The Project Gutenberg EBook of The Practitioner. May, 1869., by Various

This eBook is for the use of anyone anywhere in the United States and most
other parts of the world at no cost and with almost no restrictions
whatsoever.  You may copy it, give it away or re-use it under the terms of
the Project Gutenberg License included with this eBook or online at
www.gutenberg.org.  If you are not located in the United States, you'll have
to check the laws of the country where you are located before using this ebook.

Title: The Practitioner. May, 1869.
       A Monthly Journal of Therapeutics

Author: Various

Editor: Francis E. Anstie
        Henry Lawson

Release Date: June 5, 2019 [EBook #59682]

Language: English

Character set encoding: UTF-8

*** START OF THIS PROJECT GUTENBERG EBOOK THE PRACTITIONER. MAY, 1869. ***




Produced by Richard Tonsing and the Online Distributed
Proofreading Team at http://www.pgdp.net (This file was
produced from images generously made available by The
Internet Archive)









                           THE PRACTITIONER.

                               MAY, 1869.




                        Original Communications.




               ON THE RESTORATIVE TREATMENT OF PNEUMONIA.

                 BY JOHN HUGHES BENNETT, M.D., F.R.S.E.

   _Professor of the Institutes of Medicine, and Senior Professor of
           Clinical Medicine in the University of Edinburgh._


I have long formed the opinion that the prevailing method of determining
the value of any particular medicine or mode of treatment is essentially
faulty. Practitioners, after watching a few cases, form a favourable
opinion of this or that mode of procedure; they then publish their
views, supporting them with their successful cases, and strongly
recommend them to the consideration of their medical brethren. Then
follow trials more or less numerous by others, some of whom think the
method recommended good, whilst others find it useless or injurious.
Such a system is characteristic of an imperfect acquaintance with
medicine, and during the progress of many centuries, while it has led to
some valuable knowledge, has for the most part only tended to
superficiality and the utmost contrariety in medical practice. What
seems to be necessary at present for determining the real value of any
kind of treatment is—

  1st. Rigid accuracy in the diagnosis of the case.

  2d. A clear comprehension of the nature of the pathological condition
    treated.

  3d. An acquaintance with the natural progress of the disease.

  And

  4th. A tabulated account of the cases treated, showing the care with
    which they were observed, and their chief symptoms, including the
    time they were under treatment, and the termination in success or
    failure.

Doubtless this method of determining the value of any treatment requires
a high degree of medical knowledge, and some trouble; but I would
suggest that it is the only one capable of inspiring confidence and
permanently advancing the interests of the medical art. If it cannot be
carried out during the exigencies of every-day practice, there is
nothing to prevent its prosecution in our public hospitals, where the
patients are under constant observation, and where there are in many of
them a staff of assistants whose business it is to make the necessary
records.

The chief obstacle to obtaining accuracy in result is the general
conviction among medical practitioners that a different treatment is
required, even in fixed morbid conditions, according to the symptoms
which may be present. The progress of diseases is never absolutely
uniform, and no doubt the occurrence of particular phenomena often
require special interference. This secondary treatment of symptoms,
however, should never be allowed to interfere with the primary
management of the morbid condition; and it is the neglect of this rule
which has led to such injurious results in the treatment of many
diseases. If, for example, in order to relieve cough in phthisis we give
opiates and expectorants, how can we maintain the appetite and improve
the tone and digestibility of the stomach, on which the assimilation of
food, cod-liver oil, and nutrition essentially depend?

Since the publication of my papers and treatise on the Restorative
Treatment of Pneumonia I have watched with great interest what has been
published by the profession on this subject. The only published series
of cases that I am acquainted with is given by Dr. T. N. Borland, of the
Boston City Hospital, U.S. He tabulates according to the form I
recommended 90 cases of pneumonia, of which he says twelve died—a
mortality of one in 7½ cases.[1] Of these, four had phthisis; two were
chronic, having been admitted on the eighteenth and twenty-first days of
the disease; one was utterly prostrated on admission, and died the
following day; one was a case of surgical injury, transferred to the
medical wards on the occurrence of fatal pneumonia; and one was a case
of typhoid fever—leaving only three fatal cases of true primary acute
pneumonia. Of these, one died of cerebrospinal meningitis; a second
suddenly, from supposed embolism; and a third, from extensive double
pneumonia, with violent delirium. Details of the post-mortem appearances
are much desired in these fatal cases. A rigid scrutiny into the true
character of these cases therefore shows, instead of a mortality of one
in 7½ cases, as is alleged, a real mortality of only one in 27
cases—that is, three deaths in 82 cases.

Since I published the accounts of 129 cases, on which my statistics were
founded,[2] with four deaths, and a mortality therefore of one in 32¼
cases, I have treated in the clinical wards of the Royal Infirmary 24
other cases, with one death. This increases the mortality to 1 in 30⅗,
in the total of 153 cases. Of these a tabulated account will be
published, without which I venture to say little information can be
obtained with regard to the results of any kind of treatment. Of this
the analysis of the Boston cases offers sufficient proof; for although
Dr. Borland says: “The greater proportion of these cases have been
treated according to the plan set forth by Dr. Bennett, by restoratives
directed to further the natural progress of the disease,” he does not
appear to have remarked that all my cases were those of acute primary
pneumonia, and not consecutive or secondary cases in individuals
weakened by phthisis, broken down by long starvation and surgical
injuries, or such as have become chronic with gangrenous abscesses.

Dr. Popham of Cork[3] tells us that he treated 30 cases of pneumonia by
the restorative plan, and that, with the exception of two who were
admitted in a dying state, all recovered. In 28 cases, therefore,
admitting of treatment, all recovered. It is much to be regretted that
these cases were not tabulated, so that the reader might judge of their
extent, severity, and progress. We are told, however, that six were
cases of double pneumonia; in eight the left lung only was engaged, and
the right lung in fourteen. Dr. Popham also tells us that instances
occurred so grave that he did not consider himself justified in trusting
to restoratives alone. He therefore gave 5 grs. of bicarbonate of potash
in mucilaginous liquid, and also employed epispastics. He is of opinion
that the alkaline salt diminished the viscidity of the sputa, rendered
the cough less harsh and the urine more alkaline. I hope Dr. Popham will
pardon me for believing that these supposed advantages are to a great
extent imaginary, and that his excellent paper can only be regarded as a
valuable contribution, confirming the advantages of the restorative
treatment.

An excellent example of a mild mixed treatment is described in a lecture
by Dr. Sieveking,[4] who, in opposition to the views I have advanced,
and the restorative treatment which has been proved to be so beneficial
in pneumonia, lays down for his students two principles. These are,
first, that pneumonia is not an entity, and second, that pneumonia
differs in type at one and the same time, and therefore demands a
varying treatment. As this last idea still extensively prevails among
medical practitioners, it may be useful to analyse the evidence
furnished by Dr. Sieveking of its correctness. It consists of four
cases, very imperfectly recorded.

_Case I._—A robust man, æt. 26, admitted on the sixth day with pneumonia
of lower half of right lung posteriorly. The treatment was confinement
to bed and low diet. On the thirteenth day there was debility, for which
quinine and ordinary diet was given. On the seventeenth day he was
discharged well.

Now I have little doubt, and the cases I have recorded prove, that if
this robust man had been well supported from the first he would have
recovered much sooner, and that the quinine was altogether unnecessary.

