. At this time her pulse wras good, her appetite good, and she made no complaint.

Saturday, 7. Found her sitting up in bed sewing. Enjoined entire rest.

Sunday and Monday she remained in bed, but appeared quite well.

On Tuesday, 10th, Dr. Haxall left home, and Dr. Patteson saw her ; she was then sitting up and appeared quite well. On that day, after the doctor's visit, she engaged in a romp with one of her friends, and afterwards sat by an open window for some time. On that night (or the next?) she also sat by an open window, watching a fire that was in progress in the immediate neighborhood.

On Wednesday, 11th, she experienced some slight stiffness of the jaws, which continued with a slight increase up to Saturday, when her husband consulted Dr. Patteson. On Sunday, Dr. Patteson saw her about 3 o'clock, when he ordered her calomel and Dover's powders, aa grs. x. At 7 o'clock on Sunday evening, I visited her with Dr. P.

When I saw her, the case presented the following symptoms : The patient lay on her back with the head drawn slightly backwards and resting on the occiput ; the muscles of the back of the neck were in a state of tension, though not excessive; the jaws were closed .quite firmly, the patient not being able to open them more than ^ inch ; the masseter muscle was firmly contracted, and its fibres could be felt hard and resisting as when the teeth are strongly closed by a volun- tary effort. There was considerable difficulty in swallowing, every attempt to do so being accompanied with pain and an increase in the tension of the muscles. She complained of severe pain just below the sternum, passing through to the right shoulder, doubtless caused by spasmodic action of the diaphragm. Her pulse was soft, com- pressive and more frequent than usual, probably 95. Her skin was relaxed and covered with slight perspiration, and she was suffering somewhat from nausea, caused probably by the Dover's powder wrhich had been administered.

She was directed to take Hoffman's anodyne 3j, black drop gtts xx., every three hours, and to inhale sulphuric ether, which Dr. Patte- son had already exhibited, through the night, "pro re nata;" and in the morning to take a tablespoonful of castor oil.

September 16th, 9 o'clock, A. M. Pins taken two doses of the ano- dyne and repeatedly inhaled the ether. During the morning has dozed a good deal. Did not take the oil until a few minutes before our visit. Her condition very similar to that of last night ; complains very much of the spasm of the diaphragm. Directed to continue the use of ether, to take a teaspoonful of oil in three hours; and if the bowels

32 Johnson's case of tetanus.

were not then opened, to have a stimulating enema. Dr. Patteson visited her at 3 o'clock, and finding that only the lower bowels had been evacuated, directed Croton oil, gtt ij, in mucilage, to be repeated in two hoars if it did not operate.

At 6 o'clock, P. M., we visited her together, and found that the bowels had just been fully evacuated, the passage not being very offensive, and presenting a healthy and natural appearance. She was more quiet, complained less of the diaphragmatic pain, and seemed to swallow with more ease. During our visit, a tendency to tetanic spasm coming on, it was speedily controlled by the exhibition of the ether, under the influence of which she became composed and relaxed. With the view of favoring the purgative action of the oil, she was directed simply to continue the use of the ether, and only to resort to the anodyne in case of excessive purgation or great tetanic action.

September 17. We were summoned about 7 o'clock this morning to see the patient, a tendency to syncope having occurred upon raising her in bed. We found her with a very pallid countenance, increased tension of the elevator muscles of the lower jaw, and increased tend- ency to spasm of the muscles of the back of the neck ; the pulse more feeble, though not indicating great prostration. She had passed a tolera- bly quiet night, inhaling the ether frequently, and being always relieved by it. She had had two more evacuations of the bowels. She com- plained more of the diaphragmatic pain than last night. She was direct- ed assafcetida 3 ij., opium grs. xvi., water 1 iv., an ounce of which to be thrown into the rectum every two hours ; also a blister to be applied over the spine three inches wide, from the nape of the neck to the dorsal region. Beef tea ordered for nourishment, and occasionally a little toddy. We saw her again at 3 o'clock ; two clysters had been administered, the blister applied and some of the beef tea taken. She had continued to use the ether. There was an abatement in the spasm of the muscles, and she had been much more quiet and com- posed. At 6 o'clock, P. M. — Still farther improvement ; she can sepa- rate the jaws sufficiently to admit the index finger; complains of no pain; pulse more full, and countenance less pallid and more natural. During the day the parts over the affected muscles were constantly anointed with an ointment of aconite. Directed to dress the blister with stramonium leaves, and to continue the above remedies "pro re nata. "

September 18. Passed a comfortable night ; rigidity of muscles about the same as last night ; complains of no pain ; pulse a little ex- cited and skin a little warmer than natural. Directed to use ether less freely ; to take beef tea and the assafcetida enema if necessary. At 3 o'clock had not taken the enema. Ordered her a cathartic ene- ma, which was given, and followed by free evacuation of the bowels. At 6 o'clock, P. M., found her very restless ; the spasms increased; constant tendency to throw the head backwards and some slight ten- dency to opisthotonos ; complains again of diaphragmatic pains. Ordered 25 droits of black drop in a teaspoonful of Hoffman's anodyne, immedi- ately to be followed by the anti-spasmodic enema; these to be admi- nistered through the night "p-o re nata; " the ether to be used freely.

TRANSACTIONS OF MEDICAL SOCIETY OF VIRGINIA. 33

We left her about half an hour after the administration of the first dose of the anodyne, sleeping quietly.

September 19. Passed rather an uncomfortable night, sleeping but little. Took three doses of black drop and Hoffman's anodyne and several enemata. The spasms are persistent to-day ; condition very much as last night. Directed her to take 50 drops of black drop every two hours, to use the enemata, and to drink milk toddy and julep. At 2 o'clock she was more calm, and had passed a more quiet morning. Ordered her croton oil, two drops every two hours, until the bowels were evacuated, and a solution of extract Indian hemp in 1 gr. doses every two hours. At 6 o'clock, found her more feeble, her respiration much more difficult and wheezing. Her voice was al- tered, indicating an evident contraction of the "rima gloltidis." Her pulse was feeble and countenance pallid.

From this time she continued to grow worse, the respiration be- coming more and more laborious, until about 10£ o'clock, when she expired, apparently from asphyxia.

In reply to questions asked by several members, Dr. J. stated that the ether was administered constantly and sometimes until complete anaesthesia was produced. It was taken with much avidity, and greatly relieved the agony of the patient, but did not relax the spasms.

Dr. Snead entirely concurred in the opinion which had been ex- pressed by Dr. J., and believed there was no such thing as idiopathic tetanus ; that there must always be irritation, if not a wound, found in some part of the body, from which the impressions giving rise to teta- nus emanated. • In this case he thought it was unfortunate that the womb was not examined.

Dr. Johnson replied, that it was determined in consultation that no good could result from such an examination, and it was therefore not made. He did not, however, defend the opinion.

Dr. Gibson believed, notwithstanding the opinion wThich had been expressed by other gentlemen, that there was such a thing as idiopathic tetanus, and proceeded to draw the distinction between the two forms, calling those traumatic which could be traced to a wound as the ex- citing cause, and all others idiopathic. The case under consideration he thought was traumatic, the womb being the seat of the injury.

Dr. Cunningham remarked, that it had been his lot to see thirteen cases of this formidable disease, and that he also believed in the ex- istence of pure idiopathic tetanus. In two of his cases there was no wound whatever. The first was a very formidable one, attended with as violent symptoms as any case of traumatic tetanus. It occurred in a child, and was produced, he believed, by worms. The other oc- curred in the person of a laborer in a rolling mill, who slept in a cold place after being heated and fatigued. He suffered violently with te- tanus three or four weeks. In this case he used the most active pur- gation, with calomel, croton and castor oils. The patient recovered.

Dr. Johnson said he had been misunderstood. If the absence of a wound was sufficient to establish idiopathic tetanus, then he be- lieved in it, and these were cases ; but, according to the position he had 3

34 TRANSACTIONS OF MEDICAL SOCIETY OF VIRGINIA.

taken, mere irritation of any part transmitted to the spinal marrow, and finding it with an exalted excitability, might produce tetanus. In Dr. Cunningham's cases, intestinal worms produced the irritation in the one, and the effect of cold in the other.

Dr. Cunning-ham replied to an enquiry, that both of the cases were attended with opisthotonos. He then said, that although the pathologi- cal difference, based upon their exciting cause, was not clearly defined, a practical difference between the two forms seemed important, inso- much as idiopathic (or the chronic tetanus of writers) was less danger- ous than the traumatic or acute.

Dr. Brockenbrough remarked, that in 1842 the county of West- moreland was visited by a great many northeasters, and he de- tailed two or three cases of this disease produced by them, which terminated fatally. He regarded them as cases of idiopathic tetanus.

Dr. Scott preferred to read what he had to say on this subject, whereupon he proceeded to read a paper, which will be found on file. In it he commented upon the views of several authors — Wood and Watson among them — and thought them rather vague, teaching but little whereon we could build any rational treatment. He preferred to adopt the conclusions of Marshall Hall, as they were based upon experiments which he thought satisfactorily proved this to be a disease of the excito-motory system. The terms centric and eccentric he thought much better to express the different forms of the disease, as they were much more definite than idiopathic and traumatic. He referred to Trousseaus' account of the effects of strychnine, and said that he be- lieved in tetanus the same organs were not only affected, but they were in the same condition as when under the influence of strychnine. He attributed the occurrence of sleep in the disease, to an exhaustion of the superabundant nervous excitability. Patients sleep because spasm has relaxed, not that sleep relaxes spasm. During rest, time is given for accumulating a new supply of excitability, and spasms again follow. As to the treatment, Dr. S. had nothing to say, having seen only two cases : they were treated with assafoetida and opium, and, he supposed, calomel — both patients died.

Dr. Gooch said he would respond to the call made by the able re- porter this evening, on members, to detail their experience. He had seen a good many cases in this country and in Europe, but was sorry he had not made better notes of them. He had seen cases which he considered idiopathic, according to the accustomed signification of that term, being attended with no traceable injury, inflammation or irrita- tion. He preferred the terms centric and eccentric, and thought it pro- bable there was no centric tetanus : the so-called cases were epileptoid disease. He referred to Dr. Johnson's case, and said he should have deemed an uterine examination necessary. In regard to the tobacco enemeta, he should not have used them, as Dr. Johnson had said, be- cause the tendency of the case was downward, and the patient very feeble — moreover the bowels were opened well. He considered to- bacco in nine cases in ten an invaluable agent. It is directly a ner- vous sedative, and indirectly so, by proving an efficient laxative, ridding the bowels of their irritating load. It was freely used in British prac-

TRANSACTIONS OP MEDICAL SOCIETY OF VIRGINIA. 35

tice. Etherization is a great boon to the poor tetanic. But this was only an adjuvant means. He considered the treatment in the case be- fore us, like it most generally is — not curative, but merely •palliative. We should be searching now for some remedy, and no longer relying upon soothing and palliating the most severe symptoms. In this case he thought it exceedingly probable that quinine, in full doses and often repeated, might have saved the patient. We agree that it is a sedative, besides being a fine tonic. In addition to this theory we have evidence in its favor. The case reported to the society last year, by Dr. T. S. G arnett of Westmoreland, has two bearings on this discussion : Firstly, it was one of terrible character, with no traceable cause, (an idiopathic case,) resisting the whole list of remedies most energetically applied ; and, secondly, it yielded to a treatment with quinine and alcohol, adopted when the case was of forlorn hope.