_Case II._—A healthy man, æt. 22, admitted on the seventh day with
double pneumonia at the bases, but to what extent is not stated: had
marked dyspnœa, and other apparently urgent symptoms. He was bled by
venesection to six ounces, and an acetate of ammonia mixture ordered,
containing 1/12 gr. of antim. tart. for a dose, to be taken every three
hours. On the following day there was great relief, and the disease was
“knocked down,” although it is stated that dulness over the bases
continued. He was dismissed cured “a few days” afterwards.

We have here the dyspnœa so commonly present in cases of double
pneumonia on the sixth or seventh day, which readily disappears by
itself, and is relieved by a warm poultice. It is supposed, however,
that a small bleeding of six ounces “knocked down,” or, as some call it,
jugulated or strangled the pneumonia. What really happened, however, was
that the dyspnœa and apparently urgent symptoms disappeared on the
eighth day, which is the usual occurrence. It is distinctly stated that
the lungs remained consolidated, so that no impression was made on the
disease. What is meant by being dismissed “in a few days” it is of
course impossible to tell.

_Case III._—A girl æt. 15, admitted on the eighth day, with double
pneumonia—the left side more affected than the right, but the extent on
neither side stated. She was ordered mist. ammon. acet. with small
quantities (?) of morphia. Two days afterwards articular rheumatism
appeared. On the following day six leeches were applied to the left side
with marked benefit, and a small quantity (?) of antimony was added to
the mixture. Dismissed cured on the thirty-second day.

Here was a case of double pneumonia and acute rheumatism running their
natural course in a weak subject. Is it to be supposed that six leeches
to one side modified the one, or that the “small quantities” of morphia
and other treatment influenced the other? Would not the course of both
have been shortened by a restorative treatment?

_Case IV._—A labourer, æt. 23, admitted on the eighth day, with
pneumonia below the fourth rib, anteriorly on the right side. “Six
leeches with saline mixture, containing 1/12 gr. of antim. tart.,
followed by a blister, appeared (!) to give temporary relief.” On the
twelfth day typhoid fever declared itself, with bronchitis. Brandy,
stimulants, and poultices were then ordered. Dismissed cured on the
thirty-fifth day.

Dr. Sieveking says of this case that probably the patient might have
done equally well without the leeches and tartar emetic. Of this there
can be no doubt. The progress of broncho-pneumonia is always more
tedious than that of simple pneumonia, and the recovery was further
delayed by the complication of typhoid fever. Can the treatment be
defended?

How is it shown in these four cases that the pneumonia in all of them
was not precisely the same, that it varied in type, or required a
different treatment? That it may be complicated with various diseases,
and be associated with strength or weakness of the individual attacked,
is no proof of any specific change in the disease itself. In this
respect it is in no way different at present from what it has ever been.
Then, as to treatment, can it be seriously maintained that the low diet
in the first case, that the loss of six ounces of blood in the second,
or the six leeches and other treatment in the two others, benefited the
pneumonia and hastened its resolution? Of this there is no proof
whatever. Unquestionably they tended to an opposite result, as would at
once be made apparent if Dr. Sieveking, instead of lecturing on four
cases, would tabulate one hundred cases so treated, and let us count
what follows. I submit, therefore, that the principles laid down by Dr.
Sieveking are in no way supported by his own facts; and, as they are
directly opposed to the conclusions derived from more extensive data,
they offer no evidence in favour of that mixed treatment which seems so
reasonable, and is so popular with many members of the profession.[5]

The question of blood-letting as a point of scientific practice has
again been raised by Dr. Richardson,[6] who, appealing to that love of
authority so powerful among medical men, asks—“Is it possible that
twenty centuries were grossly abused by the infliction of what in the
present state of feeling, was, on occasions, akin to crime? I believe
not.” He then proceeds to discuss ten propositions—or, as he calls them,
discoveries made by the ancients; and asks with regard to each of them
how far the application of them is sound and judicious practice. His
conclusion is, that blood-letting is still useful in some stages of
typhus fever; in cases where there is sudden tension of blood, of which
sunstroke is an example; in cases of chronic congestion of brain; in
cases of acute pain from serous membrane; in some classes of spasmodic
pain; in cases of sudden arrest of circulation from concussion; in cases
of congestion of the right heart; and, it may be, in extreme cases of
hæmorrhage. Above all, he says, “I claim for it a first place in the
treatment of simple uræmic coma.”

It is impossible to discuss at length, in this paper, all the important
practical points referred to by Dr. Richardson. But I shall refer to two
great principles in modern as distinguished from ancient medicine, which
I think must vitiate the most of his conclusions.

1. When the authority of the ancients is invoked to determine any
procedure in medical practice, we must remember that their idea of what
constituted disease consisted in the symptoms it manifested. When,
therefore, a symptom was diminished or removed, they regarded the means
they employed as having diminished or removed the disease. That a
blood-letting relieves the pain and dyspnœa in pneumonia is an
unquestionable fact. If employed early, it is true the symptoms
returned, and the remedy had to be repeated; but if carried out on the
fourth up to the eighth day, when, according to the extent of the
disease, these symptoms usually subside, and the exudation commences to
be absorbed, it appeared to act like a charm. It was then said that the
disease was knocked down, or strangulated; and if the patient recovered,
however lingering was his convalescence, the value of the remedy
appeared to be unquestionable. This idea, it seems, still prevails with
some physicians, as we have previously seen that Dr. Sieveking
instructed his pupils that he had “knocked down” a double pneumonia by a
small bleeding, although the condensation of the lungs—that is, the true
disease—still continued.

But modern research has demonstrated that there is no relation whatever
between the symptoms and the morbid state of the lung, which it is the
object of the well-informed physician to remove. It would be easy to
show that there are many cases where all the symptoms of a pneumonia
have been present, but where a post-mortem examination has proved that
there was no inflammation of the lung; and that a still larger number of
instances might be cited where fatal pneumonia has occurred without any
of its symptoms having existed during life. Such was the unacquaintance
of the past race of practitioners with diagnosis and pathology as now
understood, that no confidence whatever can be placed on their
impressions as to what disorders were or were not benefited by bleeding.

That in certain cases a full blood-letting modifies or cuts short
symptoms, I agree with Dr. Richardson in thinking is just as manifest a
truth now, as it was to Galen or Cullen. But I claim for the modern
physician a knowledge and a power far beyond that of alleviating
symptoms: viz., a true knowledge of the lesion which causes the
symptoms, and the power of conducting the disease to a rapid favourable
termination, notwithstanding what appears to the inexperienced or
uninformed the most alarming and fatal phenomena. He is enabled to watch
with accuracy by means of his stethoscope the removal of the
consolidation of the lung, to favour the resolution of the exudation,
and to assist the excretion of the absorbed products from the economy.
These are the aims of the modern practitioner—not so much the
alleviation of symptoms as the removal of the morbid state—not soothing
his patient, but saving his life. That he is capable of doing this by
studying pathology and disregarding the authority of the ancients is no
longer a matter of opinion, but is positively demonstrated, by attending
to the other principle, which also is not referred to by Dr. Richardson.