Dr. Scott asked how quinine could be both a sedative and a tonic ; and if it was, he did not see the object in giving it for this double effect.

Dr. Gooch said, that if the sedative was the principle of cure, (and he believed it was,) he should think quinine a powerful and use- ful drug; and if the spasms could be broken in upon, he should assur- edly use a tonic , and should rather use this anti-periodic, in hopes that it would prevent the recurrence of them. He would answer the other part of the query, by asking another : How is the cold douche both a sedative and a tonic in mania potu?

Dr. Haskins said he believed the correct pathology had been stated ; that tetanus was a disease affecting especially that portion of the nervous system concerned in the performance of the reflex func- tions, and consisted in a morbid increase or exaltation of its excita- bility. This no one had denied. Now, assuming this to be the cor- rect pathology, he did not believe the mode of treatment adopted by ourselves, and recommended by the highest authorities, was the true or philosophical one. The remedies used in the case reported, ether, opium, alcohol in some form, and a few other nervous stimulants, make up our list. What principle, he asked, would indicate the propriety of stimulating a nervous system already in a state of hyper-excite- ment? This plan of treatment may be defended, perhaps, upon a principle alluded to by Dr. Gooch. He has said quinine was a stimulant in small doses, and a sedative in large ones ; and we all agree with him. In this admission, however, I do not conceive that any objection to the use of such articles is removed. This phenome- non is in accordance with a well known law of the animal economy, ■ " that undue action is followed by subsequent depression." They cause an expenditure and exhaustion of the super-excitabilit}^ and temporary sedation is produced. This whole class of medicines are, nevertheless, nervous stimulants, though, secondarily, they may be seda- tives. If these remedies operated principally upon that portion of the nervous system involved in the disease, I confess that my diffi- culty would be in a measure removed. But opium, alcohol, &c. act first upon the brain. Ether illustrates it well. Labor throes, respi- ration, &c. go on uninterruptedly, while the patient is in a state of

36 TRANSACTIONS OF MEDICAL SOCIETY OF VIRGINIA.

anaesthesia. There is a complete depression of the sensorium at the same time. It then seems to me that all we gain by the use of such articles is the production of insensibility to the pain of the spasms. If, however, it be a correct principle of treatment when we wish to produce sedation in any organ, to do so by stimulating it until we have exhausted its excitabilit}T, would it not be much more plausible to use in this disease strychnine, which we know to act directly upon the excito-motory system ? Would not large doses of strychnine pro- duce the opposite effect of small ones? — the desirable effect. Dr. H. appealed to Dr. Gibson, as a lecturer upon surgery, and one whose province it had been to investigate especially this disease, for his opinion as to the existence of centric tetanus, discarding the old and indefinite terms, traumatic and idiopathic.

Dr. Gibson was not prepared to say that there were cases of more centric tetanus than those arising from effusion, pressure on spinal marrow, &c. He differed with Dr. H, and did see great good arising from the use of opium. Patients die of exhaustion, or of asphyxia ; and, as opium gave rest, he thought it very valuable. He highly approved the treatment of the case, notwithstanding the stric- tures of Dr. H,

Dr. Johnson said he believed Dr. Haskins' theory and explana- tion of the different effects by different sized doses to be correct. But why not suppose that these remedies act on the spinal marrow di- rectly, as well as on the brain? Is it probable that we only reach this system with them, going round by way of the brain ? We re- lieve colic by venesection and opium. Is it not by direct action on the spine, which furnishes the nervous influence giving rise to the con- tractions ?

Dr. Cunningham said we do not act upon the principles of mo- dern pathology : as a London doctor remarked, " It would ruin the practice of physic." In reply to Dr. Haskins, he would ask, why give stimulants through the brain in hysteria or delirium tremens, where we know the nervous system to be in a state of hyper-exalta- tion. We act with the means which we possess, because we know their effects, not because we know how they act.

Dr. Haskins replied, that if his strictures upon the treatment of tetanus had been thought to apply to the case under consideration, he had been misunderstood. So far from disapproving the treatment practised by Dr. Johnson, it was what he should have felt himself bound to have done under similar circumstances. But we were here now in the medical society, and should discuss philosophically the principles of treatment indicated by pathology, regardless of the ab- surdities into which we may be led. Dr. Cunningham has referred to the success of nervous stimulants in the treatment of hysteria and mania potu as an argument why they should be used in tetanus. Now, as regards the former of these diseases, though involving principally the same nervous system, we know its form to be entirely different from tetanus, and rarely ever proving fatal — indeed ceasing of itself after a short time, whether medicines have been administered or not. Is it then fair to conclude, that in all cases where medicines have been

TRANSACTIONS OF MEDICAL SOCIETY OF VIRGINIA. 37

administered, that they have arrested the paroxysm ? As to mania potu it does not generally depend upon excitement of the nervous system, but on the contrary, is due to the absence of an accustomed stimulus. We can therefore readily see why it should be relieved by stimulation. But the Doctor apprehends that our modern pathology " will ruin the practice of physic." Now he himself has stated that he never saw a case of traumatic tetanus recover under the present practice ; and this is but the concurrent testimony of all the members of the society, as well as all authors who have written upon the dis- ease. It has also been shewn this evening, from statistical tables, prepared by Curling, that of 128 cases, (including every variety of the disease,) only 56 have recovered. I for one, sir, do not feel that we shall sustain any great loss, even though our modern pathology does ruin such practice as this.

Dr. Maupin made some remarks upon the general principles of the disease and of sympathy, and said we must fix our disease and its laws by reasoning, and then by experience build a system of treat- ment.

Dr. Snead said he wished to be understood as one of those who believe idiopathic tetanus had not been established.

Dr. Bolton had seen two cases recently. One supervened on an abscess and erysipelas of arm, and was fatal. He used chloroform in it, and with marked advantage.

Dr. Parker remarked that one of the cases referred to by Dr. Bolton was his — traumatic and fatal. He should always use chlo- roform, having seen its great benefit. He had seen an infant aged 13 days, die with congenital tetanus.

Dr. Terrill, of Hanover, had used tobacco enemata until com- pelled to desist, together with the usual recorded treatment, in a case of traumatic tetanus, but his patient died.

The subject was then informally laid over.

Dr. Bolton exhibited a flannel bag of unbroken flies, which he said was given him by a patient from the country, and had been used for 17 years to blister. She said, by moistening one side with warm vinegar and applying to the surface, it would draw in an hour. An additional advantage which this acetate of cantharidin possessed, was, that it was not so apt to produce strangury.

December Meeting.

After the election of several members and the transaction of some business, Dr. Merritt read an elaborate essay on "congestive fever." As the author of this paper has had great experience in this, one of the most serious diseases of the South, and as we think his views of its pathology and the correct treatment are good, we will publish the main points in our next Number.

38 COLLODION IN ERYSIPELAS.

Collodion — Its Use after Leeching and in Erysipelas.

Like most other American inventions, whether of great or of little importance, this article has been claimed by our trans-atlantic friends. A paragraph passed around the American papers stating that this liquid adhesive plaisterhad been invented by a French chemist — pro- bably a Mons. Alexandre. This is not so ; and, though of no great mo- ment, yet " to render unto Caesar that which is Caesar's," is but just and proper, and I take pleasure in stating that it was first made in Paris by a young American from Boston — I believe, a Mr. Maynard. Charriere, the great instrument maker in Paris, applied it, the day after it was first made, to my hand to cover the wound made by Mr. Alexandre's artificial leech which we were trying — Mons. Charriere applied it, saying that it was a neat preparation made and given to him for trial by our countryman, Mr. Maynard.

It is an exceedingly useful substance, and has been applied to all sorts of uses in the arts and sciences.

A short time since I had occasion to apply a dozen leeches to an infant of only a few months' age. I was called an hour or two after the operation to stop the bleeding, (which had been twice arrested by cold cloths and pressures, but only for a time.) Other means failing, I poured thick collodion over the bites, previously pressing the surface with a dry towel, and in a few minutes I left my little patient perfectly secure from any recurrence of haemorrhage. We know that children have bled to death from leech bites, and they are sources of no ordi- nary trouble frequently. This preparation is a convenient, comfortable and certain application, and should be always at hand. It is better to apply a thick collodion, so that it may be dried and adherent before any blood can accumulate under it. It seems to be a temporary styptic, and the bleeding is arrested long enough for it to dry, when it is prevented. It usually peels off in from two to five days, and is a source of no inconvenience whatever.

It is reported in the " Lancet" to have been used, with great suc- cess, by Mr. Luke, of the London hospital, in the treatment of ery- sipelas. He says, "it would appear that collodion fulfils two import- ant indications ; it protects the inflamed surface from the contact of the air, and it contributes, by the pressure it effects, in driving the blood from the distended capillaries." G — .

We believe that the treatment recommended below for scarlet fever has not had as fair a trial as the high standing of its author would de- mand for it. Though Dr. Lindsly's letter is not very recent, we deem the subject one of much practical interest, and give it in full.— Ed. To the Editor of the Boston Medical Journal.

Washington, April 11, 1850.

Sir : As everything relating to the treatment of scarlet fever, a disease almost as fatal and destructive as cholera itself, is of great in-

INUNCTION IN SCARLET FEVER. 39

terest to the profession and the public, I desire to call the attention of your readers to the mode of treatment recommended by Dr. Schnee- mann, physician to the king of Hanover, as contained in a recent num- ber of the London Lancet. The plan proposed by Dr. S. has not re- ceived the attention from the medical profession in this country or in England, so far as my knowledge extends, that its importance de- mands. My experience with it is now considerable, and I think I can safely recommend it as a very valuable addition to our means of con- ducting this dreaded disease to a satisfactory termination. It is phi- losophical and rational in theory — simple and efficient in practice.

Its modus operandi will be seen at a glance, and will commend itself to every discriminating physician ; for every one, I think, will admit that the chief weight of this disease falls upon the skin ; and of course whatever tends to restore the deranged functions of this im- portant part of the body will contribute most materially to alleviate all the symptoms. The employment of this remedy of course will not prevent the use of such other means as experience sanctions, and each particular case calls for, as laxatives, febrifuges, application to the throat, internal and external, &c.

I hope a fair trial will be given to this mode of treatment by the profession, and the results made known through the journals, that its true value may be definitely ascertained. I subjoin the most impor- tant directions given by Dr. Schneemann, in a somewhat abbreviated form.

HARVEY LINDSLY, M. D.

Treatment of Scarlet Fever ly Inunction.- — From the first day of the illness, and as soon as we are certain of its nature, the patient must be rubbed morning and evening over ihe whole body with a piece of bacon, in such a manner that, with the exception of the head, a co- vering of fat is everywhere applied. In order to make this rubbing in somewhat easier, it is best to take a piece of bacon the size of the hand, choosing a part still armed with the rind, that we may have a firm grasp. On the soft side of this piece slits are to be made, in or- der to allow the oozing out of the fat. The rubbing must be tho- roughly performed, and not too quickly, in order that the skin may be regularly saturated with the fat. The beneficial results of this appli- cation are soon obvious. With a rapidity bordering on magic, all, even the most painful symptoms of the disease are allayed ; quiet, sleep, good humor, appetite return, and there remains only the im- patience to quit the sick room.

The advantages of the treatment indicated may be summed up as follows :

1. The improbability, we might almost say the impossibility, of the patient getting cold while the skin is thus covered with fat, a point in no disease more important than here.

2. The dry brittleness of the skin and the tormenting itching are by it not only materially alleviated, but generally entirely removed.