2. In all the circumstances which Dr. Richardson thinks blood-letting
still useful, we have no solid foundation on which the practitioner can
repose with confidence as a general rule of practice. To refer to the
opinions of the ancients is, as we have seen, useless; and to support
their notions by citing one or two exceptional cases is of no advantage
whatever. Indeed the quotation of successful cases, without also stating
the failures that have been experienced, is the chief cause of the
imperfection of practical medicine. It has been demonstrated that when
the practice of bleeding in acute pneumonia was universal, the result
was one death in three cases. That was what occurred in the carefully
diagnosed and picked cases of M. Louis, as well as what happened in our
best hospitals. In those days practitioners triumphantly pointed to the
two cases out of three that they snatched from what was then considered
a fatal attack of illness. Indeed it might easily be shown that the
worst practice might be defended by what are called successful cases. So
far from two survivors out of three being good practice, we have seen
that the abandonment of blood-letting and the adoption of a restorative
plan of treatment has resulted in diminishing the mortality to one in
twenty-seven or thirty cases.

What I object to in medical literature is that prevalent kind of
writing, which consists of plausibilities supported by successful cases.
What we have at present a right to expect in the way of generalization
or theory is that it should be based on positive researches, and not on
fallacious authority; and as regards practice, we should have a
reasonable number of cases recorded, in which the failures are given as
well as the successes. To say that this or that treatment is good,
because this or that case recovered, is of no advantage to medicine,
unless it stimulate the practitioner to record his cases, tabulate the
result, cease from vague opinion, and demonstrate the exact ratio of his
success. It is satisfactory for the present state of medicine that such
is the kind of inquiry now prosecuted by our most intelligent
physicians.

When, therefore, Dr. Richardson is of opinion that a restoration of
blood-letting is useful in some stages of typhus fever, and other
circumstances previously referred to, I venture to think he should show
how the mortality of that disease would be diminished thereby, when
contrasted with the nutrient system of management introduced by Dr.
Graves of Dublin. The same argument refers to other cases he has
referred to. I believe with him that there are instances of uræmic coma,
in young and vigorous subjects, which may be cured by blood-letting, but
as we have not yet accumulated a sufficient number of such cases it
would be premature to speak confidently of the results.

But with regard to the treatment of acute pneumonia I regard the
following axioms as fully established, viz.:—

1. The great end of medical practice is to remove the consolidation of
the lungs and restore those organs to their natural condition as rapidly
as possible.

2. To this end everything that diminishes vital strength should be
avoided, and nutrients administered as early as possible, to favour the
cell transformation necessary for removing the exudation from the lungs.

3. There is no relation between the violence of the symptoms or force of
the pulse and the fatality of the disease. Young and vigorous subjects
suffer most, but almost always recover soonest.

4. The weak pulse, want of reaction, non-disappearance of the pneumonic
consolidation, or its appearance during the progress of exhaustive
diseases, are the unfavourable signs of pneumonia.

5. Continued exercise or work after the attack; low diet, large
blood-lettings; depressants, such as tartar emetic and sedatives;
expectorants, such as squills and ipecacuanha; mercury and violent
purgatives, are opposed to the restorative treatment of the disease, and
when not fatal, tend to prolong its duration.

6. Small blood-lettings of from six to eight ounces may be used in
extreme cases, more especially of double pneumonia or of
broncho-pneumonia, as a palliative to relieve tension of the
bloodvessels and congestion of the right heart and lungs.

7. Local pain is best relieved by large warm poultices.

8. The true disease, that is, the exudation which has infiltrated itself
through the pulmonary tissues and been coagulated, constituting
hepatization, can only be removed, first, by its transformation into pus
cells; second, by the molecular degeneration and liquefaction of these;
third, by absorption into the blood; and fourth, by excretion of the
exuded matter in a chemically altered form through the evacuations.

9. These processes are favoured by supporting the vital powers: first,
by rest in bed immediately after the attack; second, by beef-tea and
milk during the febrile period, with a moderate amount of wine, if the
pulse be feeble; third, by beefsteaks and solid food as soon as they can
be taken, with more wine or a little spirits, if the pulse falter;
fourth, by mild diuretics on the seventh or eighth day, to favour
excretion by the kidneys.

10. The same pathology and principles of treatment apply to all simple
cases of pneumonia, whether single or double—the latter being only
modified by the weakness of the patient, when more restoratives and
stimulants are required.

11. In complicated cases other treatment may be required, according to
the circumstances of the case; the pneumonia, however, being always
influenced in the manner previously detailed.

12. Since I commenced the treatment of pneumonia by restoratives on the
principles just detailed, in 1848, 153 cases of the acute form of the
disease have entered my clinical wards in the Royal Infirmary. Of these
129 were simple, and 24 complicated cases. They have been recorded by my
clinical clerks, and the progress of each case superintended by my house
physician. The whole investigation and the results have been arrived at
in public, before successive large clinical classes. Of the 129 simple
or uncomplicated cases, of which 35 were double, all recovered,
notwithstanding many of them presented the most apparently alarming
symptoms. Among the 24 complicated cases were five deaths—1 from
ulcerated intestines, 2 from cerebral meningitis, and 2 from uræmia
following Bright’s disease. Of the whole series, the deaths were 1 in
30⅗ cases. Among the simple cases, single or double, the mortality was
_nil_.




                     NOTES ON THE USE OF POULTICES.

    BY GEORGE W. CALLENDER,| _Assistant-Surgeon to St. Bartholomew’s
                               Hospital_.


Attention is at present attracted to various applications having for
their object the better healing of wounds and sores of different kinds;
but I should be sorry if, in the search after new, one at least of the
ancient remedies should fall into disfavour. It has been asserted that
poultices are often used to conceal defects of treatment, a kind of
refuge in ignorance of any more advantageous applications, and that they
often do positive harm by inciting profuse, and consequently exhausting,
suppuration, and, no doubt, it is true they favour the tendency to
suppuration which may exist in particular instances, and that they will
increase a suppurating discharge when the latter is already established.

Most remarkable results, however, follow the use of poultices in certain
cases—of lupus, for example. A woman attends at my out-patient room with
ordinary lupus which, when first seen, had eaten away the middle portion
of the upper lip, and had encroached upon the septum of the nose. A
bread poultice was applied day and night to the ulcerated surface, and
she took iodide of potassium. The sore was soon and completely healed.
After six months she returned with the disease worse than ever, but it
quickly healed again under treatment, and would, I am sure, remain well
if she were ordinarily watchful over it. As the iodide of potassium may
have had some influence in this instance, its use was dispensed with in
other cases. A woman was taken into Sitwell ward with extensive lupus of
the nose. It was with difficulty we persuaded her to submit to such
simple treatment as the application of bread poultices continuously to
the sore; she craved for physic, which was denied her. Very quickly the
sore healed, and she left well. It is needless to record other and
similar cases which have been treated in this simple fashion with the
same satisfactory results.

Some months ago a man was sent to me from Woolwich with an ulcer on the
outer angle of the orbit extending to the conjunctival surfaces of the
lids; it was irregularly scabbed over. In my opinion, and in this I was
confirmed by several of my colleagues, it was an example of so-called
epithelial disease; at all events it had been an open and increasing
sore for nearly five years, and before proceeding to remove it I agreed
to try the effect of some local caustic. To clean the surface a bread
poultice was applied, and it mended so much that this application was
continued, when great part of the sore healed rapidly, and the remainder
cicatrized after being touched with caustic zinc.

All surgeons are familiar with the good results which follow the
application of a poultice to an acutely inflamed surface-part. Quite
recently a woman has been under my care with inflammation of the tissues
about the internal saphenous vein. She has progressed quite well towards
convalescence by keeping the limb at rest, and by having the inflamed
vein-track covered with a large poultice of linseed meal; no other
treatment has been required. It is a common fault, not so much perhaps
in hospital as in private practice, not to give a poultice the chance of
curing a local inflammation by limiting its application to the part
affected. A poultice to be of any use should widely cover the tissues
which surround the seat of inflammation; for example, if the hand is
inflamed the poultice should not only completely envelope it, but should
extend at least half-way up the fore-arm: and this rule holds good
especially when poultices are used for superficial or for subcutaneous
diffused inflammation.