40 SPECULUM IN UTERINE DISEASES.

Every practitioner knows how often the itching and burning of the skin in scarlet fever are unendurable to children, keeping them con- stantly in distressing movements, and robbing them of sleep. Hence children are generally well satisfied with this process, and often ask for its repetition long before the time is come.

3. The influence on the physiological functions of the skin is still more important. Daring the coming on of scarlet fever the skin be- comes diseased, in consequence of which it loses its vital power. During this illness, and until a new covering is again prepared for the surface, the functions of the skin are very imperfectly performed, or during the desquamation probably not at all. In order to explain the extent and importance of the imperceptible functions of the skin in a merely mechanical view of the matter, the reader is referred to the accurate experiments of Seguin, which fix the quantity of matter thrown off from the outer skin at eleven grains per minute in a grown person, therefore more than two pounds per day. What efforts must it cost the organism to lead so large a quantity into other paths, in order to throw it off, when the skin is incapable of doing so !

4. With this disappearance of the desquamation disappear all those bad symptoms which attend on it. In order to give a striking proof of the importance and bad influence which the interrupted functions of the skin produce on the healthy activity of relative, even if dis- tant, organs, we may cite the fact that death is always the result where more than one-half of the skin has been destroyed by fire or boiling liquid. A similar destruction of the skin ensues in scarlet fever, with this difference — it takes place gradually, and thereby the organism is better enabled, by employing all the activity of the body, to find aid against the mischief which must result from the cessation of the func- tions of the skin.

The Speculum in Uterine Diseases.

At one of the meetings of the Royal Medical and Chirurgical Soci- ety of London, the distinguished obstetrician, Dr. Robert Lee, read a paper on the use of the speculum in the treatment of uterine diseases. Quite a bitter warfare has since been going on between the friends and opponents of the instrument, among whom are many of the most eminent English physicians. It seems very strange that such diversi- ty of opinion and observation should exist as to the real condition of the membrane about the os and cervix uteri. Some insist that there is never any ulceration, abrasion, &c, unless of specific character, and Dr. Ash well is one of these. That author has said " that the use of the speculum has almost become a professional dishonor, and that the necessity of employing it as frequently as it is now employed by respectable practitioners, would compel him to retire from the practice of diseases of women." In commenting upon the views of

SPECULUM IN UTERINE DISEASES. 41

Dr. Ashwell, and his " unguarded expression," Dr. Tilt, a gentleman who has lately put out a work on " the diseases of menstruation" which will elevate him to the highest rank as an author, very tersely remarks:

"I can easily understand that a noble nature should aspire after a better world, where there may be no distinction of sexes, and where no obstetric physician will be required to meddle with delicate organs. But as long as there are bond fide women in this sublunary sphere, those organs which constitute them women must be assisted in their functions and ministered to in their diseases, and unless the medical attendant is himself indelicate minded, there is, as Dr. Locock tersely remarked, no more indelicacy in doing so than in curing a sore throat by cauterizing the tonsils."

The reader is referred to the Lancet for the very interesting debate and communications on the subject, but as we think the following let- ter as applicable here as in England, if not much more so, we give it.

" To the Editor of The Lancet.

" Sir — If you will allow me space, I would offer a few remarks on the use of the so much abused speculum uteri. I have for some time adopted it in my practice, and have found it so valuable an aid to diagnosis and treatment, that I consider its use in uterine disease as indispensable as is the stethoscope in affections of the chest. In proof of this assertion, I would cite the following case, which re- markably illustrates not only its utility, but its necessity. I was consulted, about four months since, by a married lady, who presented symptoms of uterine disease, and on stating this to be my decided opinion, I was requested by her mother at once to ascertain the fact. On examining with the finger per vaginam, the labia uteri presented that velvety feel described by Dr. H. Bennet as indicating the exist- ence of ulceration, and also considerable induration ; my diagnosis was afterwards confirmed by the speculum. I lost sight of this pa- tient until very recently, when she again requested my attendance. I found her with all her symptoms much aggravated. She told me that she had been under the care of one of the obstetric physicians who are now taking so prominent a position in the present anti- speculum crusade, and who had been occasionally attending her during the last seventeen years. This gentleman had always de- clared that she was laboring under stricture of the rectum, for which he had been diligently drugging her during that long period. In this opinion he was strengthened by another eminent obstetric physician of the same school, who occasionally saw the patient. On becoming worse she again sought my advice, but I declined any interference unless I was permitted to make a thorough investigation of her case. To this she willingly consented. I first passed my finger easily into the rectum, through which it was declared " a crow-quill could not enter." I felt a hard, projecting tumor, completely filling the hollow of the sacrum. This I discovered, on examination per vaginam, to

42 EXCHANGES.

be the retroverted fundus uteri, much enlarged, and excessively tender to the touch. The labia uteri presented unmistakable granular ulcerations, with induration extending up the walls of the cervix. Now, I would ask, am I to believe the evidence of my senses, or am I to take the opinion of men who would not for the world use that dangerous instrument called Simpson's uterine sound, and w7ho are of too pure a school of medical ethics to make a vaginal examination ? I would ask the profession, in sober earnestness, are we to accept the dicta of such men, as to the use of instruments which many of us have proved to be of incalculable value, and which have been intro- duced to us by men certainly of as high professional standing as any who oppose their employment. Of what value are the opinions of those who either declare that they have never derived any information whatever from the use of the speculum, or who altogether ignore the use of instruments in uterine diagnosis ?

" Whilst I am upon the subject, in conclusion, I would hint to Dr. Marshall Hall, that should his opinions become known to the wives and daughters of England, they would repudiate his championship of their morals, and would throw back upon him with indignant scorn the sentiments he has dared to attribute to them.

" Requesting you will favor me by giving insertion to this letter in your forthcoming journal,

"I remain, sir, your obedient servant,

"W. Moon."

OUR EXCHANGES.

Our thanks are due to the editors of the following works, who have been good enough to commence exchanging in prospectu. We wel- come them to our table, and hope that our acquaintance will be mu- tually agreeable.

The New York Register of Medicine and Pharmacy, a neat semi- monthly of 16 pages, edited by Dr. C. D. Griswold. We have re- ceived the six numbers issued, and are much pleased with it. The December (15th) Number, after noticing our prospectus, goes on to say :

" It is often remarked that we have already too many medical jour- nals, more than can be supported, &c.,and we have no doubt but that the same kind of objections have been urged against each new publica- tion, since the first one was established in this country. Franklin was advised not to set up a second newspaper in Philadelphia, on the ground that it could never be sustainecl, as Philadelphia had already attained its full growth ; and so it is, that there are always prudent ones, who advise against any undertaking for which they may be called upon to subscribe. We may have too many journals, but we have not enough good ones, nor are xhey sufficiently well patronized. Let every

EXCHANGES. 43

man double his subscription list for one year, and after that time it will cost him but little if any more than he now pays — such is the influ- ence of patronage upon the press. With a proper spirit of indepen- dence, the medical journals of this country might do much to relieve the profession from its worst evils ; but as it now is, the doctors are handled more like sick babies, and their defects covered up writh the scrupulous care that a foolish mother would screen the errors of her spoiled boy. The truth is, our journals, or many of them, are con- servative to a degree which impairs not only their own interest, but lessens the good they might do the profession. We do not like to see the many suffer from the errors or vices of the few, and it is not right that it should be so. A journal that has no character or principle or opinions independent of the communications upon its pages, is not worth having. As with the stethoscope we ascertain the condition of internal structions, whether they are healthy or unhealthy, so through our Virginia cotemporary, may we have revealed to us the true condition of the heart of the profession."

The Southern Medical and Surgical Journal, a good monthly, 64 pages, edited by Dr. J. P. Garvin, Augusta, Georgia. We perceive by the December Number that this work will in future be conducted by Professor L. A. Dugas, of the medical college of Georgia. This gentleman is the successor in the chair of surgery to Dr. Paul F. Eve, who was last year appointed to Dr. Gross' vacant chair in the university of Louisville. We see by an advertisement that " Dr. Eve will resume the practice of his profession in the city of Augusta by 10th March 1851. We suppose, then, that Dr. E. will resign his new professorship and go back to the field of his old labors. He is the chairman of the committee on surgerv of the American medical association, and asks that communications may be forwarded to him to Louisville or Augusta either.

Though " the editor, publisher and printers were all suffering from break-bone fever" they got out a very good number. It opens with the conclusion of a very interesting paper " On the present state of Medicine," by Dr. C. Todd Quintard, of Roswell, Georgia. Its peri- scope is well made up.

The Boston Medical and Surgical Journal, a weekly of sixteen pages, and a number of advertisements. Its editor, Dr. J. V. C. Smith, is writing letters, interesting enough to the general reader, from the East. His last is from Alexandria, and is principally devoted to the harem, the city, and other things not medical. We see by this paper that there are negro medical students in the Harvard university ! and a white woman. The students remonstrated, but to no purpose. This paper publishes the marriages of the Massachusetts doctors, and we

44 VIRGINIA MEDICAL SCHOOLS.

are pleased to see that our old friend Prof. Jeffries Wyman, late of the Richmond medical college, has " taken unto himself a wife."

The New York Medical Gazette and Journal of Health, weekly, edited by Dr. D. Meredith Reese : a medical newspaper, worth to New Yorkers its subscription. It tries to conciliate the Southern medical students to the Northern colleges.

The Northern Lancet and Gazette of Legal Medicine, edited by Dr. F. J. D'Avignon and Dr. Horace Nelson, of Plattsburg, New York : a double column octavo, very indistinctly printed, and not much of a " Northern Light?'' in medico-legal science. We adopt, however, his notice of

The American Journal of Medical Science. Dr. Isaac Hays, Phila- delphia. " This excellent journal needs no recommendation of ours in inducing the profession to extend their patronage to a publication which may be considered as truly American."

The Philadelphia Journal of Pharmacy, another national work of great value, most particularly to all apothecaries and country prac- titioners, who are necessarily both prescriber and compounder. To this work we shall look to keep us posted in the new preparations.

The London Lancet, which is so expeditiously re-printed in an un- abridged form by Messrs. Stringer & Townsend of New York, is fur- nished us by Messrs. Morris Sf Brother. This work we would not be without, and its circulation is so general we need not say a word in its praise.

dSP" Other works receiving this Number will please exchange. Authors and publishers sending works for review, will please do so through the Richmond booksellers, or, post paid, by mail.

VIRGINIA MEDICAL SCHOOLS.

It is a source of pride and congratulation among Virginians to see the present flourishing condition of our colleges, and to know that they are rapidly assuming that position which their merit demands, and which it is the duty of every Virginian to aid them in attaining. The stigma upon the state, that it cannot educate its own sons, is being rapidly wiped away ; and the time is close at hand when we will no longer be going to the North to seek fountains of wisdom and learn- ing. The present session of our medical schools proves that a proper feeling of state pride is being awakened, and we feel quite confident

MEDICAL SOCIETIES- 45

that in a few years our state will occupy the position in medicine with the South that Philadelphia once did with the whole Union. The climate of any city further South than Richmond is too warm for an- atomical pursuits, and evidence is abundant that Southern medical students are not going further North. So we are warranted in the be- lief that this state is soon to become the seat of the great medical school of the South. We know that the older members of the pro- fession were all educated in Philadelphia, and that they have that love and veneration for their alma mater which is so natural. But we believe that they are also duly impressed with the importance of throwing off that vassalage which bound us to the North, and which circumstances no longer render necessary. The progress of medicine has been so rapid, and the means of communicating it has become so much facilitated, that there is no longer that centralization of Ameri- can medicine necessary as was the case when our country was young and its population sparse and scattered.