A little girl I saw recently in Sitwell ward had a fierce attack of
inflammation, after measles, which involved one side of her face and
neck. As it threatened to lead to suppuration we made three punctures,
carried deeply amongst the tissues, and then applied a succession of
large poultices to the entire of the affected side. In twenty-four hours
the child, from a condition of great depression, was well enough to
leave the hospital—the swelling was much reduced, probably by the
draining away of serous fluid, but no suppuration was established. I
often direct a bubo to be punctured with a grooved needle, the needle
being carried across so as to make a double opening; poultices are then
applied, and if the parts are moderately rested, the swelling will
usually subside; if the bubo is suppurating the same treatment will
suffice to evacuate the pus, and this having discharged the bubo
disappears, and no trace even remains of the openings through which the
pus has passed out. In cases such as those referred to, some without,
some with a surface lesion, the mischief is remedied without any
suppurative action being set up by the use of the poultices.

It is desirable, when there is much discharge into a poultice, to dust
over the skin about the openings whence the discharge issues some oxide
of zinc, or some other drying powder; if this precaution is not taken
the matter will irritate and probably enlarge the opening, or will
produce vesicles, which break and leave excoriations, or painful papulæ
on the adjacent integument. It should be remembered also that great heat
is not needed with the poultice; it should be comfortably warm to the
patient, and should never be allowed to get, by comparison with its
condition when applied, so cold as to lessen the temperature of the
part.

Ulcers of many kinds will heal rapidly when treated with poultices; and
when I use the word “rapidly,” I refer to comparative quickness of
healing, as ascertained by measuring the chief diameters of the
ulcerated surfaces; their progressive over-closing is thus very
accurately checked from week to week. This refers more especially to
ordinary ulcers, such as result from injuries. A boy now attends in my
out-patient room who under this treatment is healing up a sore on the
fore-arm, the remains of a bad crushing of the part. Sometimes this
healing is hastened by dusting the ulcer twice daily with powder of
oxide of zinc before the poultice is at such times applied. In Sitwell
ward a woman is just well of a severe phagedænic sore involving the skin
over and below the knee. Mr. Cumberbatch, the dresser of the case, kept
the parts at rest by swinging the limb, and applied at first an ordinary
linseed poultice, then warm water dressing (another form of poultice),
and, to expedite the healing of a few remaining sores, some resin
ointment. The cure has occupied twenty-six days, a very rapid progress
considering the constitutional nature of the affection: no medicine was
needed.

I never could understand, seeing it is desirable to keep the parts
immediately after an operation warm and quiet, why those objects should
not be attained by the use of poultices; nothing I know of is more
efficient to lessen the trouble caused by the starting of a limb after
amputation, than the weight of and the resistance offered by a large
poultice surrounding the stump. But their employment is in disfavour,
first from the fear of their provoking recurrent bleeding, although this
reckons for little if due care has been taken to have the wound
thoroughly dry before closing it, and unless this care is taken there is
little chance of its uniting by the first intention; secondly, by the
prevailing notion that such union is prevented by the relaxing influence
of this kind of dressing. Wishing to put this to the test of experience,
the following cases, amongst others, were placed under treatment.

Having occasion to remove the larger portion of the left upper jaw of a
female, about forty years of age, I brought together the incised wound
of the face with wire sutures, and directed a bread poultice to be at
once applied and renewed at intervals. The entire wound united by the
first intention. A boy had his hand and fore-arm crushed by machinery,
and it was necessary to perform amputation below the elbow. The flaps of
integument were carefully adjusted, and the stump was poulticed. On the
ulnar side the tissues united without suppuration; on the radial a
portion of skin sloughed in consequence of the hurt it had sustained at
the time of the accident, and on this side consequently the repair was
less quickly completed. I recently amputated at the thigh, on account of
strumous disease of the left knee of a boy, and brought the flap
surfaces into apposition. The wound was at once covered with a linseed
meal poultice. The next day, the stump being swollen, the wire sutures
were cut. Bread poultices, and then warm water dressings, were
afterwards employed, and the wound healed without any suppuration having
been set up by the action of the local remedies. What pus did form was
no more than might have been expected from incomplete primary union of
portions of the cut surfaces.

I should like to see a more extended trial given to applications which
keep a wound warm and moist continuously from the time of the operation.
I think their use would give satisfactory results. No doubt they are
most serviceable remedies throughout various forms of ulceration, and
especially so in cases of lupus.




   THE HYPODERMIC INJECTION OF MORPHIA IN MENTAL DISEASE: A CLINICAL
                                NOTE.[7]

             BY C. LOCKHART ROBERTSON, M.D. CANTAB., F.R.C.P.

 _Medical Superintendent of the Sussex Lunatic Asylum, Hayward’s Heath._


In the first number of the _Practitioner_, July 1868, Dr. Anstie has
published a Paper on “The Hypodermic Injection of Remedies,” in which he
truly says, that despite the satisfactory working of the method and of
the greatly increased power in handling remedies which it gives us, it
is still very much unappreciated. Believing that this remark applies
even to the employment of the hypodermic injection of morphia in the
treatment of mental disease, I venture on this occasion to lay before
the Medico-Psychological Association in the half-hour we devote to
Clinical Discussion, a brief outline of three successful cases
illustrating the treatment by the hypodermic injection of morphia in
recent mania, chronic mania, and melancholia respectively.

In October 1861 Dr. W. C. Mackintosh published a Paper in the _Journal
of Mental Science_ on “The Subcutaneous Injection of Morphia in
Insanity,” which first drew my attention to this method of treatment. In
the Reports of the Somerset Asylum, Dr. Boyd has also recorded his
opinion of the value of this treatment in cases of maniacal excitement
with sleeplessness, and in that form of destructive mania accompanied
with dirty habits.[8]

The detail of the hypodermic method of treatment is carefully stated in
Dr. Anstie’s Paper, and to this I must refer those who desire farther
information regarding it. I use a solution of 6 gr. of the acetate of
morphia to the drachm; Dr. Anstie’s strength is 5 gr. I always commence
with ♏︎v of the solution (½ gr.), and in only one case out of many
hundred hypodermic injections of morphia has any injurious effects
followed the remedy thus used.

CASE I. _Recent Mania._—J. H. W., No. 1,563, female, aged 20, single;
domestic servant. Form of disease, acute asthenic mania.

_History._—Never had any previous attack. No history of insanity in her
family. Has been engaged for some years as a domestic servant. No reason
can be given for her illness. It is stated that for the last three or
four months she has been strange, and at times depressed, and that about
three weeks ago she suddenly became maniacal, and has remained in a
state of violent excitement ever since.

_Progress._—On admission at Hayward’s Heath, on the 22d of March last,
she was in a state of the most intense maniacal excitement, and very
incoherent. Physically, she was suffering from marked typhoidal
symptoms, her pulse was feeble and very rapid, her skin dry and harsh,
her lips and teeth covered with sordes, her tongue coated with a thick
creamy fur. She refused all food, and had had no sleep for several
nights.

Although she could not be prevailed on to take any solid food, she was
coaxed at times during the first two days after her admission to take ½
gr. of morphia in a little brandy, but she was almost invariably sick
after it; moreover, the excitement continued, and she could obtain no
sleep.