The Medical college of Richmond has a much larger class than ever before, and the proportion of second course students is very great. The faculty are lengthening their course, and steadily raising their standard of graduation.

The medical class of the University of Virginia is unprecedentedly in- creased, and far greater in proportion than any of the academic de- partments. This speaks well for professional education in Virginia, as the university is universally granted to be the most thorough drilling or preparatory course in our country.

The Winchester medical college has a very respectable class, and we learn the professors are advancing its interests with a zeal and in a manner worthy of the praise of the profession.

The medical department of Randolph Macon college is also on the in- crease, and we believe preparations are being made there to extend the course.

From want of accurate information, we defer stating the numbers,, &c. of our schools, but we will do so in a future number.

MEDICAL SOCIETIES.

We give in the present Number an abstract from the very interest- ing debate in the Medical Society of Virginia at its November meet- ing. This body holds regular meetings, on the third Tuesday of every month, in the hall of the Richmond library association, corner

46 PURIFICATION OF CHLOROFORM.

of Main and 11th streets. Its annual meeting is in May. Its officers for the present year are : President, Dr. Ro. W. Haxall ; vice-presi- dents, F. Marx and James Beale ; secretary, P. CI. Gooch ; corres- ponding secretary, Carter P. Johnson ; treasurer, James Bolton ; li- brarian, W. J. Clark. The society is in a very flourishing condition, and has a large number of members throughout the state. In a future Number we will give a full account of its organization and history. We learn that societies exist in Petersburg, Norfolk, Fredericksburg, at the University of Virginia, Wheeling, Loudoun, and in Greenbrier county. There are others, doubtless, in the state, and some of them are prospering. We would be glad if the secretaries of these bodies would furnish us with their proceedings for publication. It is said, "that the medical press is the nurse of medical talent;" so, we con- ceive, are medical societies.

If the profession would be more careful not to use articles which are not pure, less complaint would be heard of remedies of all sorts which produce good or bad effects according to their preparation. If chloroform were always as good as it should be, we believe many of the bad consequences attributed to it would never have been heard of.

For the benefit of our readers who do not take the American Jour- nal of Pharmacy, we publish the following article of Dr. Gregory, to- gether with the editor's remarks :

Notes on the Purification and Properties of Chloroform, read before the Iloyal Society of Edinburgh, by William Gregory, M. I)., Professor of Chemistry in the University of Edinburgh.

1. Chloroform has been prepared both from alcohol and wood- spirit. The latter has been used for the sake of cheapness ; but as it is a mixture of several liquids, all of which do not yield chloroform, it gives an impure product, in a proportion which varies much, but is always below that obtained from alcohol. There is therefore not only no advantage, but the contrary, in using wood-spirit, which is not, after all, much cheaper than alcohol.

2. But the chloroform from these two liquids, when fully purified, is quite identical in all its properties. Its smell, density, boiling-point, and action in the system, are in both cases exactly the same. That from alcohol is no doubt more easily purified than the other, but it also contains certain volatile oily impurities, which must be removed be- fore it can be safely used. The peculiar oils which adhere to both kinds of chloroform are not identical, or at least, not all identical, but they are of analogous constitution and properties.

PURIFICATION OP CHLOROFORM. 47

3. Soubeiran and Mialhe have examined these oils. They contain chlorine, have a disagreeable smell, and when inspired or smelt cause distressing headache and sickness. In the case of wood-spirit, some of its own impurities distil over unchanged, and are also found in the chloroform.

4. It is well known that many persons, after the use of chloroform, have suffered from headache, nausea, and even vomiting, as I have more than once seen. Headache and nausea I have myself often ex- perienced, when I have tried different specimens of chloroform, with- out taking so much as to produce the full effect.

5. Perfectly pure chloroform does not, so far as I have seen or ex- perienced, produce these disagreeable effects. It is therefore highly probable that when they occur, as they do with some individuals, from the use of chloroform of more than the average goodness of quality, they depend on the presence of a trace of these poisonous oils.

6. All good manufacturers of chloroform purify it by the action of oil of vitriol, which destroys the oils, while at the same time a part of the acid is reduced to sulphurous acid. The chloroform, to remove this, is then distilled with lime or carbonate of baryta, and is tolerably pure if the process be well conducted.

7. But it is not quite pure, and contains a trace, more or less dis- tinct, of the oils. I have found this to be the case with all the best chloroform made here up to 1849 ; and I have several times seen headache and sickness from the use of such chloroform, which was the best anywhere made. I must add, however, that the quantity of oils in the chloroform of the best Edinburgh manufacturers, although variable within certain limits, was always so small, that that product was fit for use, and only caused headache, &c. in a few peculiarly sensitive persons.

8. It was desirable to have a test for these impurities, as well as an easy and effectual mode of removing the last traces of them, especially as many sorts of chloroform not made here were far inferior in quality to that prepared in Edinburgh. One very delicate test is, that of oil of vitriol, which should be quite colorless, pure, and of the full den- sity of 1.840 at least, as it may be obtained by Mr. Kemp's process, lately read to the Royal society ; when agitated with the chloroform, it becomes yellow or brown, from its action on the oils, which it chars and destroys. Any change of color is easily seen by contrast with the colorless chloroform which floats above. Pure chloroform gives no color to the acid. It is essential that the oil of vitriol be colorless and also of full density ; for if colored, it is not easy to see a slight change on its color ; and if below the proper density, that is too weak, it is not much colored by a chloroform which will render dark brown the acid of proper strength.

9. Another test, still more delicate, I find to be the smell of the oils. When chloroform is poured on the hand or on a handkerchief, it ra- pidly evaporates ; but the oils, being less volatile, are left behind ; and their smell, previously covered by that of the chloroform, is easily re- cognised. Until very lately no chloroform was sold, or indeed known, which would, stand this test, or even the former.

48 * PURIFICATION OP CHLOROFORM.

10. Up to 1849, the best commercial chloroform had a specific gra- vity of 1.4S0, which was- considered a guaranty of its purity ; but it had been obtained by chemists of specific gravity 1.494, and even 1.497. I have found that chloroform of 1.480, when once more acted on by oil of vitriol, which destroys the oils and becomes brown, may be obtained after removing the sulphurous acid, of specific gravity 1.500 at 60°. This I take to be the specific gravity of pure chloroform. Our best makers have lately, much to their credit, pushed the purification so far as to furnish chloroform even of this highest density, and also in other respects such as it ought to be.

11. There are still, however, many makers in other places whose chloroform is not so pure ; and I shall now describe the method which, with Mr. Kemp, I have employed for purifying, perfectly and easily, any commercial chloroform, except one remarkable specimen — a process which will enable any medical man to purify it for himself with the greatest facility.

12. The chloroform, having been tested as above, and found more or less impure, is to be agitated with the oil of vitriol, (half its volume will be sufficient,) and allowed to remain in contact with the acid, of course in a clean, dry and stoppered bottle, and with occasional agita- tion till the acid no longer becomes darker in color. As long as the action is incomplete there will be seen, after rest, at the line of con- tact, a darker ring. When this no longer appears the chloroform may be drawn off, and for greater security once more acted upon by a quarter of its volume of the acid, which should now remain color- less. It is now to be once more drawn off, and, in a dry stoppered bottle, mixed with a little powdered peroxide of manganese, with which it is gently agitated, and left in contact until the odor of sul- phurous acid is entirely destroyed and the chloroform has acquired a mild, agreeable, fruity smell. It has then only to be poured off into a proper phial. It will now leave no disagreeable smell when evapo- rated on the hand. [If the commercial chloroform, after having been

frequently well shaken and left for some time in contact with the acid, has given to it only a moderate tinge of color, it is probable that it may be completely purified by the first process. To ascertain this, test a fresh portion in a tube with fresh acid, shaking well, and allowing it to stand for some time. If it do not color the acid at all, then the whole chloroform has only to be finally purified by the oxide of man- ganese. If the acid become colored in the test tube it will be as well to act on the whole chloroform a second time with fresh acid till it stands the test. Mr. Kemp has observed, in repeating this process for me, the very curious fact, that as soon as the action is complete and the oily impurities are destroyed, but not sooner, the chloroform tested with the acid in a tube exhibits a strongly convex surface downwards, where it rests on the pure acid, or what is the same thing, the acid becomes concave at its upper surface. The smallest trace of impurity, not sufficient to affect the density of the chloroform, we have found to render the line of junction horizontal. It is probable that this may become a valuable test of the perfect purity of chloro- form ; but we shall not say more on this subject until we have

PURIFICATION OF CHLOROFORM. 49

thoroughly examined it.] This process requires no apparatus be- yond a few stoppered bottles, and a pipette, if we wish to draw cfFthe whole chloroform without loss, although nearly the whole may be simply poured off. The use of the oxide of manganese is due to Mr. Kemp, and on the large scale the chloroform may be filtered through a cylinder full of it. In this final purification of commercial chloro- form no distillation is necessary. Indeed, no rectification is required at all if it be well washed with water before using the acid.

13. It may be considered as certain that the use of chloroform thus purified will very rarely, if ever, cause the disagreeable effects above noticed.* As to more serious bad results from the use of chloroform, so often spoken of elsewhere, it is enough to state that a large proportion of the cases must be attributed to the use of a liquid so impure as hardly to deserve the name of chloroform at all.

Postscript. — Since writing the above, my attention has been called to a paper by Dr. Wilson, on the specific gravity of chloroform, which he was not able to obtain higher than 1.49S. I have therefore to add, that every specimen, whether of specific gravity 1.480, 1.490, or 1.497, which I purified as above, acquired the same density of 1.500, as ascertained by the use of a very delicate and accurate bead, (made by Lovi,) which sank at 60.°5 and rose at 59.°5 ; and also by three successive weighings with a very delicate balance. It will also be seen, that three commercial specimens had this density; I could de- tect no foreign matter in my chloroform ; and besides, every foreign matter that is likely to occur lowers the density. 1 have no doubt that Dr. Wilson's specimens would have colored the acid and left a smell on the hand.

I may add, for the maker, that after distilling the materials which yield chloroform, no distillation or rectification is needed. He has only to wash the heavy fluid with water till its volume no longer di- minishes, and then to use the oil of vitriol as above, finishing with the oxide of manganese. Distillation with the acid is of no use, because no proper contact can take place, the chloroform distilling from the surface as it would from mercury. In testing by oil of vitriol, it is

* Dr. Simpson informs me, that the purest chloroform he has used not unfrequently causes vomiting. On further enquiries, I find that this occurs when it is administered after a full meal. This can easily be avoided, and must not be confounded with the headache, nausea and vomiting alluded to in sections 4 and 5; which symptoms are persistent, and occurred in my experiments alwnys with an empty stomach, the experiments being made an hour or two before dinner. Mr. Carmichael, assistant to Dr. Simpson, has mentioned to me some facts which conlirm the view I have taken. At one period, for more than a week, Dr. Simpson and Mr. Carmichael were kept in a state of continual anxiety by the occurrence, in all the puerperal cases in which chloroform was used, of very unpleasant symptoms, particularly of frequent pulse and other febrile symptoms, lasting for some days. At last, after much annoyance from this cause, it occurred to Dr. Simpson that he was using one particular specimen of chloroform above the average in quality. As soon as this idea occurred he threw away all that remained, and returned to that which he had generally used. The unpleasant symptoms no longer appeared. [I regret much that I had not an opportunity of examining that specimen, but I may add that the maker, not an Edinburgh one, now produces chloroform of much better quality, though not yet absolutely pure.] But the striking fact is this, that Dr. Simpson and Mr. Carmichael state, that during the period above alluded to, when that one kind of chloroform alone was used by them, their handkerchiefs became quite offensive from the smell left on them, which even adhered to them after washing. There can, I think, be no doubt that here the oily impu- rities alluded to in sections 4 and 5 were present in notable quantity.

4

50 PURIFICATION OF CHLOROFORM.

best to use some ounces of chloroform, and to shake it in a phial, be- cause in a test-tube, the color produced, if not strong, may be over- looked.

While I acquit the makers of chloroform, who have sold an impure drug, of all desire or intention to adulterate it, I feel it my duty to point out that the system which permits any one to set up as a manu- facturer of this or any other potent remedy, without let or hindrance, without any test of his qualifications, without, in short, enforcing a knowledge of chemistry and pharmacy as an essential condition, is a radically bad one ; and that our law, in relation to druggists and apo- thecaries, requires reformation. In fact, the evils naturally resulting from it are only neutralized, and that but in part, by the good feeling and principle of the leading manufacturers.

To illustrate this, I may remark, that some of the makers of chlo- roform must have been very ignorant, even of what was known and published concerning its properties; for, among the specimens I ex- amined, are several of specific gravity below 1.4S0, which was long ago given as the standard, even so low as 1.347.

That this neglect proceeded more from ignorance than from inten- tion, is, I think, plain, from the fact, that a specimen labelled "Pure Chloroform" actually contained only a trace, about one-thirtieth, of that substance. I did not ascertain its specific gravit}", which must have been far lower than 1.200 or 1.100 — nay, possibly, under 1.000, because its impurity was so obvious in every other respect, and the quantity I had was too small ; but, on examining it further, I am convinced that its origin was this : — The maker, after distilli^s: the materials, obtained, of course, two liquids, a lighter and a heavier. He evidently did not know that the latter was the chloroform, and therefore threw it away, and preserved the lighter — a mixture of pyroxilic spirit — of its natural impurities, of the deleterious chlorina- ted oils, and a trace of chlorofoim. At least, such are its characters ; and it exactly resembles what would be obtained in the way sup- posed. But what a fearful degree of ignorance (without any evil intention) is here exhibited. And yet this maker was free to produce and sell pure chloroform, which was actually almost pure from chloro- form, and loaded with deleterious agents.

[A few weeks since, having occasion for some chloroform, we ob- tained a pound from a manufacturing establishment in this city. On opening the bottle, the odor of the chloroform was contaminated with that of chlorine, and the stopper had on it a greenish yellow discolor- ation. On returning it to the chemist, with the information of its impurity, we received the following note :

"Dear Sir — We have your favor of this morning, in regard to chlorine found in chlorofoim, and for the same are much obliged, as it gives us some ground other than our own opinion for declining to make the article by the late improved process with sulphuric acid. We soon discovered that this change was likely to go on, but some of our customers wanting an article of this kind, (i. c. made bv this process) particularly, we were induced to adopt the improve- ment."

NITRIC ACID IN ASTHMA. 51

This chloroform bleached moist litmus paper rapidly, first redden- ing it. The acidity is due to hydrochloric acid, generated from the chlorine and moisture adhering to the chloroform operated on by light. Mr. Abraham, in a paper on this subject, has arrived at similar conclusions. — Editor.]

Cases of Asthma successfully treated by Nitric Acid.

BY T. S. HOPKINS, M. D., OF BETHEL, GLYNN COUNTY, GEORGIA.

The following five cases of asthma, cured by the use of nitric acid, have occurred in my practice since the summer of 1847. It is not my desire to attempt any explanation as to the modus operandi of this remedy in the above disease. Its beneficial effects were accidentally discovered, and, after a fair trial in five consecutive cases, with the most entire success, I am induced to bring it to the notice of the pro- fession, trusting that in other hands than my own it may prove a po- tent agent for the relief of a disease which so often resists the best-di- rected treatment. Several of these cases were from twenty-five to thirtv-five miles distant from my office. Most of them were not seen by me from the time of my first visit and prescription until a cure had been effected. I describe them as I found them at the time of my visit, and from the history given by parents and masters, which I think can be depended upon.

Case I. — Emma, negro girl, aged five j^ears, belonging to Mr. T. G., had been asthmatic almost from birth. Nightly paroxysms of dyspnoea, cough, &c, were represented as most distressing. During the day, she would be up and about the yard with the other children. At the time that I saw her, her respiration was somewhat embarrassed, with slight elevation of the shoulders during inspiration, and a very distinct mucous rale. Her appetite was impaired, and her countenance cheerless.

I ordered nitric acid, three drops, to be increased to five, three times daily, in a wineglassful of sugared water. A month elapsed before I again saw this patient, at which time every symptom of dis- ease had disappeared. I prescribed for her in December 1847, and up to date no symptom of asthma has returned.

Case II. — I was called in November 1848, to see W. S., aged about six years, son of a planter of Glynn county. I was informed that this boy had been a subject of asthma for four or five years ; that no expense had been spared in seeking for relief in his case ; and that all the efforts of the best physicians in the neighborhood in which he had resided, had been in vain. When I saw him, he had cough, slight dyspnoea, with mucous rale distinctly audible at the distance of se- veral feet. By walking up and down the steps of the house, once or twice, the difficulty of breathing and cough Would be much increased. He was very lively and cheerful, with a good appetite, and had had no fever for months. His father informed me that, upon the least ex- posure during the day, he would be attacked at night with the most

52 MANGE.

fearful symptoms. Wheezing, panting, incessant cough, distressing dyspnoea, with impending suffocation, were the inevitable conse- quences (at night) of exposure during the day.

I ordered nitric acid, five drops, three times daily, in a wineglass of sugared water, with a strict avoidance of exposure.

In a fortnight, he had been so much relieved that his parents imagined him cured, and discontinued the acid. In a few days he re- lapsed, and I was again sent for. I ordered the acid to be continued, as before, and in one month from the time of my first visit he was cured.

Up to date there has been no return of disease.

This boy's father died of phthisis pulmonalis. Several of his mo- ther's family have died of the same disease ; and all of his brothers and sisters, without an exception, have in early childhood been suf- ferers from enlargement of tonsils and ulcerated sore throat. He is now the picture of health.

Case III. — A mulatto girl, belonging to Mr. W. D. T., aged four years. This was a case of congenital asthma.

The symptoms in this and the following case (aged about four years) were so similar to those of Case I. that I shall not describe them.

The treatment was nitric acid, three drops three times daily in a wineglass of sugared water.

This case resisted the treatment rather longer than the other cases, but was cured in about six weeks.

In Case IV., the immediate effects of the acid were perceived in a few days ; and in eight or ten days she was cured.

Case V. — I never saw. It was a negro girl belonging to Mr. C. of Camden county. She was seven years of age. Her master applied to me for a prescription, afrer giving some of the most prominent symptoms, which convinced me that the case was asthma, as he de- clared it to be.

I prescribed five drops of nitric acid three times daily.

I heard nothing more of this case for several months after I had prescribed, when I was informed by her master that she was well.

A sufficient time has elapsed, in all these cases, to convince me that they have been radically cured.

Should you deem the above remarks and cases worthy a place in your valuable journal, you will please to insert them. It is at least something new in the treatment of asthma. — Amer. Jour. Med. Science.

The " Mange" communicated to three Persons by a Pig.

REPORTED By H. R. CASEY, M. D., OF COLUMBIA COUNTY, GEORGIA.

^ I will give you the particulars of a conversation held a few days since with a gentleman of this county, and if the deduction I have drawn from the facts as reported is correct, we have presented to us (so far at least as my observation extends) a new disease of the cuta- neous system — one hitherto undescribed by dermatologists.

MANGE. 53

Mr. S. asked me " if I had ever known a man to have the mange ?" To which I gave a negative reply : having always understood that it was a disease peculiar to the quadruped. He then asked me "if I thought it possible for a man to catch it from a hog?" I replied, that there are a great many things regarded as impossible, which are not found to be so when subjected to the test — and that this might be one of the cases. He then proceeded to give me the following particulars :

He states that about the 1st of May last, having a pig badly dis- eased with the mange, and being desirous to cure him, he had some soap and water got and went to work on him with his hands — and that after giving him a good washing, he stripped him almost of his entire external with his nails. That he was entirely well at this time ; but that in about three hours thereafter, he felt an itching on his hands and wrists, and an eruption which commenced spreading upwards ; that about the same time his ankles began to itch him and the eruption there made its appearance, which also spread upwards and met the eruption from above at the half-way house — the umbilicus ; that it reached its height in about two weeks ; that the eruption was charac- terized by great heat and intolerable itching, composed of small vesi- cles, which, though not confluent, stood close together over his entire tegumentary tissue. Thus was he at the time of his commencement with the ablution — a sound and healthy man — but in a very short time thereafter, he was transformed into a Lazarus. He thought he had contracted his disease from the pig, and went to work to cure himself, using first the soap and water. This not benefitting him, he was bled and took salts. This failing, he tried pot-liquor — then the grease from fried bacon — then a solution of blue-stone. He does not think that any of the means used had any control whatever over the disease, but that it seemed to pursue its course, knowing no conqueror, until it finally wore itself out in about five weeks.

Now, from the above narrative, I can but infer that the disease in question was one identical with the mange, and that it was communi- cated from the quadruped to the man. And I am further strengthened in this view of the case, from the fact — that a female and the negro boy who held the pig while being subjected to treatment, became in like manner affected. The view I have taken of this case, I know to be in direct conflict with the long-established dogmas of the veterinary school, but I think I am sustained in my position from the facts of the case — and " facts are stubborn things." By reference to the " History of the Horse," I find the following language. The author, in speaking of the contagiousness of the mange, goes on to say — " If the same brush or curry-comb be used on all the horses, the propagation of mange is assured ; and horses feeding in the same pasture with mangy ones, rarely escape, from the propensity they have to nibble one another. Mange in cattle has been propagated to the horse — and from the horse to cattle — but there is no authenticated instance of the same disease being communicated from the dog to the horse. There is as much difference in the character and eruption of mange in the horse and dog, as between either of them and the itch in the human subject ; and the itch has never been communicated to the quadruped, nor the mange of the quadruped to the human being."

54 REMEDY FOR QUACKERY.

My only reply to the above quotation, is the presentation of the case related ; and if I am not sustained in my corollary from the facts of the case, this article will go for nothing. I pretend to no familiarity with cutaneous diseases; but "if I were called, upon to classify the mange, I should locate it in the group dermatoses scabienses of Wilson, not only from the pathology, but also from the therapeia of the dis- ease ; for I find sulphur the anchor of safety to the veterinary surgeon. Nor do I think there is anything very strange in all this ; and the only reason why we have never before had the mange communicated to man arises simply, I think, from the fact, that in all probability more caution has hitherto been experienced than was in the case before us. We have examples of other diseases occurring in the human subject, the result of propagation from the lower order of animals. In the Revue Medicale of July 1845, we have detailed a case of an officer who took the glanders and farcy from a horse, and in which experi- ments were made by M. Andouard, to test the contagiousness of the human fluid introduced into other animals — the results of which ex- periments went to prove that the disease was not only communicable to man from the horse, but that the disease was again transmissible from the human subject to the quadruped. In the Southern Medical and Surgical Journal, November 1847, we have a case of glanders in the human subject, derived from the horse, reported as occurring in your own city. Other -diseases might be mentioned occurring in the great paragon of animals, communicated from the lower order ; but I have already spun out this article to a greater length than was designed at its commencement, and will conclude by merely advising those persons who may have to treat the mange in stock to touch it lightly, and never make a curry-comb of their hands ; to which in- junction I know my friend F. will say, Amen.