On the third day the hypodermic injection of ½ gr. of morphia was
commenced, and continued every four hours except during the middle of
the night. On the fifth day she was calm, although incoherent, and had
slept during the whole of the previous night, took her food well, and
had lost nearly all the typhoidal symptoms. Moreover, the irritability
of the stomach was completely allayed.

She has since then recovered without a bad symptom, and she is now
convalescent.

This case showed in a very marked manner the advantage of the hypodermic
injection of morphia over its administration by the mouth in cases,
which so frequently occur, of acute mania with marked asthenia and
irritability of the stomach, causing refusal of food.

CASE II. _Chronic Mania._—W. H., No. 950, aged 68, single, groom. Form
of disease, chronic mania, characterised by frequent recurrent attacks
of maniacal excitement.

_History._—Strong hereditary taint of insanity. Nearly all his brothers
and sisters are more or less insane or eccentric. Much given to habits
of intemperance, but, although often strange and eccentric, was never
sufficiently insane to warrant his being placed in a lunatic asylum
until he was 64 years of age, when he was attacked with acute mania and
removed to Hayward’s Heath.

_Progress._—During the attack of mania under which he was suffering when
admitted into the asylum he was treated with small doses (♏︎x) of
tincture of digitalis every four hours. The symptoms lasted for nearly
three months. He was then calm for many weeks. On the next outbreak of
mania, equal parts of liq. opii were added to the digitalis, and with a
beneficial effect, the attack not lasting so long.

He was thus treated for some two or three years. He generally suffered
from three or four attacks in each year.

In April 1868 he had an unusually severe attack of excitement, combined
with much noise and destruction of clothing. The usual medicines having
no effect, he was treated with the subcutaneous injection of morphia (½
gr.) three or four times in the twenty-four hours, and with marked
benefit.

On the recurrence of the next attack subcutaneous injection was had
recourse to at once, and the period of excitement was reduced to little
over a fortnight.

The next attack passed off in an equally satisfactory manner. In the
January of the present year an attack of recurrent mania being evidently
imminent, the old treatment of digitalis and opium was tried for fully a
fortnight, but without benefit. On February 8th ½ gr. of morphia was
injected, and the injection continued every six hours, and on February
10th (to quote from the case-book) he was decidedly improved and free
from excitement and noise.

Not only, therefore, is the duration of the attack of recurrent mania
diminished in this case, but during the attack the excitement is much
less intense under the hypodermic method of treatment.

CASE III. _Melancholia._—M. T., No. 1,397, female, aged 57, married,
domestic servant. Form of disease, acute recurrent melancholia.

_History._—No hereditary taint of insanity. Has been insane and confined
in asylums three or four times. She is temperate in her habits, and her
attacks of insanity appear to have followed on most occasions the
puerperal condition, but the present illness is stated to be due to
family troubles.

_Progress._—On admission she was suffering from the most acute type of
melancholia, combined with insomnia, refusal of food, and a strong
suicidal tendency. Moreover she was in a poor physical condition, having
lost much in weight, and being thin and anæmic.

In the first place she was treated with stimulants, sedatives, and a
nourishing diet, but she remained from May 14th, the day of admission,
until May 20th, without any improvement, and was becoming so reduced,
from want of sleep and constant worry, that her life was despaired of.
On the 20th May, 1868 (to quote from the case-book), “she passed a very
restless night, and is much exhausted this morning: injected acetate of
morphia gr. j, and she soon fell asleep; took her food well on awaking.”

On the 23d, “injected gr. j of morphia twice daily since the last entry,
and with decided benefit, and she is much less excited. Sleeps well, and
the suicidal tendency seems to have passed away.”

On July 15th the entry is as follows:—“Has improved uninterruptedly ever
since the last entry, and is now tolerably sane.”

She was discharged recovered on 7th December, 1868, and has continued
sane to this date, although in such a case another relapse is most
probable.




      ON THE THERAPEUTICAL VALUE OF THE INHALATION OF OXYGEN GAS.

                    BY EDWARD MACKEY, M.B. LOND. ETC.

 _Joint Professor of Materia Medica and Therapeutics in Queen’s College,
                               Birmingham._


Our ordinary medicinal agents are substances from the animal, the
vegetable, and the mineral kingdoms: the one here to be treated of is of
that class of remedies which includes the great elements or forces of
nature: such are water, in all the varied forms of bath; electricity, in
its different developments; air, in all its modifications of pressure or
composition.

It is unfortunate that the application of these mighty remedies seems
liable to degenerate into charlatanism: partly perhaps because they have
the power—_wrongfully_ claimed for quack medicines—of doing good in many
apparently different forms of disease; partly because their use must at
present be limited to the few, and does not admit of ready introduction
into the practice of the many.

Nevertheless, the truthful study of these agents offers scope for the
highest science, and promises therapeutical results of the highest
value. The following cases are offered as data for judging of the value
of one of them. I do not propose to treat here of the chemistry of
oxygen,[9] nor of its physiological effects, nor even of the objections
which have been urged against its use—but simply to state facts which
have come under my own observation.

CASE I. _Emphysema pulmonum (hereditary)._—A lady of 55 had been for
many years the subject of constant dyspnœa, increased on all movement,
and often amounting to a sense of suffocation. A physical examination
revealed sibilant râles with prolonged expiration heard all over the
chest, which was of large capacity and more than normally resonant on
percussion; the heart’s action was weak and the circulation embarrassed,
as evidenced by œdema of the face and extremities.

She was subject to attacks of bronchitis occasionally, but, at the time
of treatment, the general health was in fair condition; the prominent
complaint was the difficulty of breathing.

On July 5, 1868, she inhaled a mixture of 3 pints of oxygen with 30 of
air: the results were favourable. Within a few days the dose was
doubled, 6 pints to 60: soon the proportion of 8 to 60 was used: and
later, 12 to 60, and with this dose we seemed to obtain such good
effects that I did not think it necessary to increase it. The
inhalations were taken at intervals of three or four days for a space of
six weeks; after each one, the lady experienced marked relief, which she
expressed as being able to take a deep breath and get sufficient air—a
feeling not known for years; as being able to move with comparative
ease, feeling buoyant, and more like healthy persons should feel, than
she ever remembered.

The only definite effect upon secretion was a more copious and facile
expectoration, always produced, and lasting for a day or two; the effect
upon the circulation was not marked at the time, but some palpitation
occurred, generally in the nights which followed the taking of the
larger doses; no other unpleasant symptoms whatever.

In attacks of exaggerated dyspnœa, as they occur sometimes in the
emphysematous, and in those peculiar, nervous, irritable states apt to
be induced by mental causes in the subjects of weak hearts, I have known
her come into my consulting-room, inhale for half an hour, and express
herself cheerful and composed. Nor was this the effect of fancy; for, at
first, the lady had a prejudice against the plan; now she esteems it
highly, nor has she ever found relief at all comparable to this, from
the many medicines prescribed at various times by various practitioners.

CASE II. is of the same nature, and occurred in a gentleman of 24, who
had had good health till twelve months before, when he noticed for the
first time wheezing, and afterwards cough, traceable partly to the dusty
nature of his business, partly to wearing damp clothes. The chest
symptoms continued so bad as to confine him to the house for three or
four months; afterwards, he seemed gradually to recover under the use of
tonics and cod oil, and the influence of a warmer climate, and when he
came to me in January 1869 for the first time, he looked well; however,
he complained of debility, of constant dyspnœa on exertion, and of
exaggerated attacks of it occurring suddenly at times, of some cough and
of glutinous expectoration; if he attempted to live well, as he had been
told to do—meaning especially the taking of wine—he usually got an
attack of epistaxis.