[South. Med. and Surg. Journal.

Remedy for Quackery.

In the October number of the New Hampshire Journal of Medicine is an article by Dr. Garland on a proposed "Remedy for Quackery." It is decidedly our opinion, that if the measure were adopted which is recommended by the writer of the article in question, the profession might be most emphatically placed in the same category with the class of whom they complain. Oftentimes, no doubt, when the minds of our patients are diseased, the exhibition of a placebo is attended with better effect than that of remedies more potent ; yet to make a general practice of giving pleasant or inerl preparations in form of medicines, because the patient wishes it, and would otherwise obtain that kind of remedies from the vaunting quack, would not speak well for the purity of medical science. If we wish people to free them- selves from the abominable habit of continually taking something in the shape of medicine, and particularly from those whose only claim to medical skill is their own boasting, we should endeavor to enlighten our patients, by explaining to them the laws which govern life, and

DOCTORING BY THE YEAR. 55

so much of pathology as would intimidate them from using remedies intended to cure a multiplicity of diseases. " A little learning" is not always " a dangerous thing." It was said of Frere Jacques, the natural cutter for stone in the bladder, that when the anatomy of the parts was taught him, he saw at once the danger to which his patients had been exposed, and was deterred from performing lithotomy ever afterwards. He had not the moral, courage to attempt an operation when fully informed of the danger to the life of his patient, though previously he had done so with the utmost sang-froid and with average success, exciting the astonishment and admiration of the crowned heads and many of the surgeons of Europe. In our own day are some who ranked, until a certain period, as the very best in diagnosis and prognosis ; but when the great continental pathologist gave a key, whereby functional and organic disturbance could easily and readily be detected by physical explorations, they were in a great measure despoiled of their old tact in detecting disease. The latter illustration may be considered irrelevant to the subject under discussion ; yet it has a bearing upon it. We contend, that if our patients are taught a certain amount of knowledge respecting themselves, they will be less likely to attempt to cure their own diseases, or place the least con- fidence in the boastful quack or his medicines. If we know the prin- ciples and practices of quackery to be fallacious and mercenary, would it be the part of wisdom in us to place ourselves on a level with quacks, by practising their schemes to get patients and make them take our medicines? There is a way to abate the evil com- plained of; the profession themselves are in a great measure to blame for its existence. When they possess the proper qualifications and take the right means to combat the hydra monster, their cause for com- plaint will be very much lessened. — Boston Med. fy Surg. Journal.

Doctoring by the Year.

Some years since, it was my lot to reside, for a time, in a remote and frontier region of our country, and among a French population of some thousand of inhabitants, remarkable for their simplicity and primitive manners, and exceedingly ignorant upon almost all subjects, and especially so upon medical matters. Indeed there had never been a physician located among them previously to my arrival. About a year before I came into the country, it had been visited by a quack, who called himself Dr. L — y, and who contrived to obtain for himself a considerable practice, and for a short time quite a reputation. From all I could learn of him he was in the habit of using but two remedies, tartar emetic and blisters. It was said that he had obtained the anti- mony and cantharides from the wreck of a vessel on the coast — these two articles being almost the only ones saved from it. Be that as it may, he soon obtained practice with them, and was employed by se- veral families to attend them by the year. A simple-minded French- man, in moderate circumstances, from whom I obtained the following

56 BATHING.

account, told me that he thought he would also try the doctor for a year, and accordingly made a bargain with him to that effect. At the expiration of that time the doctor called for his money, which our friend Jose tendered him according to agreement, but at the same time remarked, that it was rather hard to be obliged to pay it, as neither himself or family had been sick. As, however, he felt very reluctant to pay out his money without receiving some benefit from it, he told the doctor he thought his system was in want of medicine; and on enquiry of the doctor as to his symptoms, he told him, that " somehow or other, he couldn't eat as much as usual, felt unusually sleepy at times," and requested the doctor to feel his pulse, look at his tongue, &c. The doctor, after examining into the case, prescribed for him about twenty powders of tartar emetic, four grains each, and told him to begin next morning with the powders, taking thern at intervals of a few minutes ; but that as it was necessary to take away all his bile, he must assist the vomiting by large draughts of warm water, so as to scour all out and make a clean house of it. Jose therefore went to work the next day, by heating two huge brass kettles of water — said kettles being generally used for scalding hogs. The water being ready, he then set to work in earnest with the powders, taking them in rapid succession. They soon produced severe vomiting. Jose drinking, at the same time, enormous quantities of warm water, till he had used up nearly all in the kettles. By this time, he was so pros- trated with almost incessant vomiting, that his friends became alarmed, and sent for the doctor. He instantly applied a blister, of vast size, covering almost the whole of the abdomen. On calling to see him next day, he found Jose propped up in bed, and looking quite pale and interesting. Under the blistered cuticle, was an immense collec- tion of serum, laying like a great bag on his belly. He asked Jose if he was not now convinced that he had got rid of his bile, and got. the worth of his money, or if he wanted some more medicine? "Ah, mon dieu," says Jose, holding up his hands, " I want no more dam medicine, nevare. I am perfectly satisfied! " — Exchange paper.

BATHING.

A writer in the Boston Medical and Surgical Journal utters the opinion that "once a week is often enough to bathe the whole body for the purpose of luxury or cleanliness. Beyond this we consider bathing as injurious. Flannel worn next to the skin at all seasons is proper, and infinitely more healthful than all the daily baths now so fashionable. " The argument by which this opinion is supported is as follows :

" The oil which is secreted by the sebaceous glands of the skin serves the purpose of lubricating its surface. Now, if this secretion is con-

TRANSACTIONS OF AMERICAN MEDICAL ASSOCIATION. 57

stantly removed as fast as exuded, its destined object is thereby de- feated. The excretory ducts of the perspiratory glands themselves require this unctuous matter of the skin to keep them in action. If very frequent bathing of the body is practised, it must be obvious that this matter cannot be long present to perform its office. As to the as- similations of functions of the skin and lungs, it will be apparent that when the skin acts imperfectly, or ceases to act at all, the lungs have an extra amount of duty to perform ; and it is generally in just such cases that engorgement of them takes place, constituting inflammation or pneumonia."

Transactions of the American Medical Association — Vols. I. and II.

The October number of the British and Foreign Medico- Chirurgical Review devotes eleven pages to these two volumes, and, as might have been expected, handles them in rather a cool manner. The following is the commencement of the review :

" These 'Transactions' are the chronicles of the proceedings of the first two annual meetings of the American medical association, form- ing two goodly volumes, the contents of which have little resemblance to those bearing a similar title in this country. It is true, the advance- ment of medical science is the ultimate object of publication in both cases ; but the efforts of our trans-atlantic brethren to this end are as yet but in a comparatively early stage of development. In a country in which medical education, practice and literature are in so inferior a condition as they at present hold in the United States, the earliest efforts of the lovers of science must necessarily be employed in exam- ining the cause of, and devising the remedies for, so lamentable a state of things. This work the association has undertaken with courage and ability ; and a large portion of the present volumes is taken up with an account of the results of their enquiries, and a detail of their suggestions. Already the National medical convention, which organ- ized the present medical association, had published a code of medical ethics, which met with much approbation both in America and Europe, and formed a fitting preliminary to more extended operations. The association is composed of delegates of medical societies, colleges, hospitals, lunatic asylums, and other institutions from all parts of the Union, and holds its meetings at different cities in succession, after the manner of the British association for the advancement of science. The two meetings which have taken place at Baltimore and Boston were attended by several hundreds, comprising a great number of pro- fessional names of eminence. The two volumes now before us, con- taining an account of their proceedings, are chiefly filled with reports given in by the respective committees upon the present condition and future prospects of the profession, and upon the progress of medical science. Some of these are well deserving of notice."

58 STATE INSTITUTIONS.

Then the "report of the committee on medical education" is no- ticed, and the defects of our whole system of teaching and licensing are very justly exposed. The opinion of the committee, "that most of our physicians are fully equal, and in many respects far superior, to the general practitioners of England," is flatly denied.

A long notice of the " report on medical literature," then follows. The envy of our ability to diffuse all sorts of literature, and make re- publications of foreign works, at a much cheaper rate than the English can, is palpable ; and the reviewer, of course, congratulates himself upon the petitioning of Congress to pass an international copyright act, by our association.

After noticing and extracting from several of the practical reports of the committees, the review closes thus :

" In concluding our notice of these volumes, although approving of the general tone and spirit (save as to the exceptions we have men- tioned) which have prevailed among those engaged in assembling the materials, we must be allowed to observe, that, if the medical associ- ation is ambitious of assuming a position among the various scientific bodies that issue their memoirs and transactions in Europe, a very different class of literary productions must be looked for at their hands. They must not content themselves with merely recapitulating in reports and retrospects what has already been published — a work that might be accomplished by a far less massive organization — but must themselves largely contribute to the general stock the results of experience and the fruits of meditation."

LUNATIC ASYLUMS OF VIRGINIA.

By the executive reports from these institutions, it appears that " they have never exhibited a more gratifying aspect to the friends of hu- manity than at present." The reports of the physicians contain many interesting tables of physiological and other facts, but our room will only allow us to make the following extracts :

" The number of patients who have been inmates of the Eastern Lunatic Asylum since the 30th of September 1849, is two hundred and thirty-four. Of these, one hundred and forty-five were males and eighty-nine females.

" The number of patients on the 1st of October 1849, was one hun- dred and eighty-one, viz : one hundred and seven males and seventy- four females.

" Since the 30th of September 1849, fifty-three have been received ; thirty-eight of these wTere males and fifteen females.

" The number of discharges is eighteen, viz : eleven males and seven females. One male patient eloped.

STATE INSTITUTIONS. 59

" The number of deaths is twenty-two, eighteen males and four fe- males.

" The number of patients nt present is one hundred and ninety- three, viz : one hundred and fifteen males and seventy-eight females."

Civil Condition of Patients in the Asylum from January 1st, 1847, to

October 1st, 1850.

Single, Married, Widows, Widowers,

Ages of Patients in the Asylum September 30, 1850.

Below 20 years, From 20 to 30 years,

30 to 40 " ■

40 to 50 " -

50 to 60 " -

60 to 70 " -

70 to 80 " -

Males.	Females.		Total.
121	50	-	Ill
59	64	-	123
0	16	-	16
9	0	-	9

Males.	Females.	Total.
2	3	5
28	6	34
26	16	42
28	32	60
17	16	33
14	3	17
0	2	2
115	78	193

WESTERN ASYLUM AT STAUNTON, VA.

Within the year just closed, there have been accommodated in the asylum three hundred and forty-eight patients, of whom two hundred and one were males and one hundred and forty-seven females. Of these, two hundred and sixteen occupied apartments here at the com- mencement of the year, viz : One hundred and twenty-one males and ninety-five females. One hundred and thirty-two were admitted du- ring the year, of whom eighty were males and fifty-two females.

Within the same period there were discharged, - 73

Of these, had recovered, 45

" " were much improved, - 4

" " " improved, - 2

" " " unimproved, - 2

" " eloped, - 1

" " died, 19

— 73

60

STATE INSTITUTIONS.

Tabic shewing the Civil Condition of Patients who have been in the Asylum

during the ijear.