Physical examination revealed a sibilus at the end of inspiration, and a
rhonchus with expiration over all the right lung, except the apex; the
chest was very fully developed and abnormally resonant.

I prescribed for him inhalations of oxygen in the proportion of 12 pints
to 60 of air, and he took these twice in the week for five weeks; after
each one he expressed himself in much the same manner as the last
patient, was conscious of a general feeling of renewed health, of a
greater power of breathing, and of facility of expectoration; great
improvement took place in his condition, and I think it must be credited
principally to the gas; for, although I ordered him 10 to 20 drops of
tinct. lobeliæ at night-time, and later on tinct. fer. acetatis and
frictions with the linim. tereb. acet., yet it is to be borne in mind
that he had previously had a fair trial of expectorants, tonics, and
even change of air, without anything like equivalent relief.

CASE III. _Phthisis pulmonalis._—Mrs. W——, æt. 31, who had lost her
father and sisters of consumption, consulted me in Dec. 1867. For the
last six months had had cough, for the last three had emaciated, and at
this time had the prostration, night sweats, diarrhœa, and hectic of the
third stage of phthisis; hæmoptysis had occurred several times: the
expectoration was generally purulent. There were violent pains,
especially over left chest, and examination revealed a fine crepitus at
apex of left lung. The patient was treated with ordinary medicines, and
improved gradually. Opium in the form of an atomized spray was found to
be the best medicine for relieving cough, and procuring sleep; tincture
of steel and carbolic acid used in the same manner relieved, to a
certain extent, the profuse expectoration; and although the case became
complicated with a peri-uterine hæmatocele, in February 1868 she rallied
from this also.

It was July 1868 before she could walk as far as my house. Her principal
symptoms then were debility, pains in the chest, cough, and copious
muco-purulent sputum. At this time she began inhalations of oxygen in
the proportion of 6 pints to 60 of air, increasing by degrees to 12
pints. She took eight inhalations at intervals of two days, and then
found the above symptoms so much relieved as to be able to omit all
treatment for a time. She herself attributed great benefit to the gas,
and was taking no other special medicine at the time. Since then she has
borne fairly well the cares of a large family. She has gained flesh, and
though there is still a frequent cough, and sputum, and a mucous râle
about the left apex (I examined the chest two days ago), the progress of
the disease is arrested for a time at least.

CASE IV. points precisely in the same direction. In May 1868 I was
consulted by a gentleman of 19, whose father died of phthisis. He had
been steward on board a packet plying between Liverpool and New York;
got wet through on his last voyage, lung symptoms soon set in, and he
considers that his present ones date from three months ago. He has
constant cough, for which he can get no relief, profuse sweatings,
hectic, and extreme emaciation; in short, all the ordinary signs of
softening tubercle in the right apex, and had been sent home by medical
men in Liverpool to Handsworth,—just to die. However, he too rallied
under careful nursing, and with the help of ordinary medicinal agents,
and by July was able to walk to my house, and begin inhalations of
oxygen in proportion of 6 pints to 60. At this time the above-named
symptoms were all better, and his principal complaint was of difficulty
of breathing, and of pain in the side of the chest, and these did not
yield to medicines or to liniments. He continued to inhale twice a week
for two months, and at the end of that time was sufficiently recovered
to seek for a situation. He is now in the employ of the London and
North-Western Railway Company, has gained two stone, he says, and is 6
ft. 4 in. in height. I had an opportunity of examining his chest last
week, and detected only dry and interrupted respiration in one apex. I
should add that he continued the tinct. fer. perchlor. and cod oil
during and after his treatment by gas; but he distinguished relief to
the dyspnœa from the gas alone.

CASE V.—Rev. W. M——, aged 34, lost father, brothers, and sisters from
phthisis. In February 1868, when I first saw him, the prominent symptoms
had lasted six months—the dyspepsia, the tight cough, the loss of voice,
and the emaciation.

In March the physical signs of phthisis were evident in the left apex,
as was ascertained by Dr. Russell, who saw the patient with me at that
time. I need not detail symptoms or treatment, as they did not differ
from what is usual; suffice it to say that improvement took place, but
was temporary, and in April we recommended him to visit Jersey. He was
there for three months (being considerably longer than I had intended),
and at that time he thought that he found benefit from the sulphurous
acid spray. However, he returned as bad, if not worse, than when he
went, with night sweats, extreme prostration, cough, difficulty of
breathing, and purulent expectoration. It was in this condition, and
when he had had a trial of almost every other remedy, including a
prolonged course of cod oil, that I proposed oxygen to him, and he began
it July 24, 1868, in proportion of 6 pints to 60, increasing gradually
up to 10 to 60, and taking this two or three times a week up to October
8, a period of 2½ months; during the whole course of the time, he had
expressed himself as much relieved, both as to breathing power, cough,
character of expectoration, appetite, and strength. He had gained
weight, and the malady was quiescent. He had been accustomed to come
from the country by train, and to ride back in a cab. On one unfortunate
day (October 8), which was cold and very wet, he got into a cab the
window of which was broken, drove six miles in the night air, in the
course of that night got a sudden pain in the side, and dyspnœa, and
when I saw him next day pneumonia had attacked the right lung, and he
was desperately ill.

Now the point of the case is this. It has been said that the inhalation
of oxygen is liable to cause inflammation of the lung. Did it do so in
this patient? That must be a question to be decided on the evidence, but
I cannot think that it did. The dilution of the gas was great; the same
quantity had been inhaled for weeks before without any injury, and the
other exciting cause was such a probable one. At the end of a month’s
time he was convalescent, and urgently requested the resumption of his
inhalations. I consented, and he again expressed relief from them,
especially as to the dyspnœa; but effusion in the right pleura came on
gradually, but too surely; for some time we saw the end approaching, and
he died last month. Almost to the last he expressed benefit from the
gas, and he certainly suffered less than any consumptive patient whom I
have ever seen.[10]

CASE VI.—I adduce as an instance of another variety of dyspnœa a
warehouse woman of 27, who had also lost several brothers and sisters of
phthisis. Had been much depressed by nursing the last one through a long
and painful illness; she came to me in June 1868, with symptoms of
dyspepsia and history of attacks of urgent difficulty of breathing
coming on generally at a fixed hour of 9 or 10 in the morning;
occasionally after later meals; she kept constantly sighing deeply, and
had various symptoms of hysterical temperament; had also cough and
viscid expectoration; but a physical examination revealed nothing very
definite—perhaps puerile respiration in one lung and diminished
vesicular murmur in the other.

She was treated for some weeks with various stomachic and tonic
medicines, and went into the country for a fortnight; but the symptoms
remained more or less.

It was during an attack of this spasmodic or hysterical dyspnœa that I
first administered oxygen to her, in proportion of 5 pints to 30 of air,
and again in a double dose, only on three or four occasions.

It is possible that these doses were not large enough for a fair trial;
but, however, I wish to record that relief was given, but it was slight
and not permanent. Eventually the patient recovered under the use of
bromide of potassium and quinine. She has since married, and is well.

CASE VII. _Chlorosis._—Miss P——, æt. 21, had been employed for some
years with very long hours of work in a small close room; was stunted in
growth, with chlorotic complexion, drowsiness, headache, palpitation,
dyspnœa, and great fulness of the thyroid gland. Menstruation still
occurred, though scantily, and at intervals of six to ten weeks.