Married,

Single,

Widows,

Widowers,

Unascertained,

Males.	Females.	Total
63	58	121
123	72	195
0	16	16
7	0	7
8	1	9

201

147

348

PENITENTIARY OF VIRGINIA.

It appears by the annual report of the surgeon of this institution, that during the twelve months, ending October 1st, 1850, there have been treated 515 cases of 71 diseases, injuries, &c. — of these, 110 were of diarrhoea, 54 biliary derangement, etc.

Of these cases 22 were fatal — 9 consumption — 6 scrofula — 4 bowel complaints — 2 typhoid fever and dropsy — 1 tetanus.

Death has made sad ravages with the medical profession in Cali- fornia. During a fortnight, the following physicians were swept off by cholera : Drs. Cobb, Whitlock, Noble, Mason, Yearly, Robert Mc- Namer, Green, Stansbury, Holmes, Metcalf, H. P. Hess, G. W. Held, and Barnes. — Newspaper.

CORRESPONDENTS. 61

TO CORRESPONDENTS.

Articles intended for publication should be received by the 10th of the month, at least, and must only be written on one side of the page. As printers are unacquainted with the technical language of medical men, it is very desirable that the manuscript should be clear, written out fully in a legible hand, and proper names ought to be in square letters.

Correspondents will always send their names to the editor ; when it is desirable they will be kept strictly confidential. Any disposition will be made of manuscripts desired by the author.

The short time in which we had to establish this journal rendered a circular necessary. In sending out these circulars, the postage of many of them was not paid, and for fear that it may have given um- brage to others — as we know it has to two — the editor feels it due to himself to explain why the postage of all was not paid. In the first place, he was embarking in an enterprise of great interest to every member of the profession, and one in which he only could be the loser. The pittance on each circular could not be felt by any physi- cian, but the postage on them all would have amounted to $ 100. This, though a most useless and heavy expense, would have been in- curred, had there been a certainty that his directions were correct. But of the list of some 2000 or 3000 names which we obtained, there were only a very small number with the post offices attached ; many of the names were of persons not belonging to the profession, of dead men, or those who had removed ; generally only the county was put down. Whenever it could be done, the budgets for the counties were sent by private hands, or given to a countryman for direction, and they found their way into the mail. Two only of the 2000 have not been deemed worthy of their postage ; and — particularly when the above reasons are taken into consideration — we hope there are no others who can blame us for not having paid postage on letters which we were not sure would ever get farther than to a county C. H. post office. Should there be, however, we will anxiously wait an oppor- tunity of repaying them the half-dime grievance, with full and liberal interest.

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THE

AND

VIRGINIA MEDICAL GAZETTE.

No. 2.

RICHMOND, FEBRUARY 1851.

[VoLL

An Abstract of an Essay on Congestive Fever.

BY A. T. B. MERRITT, M. D., OF RICHMOND. [Read before the Medical Society of Virginia, December 1850.]

After a medico-topographical outline of some sections of our coun- try, and some general pathological remarks —

Dr. Merritt proceeded to say, that the most malignant and un- manageable forms of " congestive fever," improperly so called, which had fallen under his notice and treatment, had been presented to him in Eastern Virginia, during several years, in great abundance and as an epidemic. As a general rule, it is true the tendency of all diseases is to run their course more rapidly in more Southern climates, and therefore no time can safely be lost in administering our remedies; but I have seen at times equal rapidity in their progress in our sec- tion of the Union. At the South, our remedial agencies seem to be followed by as prompt relief as in Virginia, and perhaps recoveries are more rapid, and as entire and satisfactory.

I will not detain you by dwelling on the different phases of mias- matic or bilious fever ; or distinguish very critically between its inter- mittent, remittent, or congestive varieties; or speak at length of its malignant, yellow or icteroid form, or its too common typhoid degene- ration, nearly always arising from neglect or maltreatment. I will make no distinction as to the simple or excitive, the inflammatory and congestive varieties of each of these specified fevers, or their degrees of violence, but proceed to describe the congestive fever, very incor- rectly so termed, as I have often seen it prevailing extensively for years together, and attacking large numbers of all ages and condi- tions, and following frequently distinctly marked cases of each of these forms of fever.

I have often used the term "congestive," as applied to this fever, which, in different parts of our country, is called by a great variety of names — as cold fever, cold plague, cold chill, congestive chill, con- gestive fever, pernicious fever, typhus fever, typhoid fever, and many

62 MERRITT ON CONGESTIVE FEVER.

other names, or rather misnomers. Most of these synonyms seem to me to be singularly inappropriate, founded on no sound pathological views, and to be in fact medico-philological solecisms. Is not the very term congestive fever, as thus applied, an absurdity? Conges- tion is a symptom of morbid action, confined to no class of diseases, and takes place at the close of many, perhaps nearly all, diseases affecting our general system. I have no strong repugnance to using the expression, congestive state of bilious or any other fever, to desig- nate the presence of extensive congestion in such fever. In our fever, as well as in cholera, it is true, there seems to be a great tendency to congestion ; and whenever it does occur in either, it is indeed " con- gestion in earnest." I have often been struck with the close analogy which seems to exist in very bad cases of each of these diseases, presenting many morbid phenomena, nearly allied, I have no doubt, in their nature, as well as in appearances. Some subtile atmospheric degeneration, however produced — some diffusive, penetrating mala- rial poison, however generated and composed, acting on our constitu- tion generally, seems to spend its chief force on the vital and natural organs, leaving less implicated the animal functions. We may there- fore safely conclude that the nervous system and its dependencies, in both of these diseases, feel the chief force or impetus of the morbific causes, and the other systems of our organism becoming involved, are at last overwhelmed in one common ruin, with symptoms, if not identical, at least closely allied and nearly analagous to each other.

But I have expressed the opinion, that congestion is only a symp- tom of disease, and not the disease itself — and very often not an essen- tial part or condition in which the other symptoms have their origin, and from which the greatest danger is to be apprehended. The oppo- site opinion has led to many views that are unsound in pathology and unsafe in practice. That temporising treatment of any disease, which looks to the relief of symptoms, must in the main be quite unsatisfac- tory to the enlightened physician, and lead to great want of success at the bedside. The leading secret of successful practice is an unfear- ing and sturdy grapple with the disease itself, and as little remedial application merely to its signs, or its symptoms, as is consistent with the quiet and comfort of suffering humanity. We may rest assured, that in medicine, as in every thing else, the old and long-established maxim — " sublata causa, tollitur effectus" as soon as we remove the cause, the effect and symptoms will cease, is true ; and that in medi- cine especially it is a maxim of inestimable value, and ought to be a cardinal rule with every sound and enlightened physician.

I do not believe that congestion in this fever is the chief or princi- pal source of danger. I suppose it will be conceded on all hands, that it is a venous congestion, and this we constantly meet with in many other diseases, with no fatal results. We see it in syncope, in concussion of the brain, in severe surgical operations and violent in- juries, and in every accident and disease inflicting a severe and decided shock on the nervous system ; yet in all these cases it is not the con- gestion, but the great prostration of nervous power, we fear. We rarely find on autopsical examination in fatal cases, congestion enough

MERRITT ON CONGESTIVE FEVER. 63

in any organ to account for fatal results, either in such cases, or in the disease under consideration.

I cannot attribute to inflammation and its consequences much of the danger and fatality of our disease. I do not for one moment believe that we would observe in purely inflammatory diseases such marked and distinct periodicity, and such obvious and decided intermissions and remissions. I cannot suppose that a degree of inflammatory ac- tion, sufficiently high to lead to a fatal termination, can be so far over- come and extinguished as to be nearly imperceptible to our senses, and the feelings of the sufferers themselves for hours, and then be re-es- tablished and rage for a short time, and disappear again of itself. I cannot believe that inflammation can be thus formed and become dor- mant, and then be rekindled for days, and finally removed by a dose of medicine, and a few grains of quinine. The very supposition is almost monstrous, and post mortem examinations in most cases display little or no inflammation. If these views be at all correct, they are the mere attendants of the disease in some cases, and not the sources of danger and death — the mere casual appendages, and not the disease itself.

I believe our disease is primarily and essentially seated in the ner- vous system ; but here it cannot remain long to any extent, without ne- cessarily extending itself, and diffusing its deleterious influences to other systems, and different organs, to the fluids as well as the solids. But to the nervous system we must look for the source of symptoms and danger. On it the malarial poison makes its first impression, and produces a prostration of the nervous power to a greater or less de- gree. The nervous power being diminished or prostrated by this morbid impression, we must look in the first place for its effects on the organic functions, and we soon find them involved in many abnor- mal and irregular actions. The nervous fluid or power being supplied in smaller and lessened quantity or force, we perceive a want of ac- tion in the capillaries and extreme blood vessels, and coldness on the surface. The extreme blood vessels seem to collapse, because they circulate now little blood, and do not receive their due proportion of nervous influence, which is necessary to this as well as every other part of our organism, for the easy and normal performance of its func- tions. The blood enters these extreme arteries on the surface, now in an enfeebled condition, with great difficulty, and circulates through them with a slow and obstructed progress. Hence we observe much shrinking, contraction and paleness on the surface ; and when the blood which passes on reaches the veins, it is there congested or stagnates, and produces the lividness, and finally, in extreme cases of this disease and cholera, the cyanotic appearance so frequently ob- served. The want of due innervation at length becoming extreme, these vessels allow the watery or serous parts of the bloodto escape from them, and we have copious and profuse sweats ; and in cholera, from a similar and perhaps identical condition of the capillaries on the intestinal surface, the serous and other discharges, which we observe in that disease. The great coldness on the surface and in the breath arises from a deficient decarbonization and calorification of the blood

64 MERRITT ON CONGESTIVE FEVER.

in the lungs, occasioned by the great general and local irregularity of the circulation.

The " function of respiration also suffers from the same deficiency of nervous influence ;" and the circulation of the blood through the pulmonary arteries, being languid and slow, or impeded, the necessary changes for its purification do not take place. We therefore have very often great anxiety and oppression in the chest, difficulty of breathing, and deep and frequent sighing. The sickness of stomach and the inces- sant vomiting and purging must be attributed to the same causes, and we may have these symptoms prevailing to an almost insufferable ex- tent. The distressing sensations experienced in syncope from loss of blood, and in a semi-paralyzed limb, are to be ascribed to a similar want of local innervation. Serous discharges from the bowels may be compared to profuse sweatings from the surface, being evidently analogous in their origin and nature. I will only notice, in addition to these symptoms in this place, the intense thirst and great internal heat of which the sick complain so much and so loudly. It is known to all physicians, that great and most distressing thirst prevails in every dis- ease, and in every condition of disease, where the blood vessels in their capillary extremities are pretty well emptied of their blood, whether this emptiness be brought on by direct loss of blood, or the usual course of this or other diseases. The very frequent sensation of in- ternal and the more rare sensation of external heat, are only examples of deranged sensibility arising from the irregular and anomalous ac- tions of the nervous system from imperfect and deficient innervation.

The heart, pulmonary and systemic capillaries, thus suffering from a deficiency of nervous supply, arising from the prostration, in a greater or less degree, of the whole nervous system, we have, of course, accumulations or congestions of blood in the veins and great internal organs, and especially those connected with the portal circulation.

This state, modification or species of miasmatic fever often presents itself under the intermittent, remittent, and less frequently, the conti- nued variety. But in such cases as appear to be continued in the com- mencement, the patients surviving, and the disease being partially or wholly unchecked for two or three days, an intermittent or remittent garb is generally assumed, and we have quotidian, but oftener tertian or double tertian paroxysms, the alternate paroxysms being alike, and occurring frequently at different hours of the day, and with varying relative severity. It presents very different and proteiform pheno- mena, depending in a great degree on the direction of its chief attack. I have already said the organic functions were in many cases espe- cially affected, but in not a few subjects the animal seem to be chiefly implicated. In the former, we trace the leading evidences of disease in the organs of digestion, respiration, secretion and circulation ; and in the latter, the brain and muscular system are the prominent suf- ferers. We also find different symptoms more obvious and promi- nent, as this or that organ has the chief impetus of the morbific cause directed against it.

The attack is usually preceded by feelings of languor and indispo- sition, giddiness or headache, and pain in the back, but at times it is

MERRITT ON CONGESTIVE FEVER. 65

very sudden, and gives little warning of its approach. It may occur at any time of the day, or in the night ; and it may present its severer characters at once, or differ in little or no respect from ordinary mias- matic fevers for days, if, indeed, it is at all different. In particular years, I have seen nearly every case of fever, when neglected or mis- managed, shew a most decided tendency to run rapidly into the form of fever now under discussion ; and I verily believe I have seen more cases of it at times, brought on in this way, than by the force of the morbific causes.

A chilly fit or paroxysm, differing in no sensible character from an ordinary intermittent or remittent, often ushers in this disease. The pains in the head, back and limbs ; the frequency, irregularity, and often the weakness of the pulse ; flushes of heat and cold, alternating with slight outbreaks of perspiration ; copious discharges of limpid urine ; slight nausea, and a dull, constricted, inelastic and harsh feel- ing of the surface, continue sometimes for hours, when they are fol- lowed by a re-action or fever more or less complete. This re-action is, however, often short in its duration, and followed by considerable relief from these symptoms. This respite lasts generally till the next day, or the disease may assume the tertian form, when these paroxys- mic symptoms re-appear, and are more severe, and followed by more dangerous phenomena; or these phenomena may be postponed till the disease has continued for several days. In many cases, the re- action is never complete, unless aided by medicine, but the conserva- tive powers of nature continue their efforts, as if tbey desired a full development of open fever. The symptoms, when this imperfect re- action and ataxic state are removed, and the disease fully formed, dis- playing in the organic functions its principal power, may now be suc- cinctly detailed. They of course do not all present themselves at the same time, or in one and the same case, but are generally to be ob- served during its progress more or less in every attack.

The pulse, though sometimes strong, frequent, laboring and irregu- lar, is generally quite small, quick, feeble, frequent and irregular, and not unfrequently fluttering, thread-like and intermitting. The number of pulsations in a minute vary from 110 to 160, or even more, and of course incalculable, though I have seen the pulse very weak, feeble and fluttering, and not frequent in a few cases. In a few cases it is not to be felt at all at the wrists, while the heart and carotid arteries beat rather violently. During the partial intermission or remission, the number of pulsations is lessened, and the volume and force of the arteries increased; but unless we now resort to prompt remedies, in order to avert the next paroxysm, the pulse each time becomes more frequent, feeble and irregular, until it entirely disappears.

The stomach is often extremely irritable, and throws up everything which is swallowed, very soon after it reaches its cavity. This is a most distressing symptom; and the vomiting being often very violent, with much retching, is accompanied by great tenderness and some- times pain in the epigastric region. The matter thrown up is some- times bilious, but oftener what has been swallowed, or a mucous or muco-serous fluid, occasionally tinged with blood. The bowels are

66 MERRITT ON CONGESTIVE FEVER.

generally, but by no means always, confined, and when moved, their contents appear unhealthy and offensive, but are sometimes wa- tery and tinged with blood, fetid, and resemble the water in which fresh meat has been washed. The respiration is very much altered, and accompanied by continued sighing in many cases. It is often " hurried, irregular and panting," and the patient complains of much " difficulty in getting his breath," and requires constant fanning, and desires every moment the accession of fresh air. Towards the close of the disease, the number of inspirations is generally greatly in- creased, but I have seen it in a few cases much diminished. The tongue is sometimes nearly natural in appearance, but it very seldom remains so long. At other times it is pale, cold, and covered with a whitish coat, which frequently becomes much thicker and darker, and brown, or brownish in the middle or over its whole dorsum. The mouth soon becomes full of a thick, tenacious secretion, and the teeth covered over with a dark sordes. The tongue and mouth, however, often become very dry, and sometimes quite red and glazed, many papillae appearing on the surface of the former in the last stage of the disease. The skin presents in many cases a most marked aspect. The hands, feet and face are pale ; the features sharp and shrunk, strongly expressive of uneasiness and alarm, which the patient does not appear really to feel. The eyes are bright, and sometimes very clear and brilliant, but after a while seem to sink in their sockets. Their membranes are sometimes slightly inflamed, secrete a thin fluid, and at last throw off a thick purulent matter, rather copiously. I have, in two cases, seen the whole eye altered in color, and the hu- mors very opaque and milk-like in their appearance, accompanied by total blindness, and a dead and shrunken appearance of the balls for several days. I feared at the time one of these patients, a little boy, would never recover his sight ; but his eyes, at once so discolored and collapsed, were at length fully restored. The general surface is cold and shrivelled, and after the sweating has continued for hours, the hands, feet and legs are like these parts in patients dying of cholera, or the hands and arms of a washer-woman. The patient, in this cold state, often complains of great and most distressing internal heat, and will bear no bed clothes. The thirst is a most striking symptom, and often very oppressive. The patient is continually crying out for water, and can never be satisfied, and whatever he swallows is returned very soon, even the little water from a melted pellet of ice. I have often been told by such sufferers, that they would swallow water, even if convinced it would kill them, so great and uncontrollable is the desire for it.

The secretions from the liver and kidneys are either very small, or suspended, and the same may be said of the secretions of the stomach and bowels in many cases. The hiccough is sometimes very distress- ing, and I have seen the patient nearly convulsed by it, the bed vio- lently shaken, and heard it at a distance of 200 yards. Along with these symptoms we have many others, the most prominent of which are, great restlessness and constant jactitation, an inability to lie in the same posture a moment, continual change of position, a moving from

MERRITT ON CONGESTIVE FEVER. 67

bed to bed, or from room to room, a perfect unconsciousness of danger; and when asked how he feels, the patient will often tell you " he is very well," and laugh at you when you tell him he is ill and must take medicine. The sick will at times walk about their rooms after they have lost their pulse, retaining in a great degree their muscular powers. The mind is often clear and unclouded nearly the whole course of the disease. While the skin is generally cold, there is often warmth about the forehead, breast, stomach and heart, and in some cases I have observed spasms in the thighs and legs. Deafness and haemorrhages are not uncommon, and general convulsions have occa- sionally occurred.

When the disease directs its chief force to the animal functions we have a different set of phenomena. Perhaps a slight chill is succeeded by drowsiness, the patient becoming in a short time comatose, and then stupid, so that he cannot be roused. The breathing is slow and stertorous ; the pulse is usually full and accelerated in some degree, but sometimes very slow. In children this form of the disease is often accompanied by convulsions, and I have often, in adults, seen the co- matose symptoms disappear in the remission and return with the pa- roxysm for several days. I might here add other symptoms, and trace those enumerated more fully, but perhaps I have said enough on this part of the subject.

I will now hasten to the treatment of this disease which I have found most successful. I can, perhaps, accomplish this object more clearly and satisfactorily, by giving a few cases, and their management, than in any other way, and conclude by some general remarks. Unfortu- nately for our profession, and more unfortunately for our patients, the ordinary treatment of febrile diseases is too often a temporising alle- viation of symptoms, or a remedial address to the phenomena, and not to the disease itself. Let us recur to the treatment, for instance, of a well defined case of bilious fever, with distinct and well marked tertian paroxysms, as it is frequently seen, and we find decided heat on the surface, activity of the pulse, torpor in the secretory organs, and the usual febrile symptoms after a chill. We perhaps bleed, and give a mercurial cathartic, which brings off bilious discharges with much relief. The next exacerbation approaches, is rather milder, and a similar course is pursued, and attended by similar re- sults. After several chills and fevers, the sulphate of quinine, or some tonic, is used, and the patient recovers, but is weak, emaciated, pale and anaemic in appearance, and we are told we were obliged to half kill our patient in order to cure him. This I have long considered one of the opprobria of medical science. But we have a more violent case, and after pursuing the above or some analogous practice for several days, it is true the fever is subdued, but too often the patient has departed with it. We look too much therapeutically to the symptoms, and use many other remedies in such cases, but our views of pathology are too confined, and our remedial applications quite too restricted. In the remission we have the most suitable time to combat the disease, and by such management we lose the first and most valuable moments, and our patients too often by such mis-

68 MERRITT ON CONGESTIVE FEVER.

management become typhoid or die. Let us, therefore, examine well into the pathology of disease, analyse its ravages on all the dif- ferent systems of our organism, address our remedies to the disease itself, and thus protect and save our patients, and adjust all the balances of the different organs.

Sept. 27th, 1832. I was called to see Mr. T. A., a wealthy and intelligent gentleman, of good constitution, and about thirty years of age. He had been sick about six days, and had taken several cathar- tics and other remedies. His face was pale and sharpened, his coun- tenance anxious, his extremities cold, and his whole surface covered with a copious perspiration. The pulse was weak, small and irregu- lar, and about 135 in the minute, with great sickness at the stomach and frequent vomiting of a muco-serous fluid. The headache, dis- tressing at first, had disappeared ; delirium last night ; tongue covered with a thickish white coat ; mouth and fauces dry ; thirst insatiable ; great restlessness ; sighing and jactitation ; hurried respiration ; no sleep for several nights ; shrivelled* and corrugated skin on the ex- tremities ; heat on the forehead and epigastric region, and a deficient secretion of urine, were some of the other symptoms. The pur- gatives had produced debilitating, watery evacuations, with little or no bile, and he had been in this state of collapse some fifteen hours. This case I consider a very fair specimen of very numerous cases that occurred, which were generally followed by fatal results in two or three days, unless promptly treated and relieved. The indications of cure were here, according to my views, an alteration of the secre- tions of the stomach, bowels, liver and kidneys, a determination to the surface, and a protection against the next paroxysm. To accom- plish these ends I gave him cal. 12 grains, opium l£ grain, and Dov. pow. 3 grains ; applied a large blister plaster, six by eight inches, over the stomach, and ordered the free use of the sulphate of quinine in four hours. I desired the action of the medicine and plaster to begin to bring the system under their influence before the use of the quinine was commenced. In a few hours he was composed, the sweating nearly arrested, the thirst, sickness of the stomach, and other distressing symptoms gone, and he, to use his own expression, " never felt so much relief in so short a time." The quinine was given in large quantity or doses, and sinapisms, with some warm stimulating drink, administered before the time of the next paroxysm, the next day, wholly averted it. He recovered at once, without one untoward appearance, and has enjoyed fine health ever since this attack. Some weeks since, in a conversation with me, he alluded to this attack of disease, and spoke of his relief as almost immediate and most surprising.

Sept. 2, 1826. I saw in consultation Col. , a strong, healthy

and athletic man, about 32 years of age. He was very much in the same situation as the preceding patient ; had been sick seven days, and the perspiration had continued some time longer. I recommended an immediate resort to the above course of treatment and decided sti- mulation. The delirium being considerable and having lasted for some time, fears were entertained of the use of opium and stimula-

MERRITT ON CONGESTIVE FEVER. 69

tion. I urged the absolute necessity of bold measures to fortify the patient against the next paroxysm, under which I was sure