She came under my care in January 1868, and after regulating her hours
and her food as far as possible I prescribed various preparations of
iron, of magnesia, of aloes and myrrh, baths, and liniments, &c.

There was a gradual improvement in her condition with occasional
relapses, which obliged her to remain under treatment for many months.
In October 1868 the prominent symptom was headache, violent and
pulsating, and it was for this that I prescribed oxygen, after the
failure of many medicines.

_November 8th._—Inhaled 6 pints diluted with 30 of air; pulse 96 before
commencing, had same frequency at the end; the only special symptom felt
was a sense of oppression at the chest, but the headache was not so bad
as usual that night.

_9th._—When she entered my room the headache was violent; she inhaled 12
pints in 60 of air, and before finishing, the headache had disappeared,
and she felt better; this occurred on several _though not on all_
occasions, but she continued the use of the gas for ten days only. She
was then obliged to be away for a time, and the headaches returned
shortly afterwards: relief had been given, but not permanently.
Perseverance here _might_ have shown good results, but an opportunity
occurring soon afterwards of a residence in the country for some months,
I recommended her to take advantage of it; she has recently returned
much improved in health, and is following her occupation again.

The two following cases are somewhat allied to the last, in being
disorders of secretion or excretion, and are examples of that so common
complaint in town people, hepatic congestion; the results were
exceptionally favourable, and although under ordinary medicines patients
generally improve in a satisfactory manner, yet the malady sometimes
shows such a disposition to return, that one really scruples about
prescribing over and over again rhubarb, magnesia, nux vomica, acids, or
blue pill.

CASE VIII.—Mrs. B——, æt. 40, mother of a large family, had been subject
to bilious attacks for many years, and had several times been under my
care. In May 1868 she had pain over hepatic region, depression, nausea,
headache, and yellow conjunctivæ; the stools were frequent, loose, and
pale; menstruation was profuse, and occurred oftener than normal.

She took at first dilute acids with tinct. rhei co. and improved, but
relapsed at the end of June, and it was then that I recommended the gas
to her; the prominent symptoms being headache, depression, complete loss
of appetite, and a constriction about the chest “as if she could not get
air enough:” menorrhagia had been going on for two days.

_June 23d._—Inhalation of 4 pints in 60: there was not any marked
effect.

_25th._—6 pints in 60, and before the inhalation was over the headache
was relieved, and all that day she felt “lighter” and better, though
rather strange; to bed early, and slept and woke without headache, the
first time for nearly twelve months, and was nearly free from her
shoulder pain.

_27th._—Dose repeated with similar good results, and no medicine taken;
the diet was regulated as it had been before. To be brief, she took
eight inhalations on alternate days, and at the end of that time was
well enough to do without treatment: not that she was quite well, but
restored to her ordinary health, and the improvement has up to this time
continued.

CASE IX.—A lady of 21, after a period of great mental anxiety and of
close application to business, began to feel extreme depression,
drowsiness, anorexia, headache, nausea, and interscapular pain; the
pulse was slow, the face pale; there were palpitation and dyspnœa
without signs of organic disease. The symptoms had lasted about two
months, when I first saw her in July 1868. She took alkalies, aperients,
and appropriate medicines, and on the 12th took inhalation, 7 pints in
60. Here again the same remarkable effect was produced, in relieving
headache before the end of the quantity. She continued to inhale a
little larger dose every third day for a fortnight, without taking any
medicine for the latter part of the time. She has remained fairly well
ever since, and voluntarily expressed the great benefit which she
derived from the gas, especially as to relieving a sense of constriction
across the chest and dyspnœa.

Both these cases were tolerably acute, and occurred in persons of
naturally “sanguine” temperament, but it is necessary to record that
another case which I have treated more recently,—a young lady of
“bilious” temperament, who suffered from hepatic congestion in a more
chronic form,—found no special effect whatever from inhalations taken on
alternate days, for a fortnight.

CASE X. was one of albuminuria in a lady of 57. The disease had
commenced four years before, and her health had been markedly impaired
for the last twelve months (dating from an attack of vertigo, and loss
of consciousness). Last winter she had had bronchitis. She was a lady
highly connected, and had been under the care of several eminent London
physicians, who had concurred in advising her to go into the country for
a time, and I was sent for to see her in November last, when she had
already been at a country-house in this neighbourhood for some months.

She was feeble, with pallid face and injected cheeks; extremities
œdematous; dyspnœa to a great extent on the slightest exertion; tendency
to fainting and giddiness; urine deposited urates, and gave a cloud of
albumen with the usual tests. Almost the only remedy which had not been
given to her was this gas. I requested her to write and ask her
physician if he concurred in its use; he wrote back to say “by all
means,” and on November 18 she began with 14 pints in 60 of air. The
pulse was 78 at commencing, and did not vary. She took it six times at
intervals of three days. I had anticipated good from it, but there was
really no marked effect. She thought, in fact, that her headache was
rather worse afterwards, but I think that was better accounted for by
the carriage drive to my house and the extra excitement.

Treatment was omitted for a time, and in the interval she got an attack
of subacute bronchitis; on recovery she hired an apparatus of her own,
and began, on December 12, 16 pints to 60. I consider that she had a
week’s fair trial, but at the end of that time, what with leakage in the
machine and non-arrival of gas, the lady’s patience failed, and the
treatment was not persevered with. I mention these matters as an
instance of one of the difficulties that an unusual mode of treatment
must necessarily contend with. However, the result of this treatment,
such as it was, gave no encouragement to persevere.

CASE XI. resembled the last in the fact of there being organic disease.
She was a delicate and refined lady, of the age of 34, unmarried. With a
history of some years of spinal debility, and of congestive headache, at
this time (September 1868) there was general prostration, numbness, and
tingling in various parts, a sense of suffocation and of constriction,
and partial loss of power over limbs; but worse than all, the attacks of
headache of frightful intensity, attended with throbbing, flushing, and
confusion of thought, and generally located over the left eye, which
then protruded very much. Of these and other symptoms, some were
explicable on the hypothesis of congestion of the spinal cord, and parts
of the cerebrum, while some suggested a grave suspicion of
ramollissement; others, again, of a chronic thickening of the membranes.
My opinion was necessarily doubtful, but with regard to remedies oxygen
offered a prospect of relieving at least some of these symptoms; it is
said to have done so in recorded cases. Moreover, the patient had had
the best obtainable advice in her own town of Wolverhampton and in the
city of Cork, remedies prescribed by her physician had not benefited
her, and for some months she had been under homoeopathic treatment at
home and at Malvern. I recommended her to hire an apparatus for her own
use; and on October 4 she began with 12 pints to 50 of air, the
inhalation to be extended over the period of one hour. The necessary
exertion tired her, and she felt no appreciable relief. I did not like
to wait longer without attempting to relieve by some of our usual
remedies, and I prescribed gr. viij pot. brom. with ♏︎viij. liq. ergotæ,
as having a special influence in equalizing the spinal circulation.

_Oct. 12._—Head bad, but not so bad as usual. On 15th, menstruation came
on, and aggravated symptoms somewhat.

I directed inhalations to be increased in strength every day, until I
reached equal proportions of air and oxygen—as much as 30 pints of each.

On October 21 had an attack of prostration to a more extreme degree than
ever known before; she seemed, in fact, at the point of death from sheer
exhaustion. And here again we are met by the important question—Was this
due to oxygen? for experience recorded of its effects seems to warrant
this apparent paradox, that although in many cases a stimulant, in some
it is a depressant; that although it will increase the vital powers when
only moderately depressed, it will tend to lower them when they are
already very much lowered.[11] Or, again, was the prostration due to the
bromide of potassium?

Candidly, I do not think that it was due to these causes, partly because
she had had no inhalation for two days before, and no medicine for three
days, and partly because a depression similar, though less in degree,
has followed menstruation on other occasions, and this had been more
profuse than usual.

For the time I gave her quinine and brandy and a little morphia, and on
the 23d permitted her to resume inhalation, beginning at 12 to 60; she
again gradually increased the dose to 30 pints in the day. For the
bromide of potassium I substituted small doses of strychnia. The
administration of the gas in varying doses was persevered with till
November 4—a full month altogether—then I recommended her to discontinue
it. The effect was certainly not marked; if there was any, it might be
in relieving the sense of suffocation, which was not so bad during that
month as it had been before and since; but on the whole the gas must be
considered to have failed in this case. However, it will be remembered
that many other remedies had failed also, and the further progress of
the case has convinced me of the presence of serious organic disease; it
is in fact two months since I have ceased to entertain or give any hope
whatever of this lady’s recovery.

CASE XII. was one of general debility with irritable heart. A gentleman
of 35, who had lost several brothers by phthisis, and had been subject
to unusual harass and exertion, began to lose appetite, to grow thin,
and to suffer from lassitude, dyspnœa, and palpitation. When he came to
me in May 1868, the symptoms had lasted for two or three months, but I
could detect no physical signs of disease. For some weeks he took
quinine, aconite, and cod oil, and applied belladonna; still he did not
improve much.

On June 21, he inhaled 4 pints mixed with 30 of air, and felt a “greater
lightness”—no increase of palpitation. After four days of treatment, he
got an opportunity of spending a fortnight in the Highlands, and I
recommended him to try the breathing of oxygen there. He returned home,
however, in July, not so much improved as we had hoped, and still
complaining much of soreness about the chest, and oppressed breathing.
From this time to September he took an inhalation every third or fourth
day, and with perceptible benefit. It is true that he took, for some
weeks of the time, the hypophosphate of lime and cod oil, but still the
effect of the inhalation in improving breathing power, and appetite
especially, was immediate enough to convince us that it had a large
share in his recovery. He has remained fairly well since.

To resume: 12 cases are here related; 2 of the 12 are of organic, and in
all probability incurable disease, and these 2 derived little or no
benefit from the inhalation of oxygen; the other 10 found benefit as
recorded, some more, some less, but all of a kind which I have not seen
given by medicine alone. It remains to ask—Is there any common character
by which we may connect together this series of cases, and which may
enable us to say, oxygen is good for such and such a class of cases, as
we say iodide of potassium or quinine is good for such and such a class?

I think that we may find some such common character in the presence of
congestion, especially venous congestion, whether of the liver, the
lungs, or the uterus: more than this I will not say at present; the
classification of carefully-observed cases, and a rational theory of
this “modus medendi,” are points that require special study, and cannot
be dogmatised upon until we have a wider basis of facts.




   ON THE HERPETIC FORM OF STRUMOUS OPHTHALMIA, AND ITS TREATMENT BY
                                ARSENIC.

                         BY ROBERT S. OGLESBY,
  _Assistant Demonstrator of Anatomy in the Leeds School of Medicine._


Strumous Ophthalmia, associated with herpes of the face, or as it may be
termed the herpetic form of strumous ophthalmia, is a disease so often
met with in general practice, and one so little amenable to local
treatment, that I venture to say a few words regarding its treatment
constitutionally. I should hesitate to occupy valuable time and space
with what appears to be a trivial subject, on which much has already
been written, did I not believe that by so doing additional light might
be thrown upon the subject. For several years past I have been
collecting evidence, carefully sifting and placing all well-marked cases
aside for special treatment. The results obtained in the earlier batches
of cases thus treated, decided me to continue such treatment for a
lengthened period. The evidence thus obtained being highly satisfactory,
other treatment formerly employed was abandoned.

During the time that has since elapsed, I have continued to employ the
same remedy with the same good results.

This form of the disease generally presents itself in fat, red-faced
children who have the appearance of robust health. On questioning the
parents, they will perhaps inform you that the child was but small and
puny at birth, and for the first few months of its life it was sickly
and delicate, and not until lately had it become so stout and healthy.
They attribute the change to the purer air the child now breathes, for
they have removed from a populous and unhealthy district to one less
crowded and decidedly more healthy.

In such a child we find traces of constitutional defect in enlarged and
rickety joints, a head big and ill-shapen, and an anterior fontanelle
not completely closed. We find a thick and prominent lip, conspicuous
for the extent of mucous membrane it shows.

The intolerance of light is so intense that the child cannot bear even a
moderate degree, but persists in burying its face in its hands, or
hiding from the light in some dark corner. But what strikes us so
forcibly, and what really is so characteristic of the case, is the fact
that the patient’s face is disfigured with patches of herpes,—a fact
which makes us hopeful, as these cases are as a rule the most amenable
to treatment. To cure the disease of the skin is to cure the disease of
the eye in the most rapid and satisfactory manner.

In the majority of the cases which have come under my care, the eruption
was confined to one-half of the face below the brow. In a small
proportion the side of the nose was not affected, and in several the
skin of the upper lip and chin escaped altogether. The vesicles in most
of the cases appeared to follow the course taken by those branches of
the infra-orbital nerve which supply the skin of the face.

My notes do not supply me with any case where the eruption invaded the
brow, although I may have overlooked some such case in my earlier
investigations on the subject. The eruption was often accompanied by a
febrile condition more intense than I have ever met with in the other
forms of strumous ophthalmia.

Before proceeding to active treatment, instructions regarding diet,
regulation of the bowels, &c. should be given. The diet should be
plentiful, simple, and nutritious; and all articles of food likely to
unduly tax the digestive powers (which are as a rule weak in such
children) should be carefully avoided. Strict attention should be paid
to the bowels, which ought to be opened at least once during each day,
but oftener if the appetite be faulty, the tongue loaded, and the fæces
light coloured and of bad odour. These preliminary instructions having
been attended to, special treatment may be adopted.

It is well to begin with small doses of the arsenic in form of Fowler’s
solution. Two drops may be given thrice daily, in some bitter infusion,
to a child between one and two years of age, and gradually increased to
four drops. Seldom is it requisite to further increase the dose. Arsenic
appears to exercise a marked control over the febrile symptoms of this
disease. As the herpetic eruption diminishes, the child ceases to shun
the light, and as the rash fades the pustule on the eye heals. The
benefit of fresh air in the more obstinate forms of the disease is well
known; but it is often difficult to convince parents that exercise in
the fresh air will benefit the child. They imagine that it is rather
hurtful than otherwise, because the intolerance of light is then a
distressing symptom, proper means not having been taken to shade the
eyes. A ready method is to place over each eye a pad of cotton wool, and
over the pads a bandage, which should encircle the head, and tie on the
occiput. The pads should be frequently renewed and the eyelids washed
with warm water.

In a future paper I hope to bring forward additional facts on the
subject, and conclude by giving the history of a number of cases.




                                Reviews.


  _Klinische Beiträge zur Erkentniss und Behandlung schwerer
    Krankheitsfälle._ Von Dr. ADOLF HERMANN. Primararzt in Pest. Wien:
    W. Baumler, 1868. Gr. 8vo. pp. 282.

  (_Clinical Contributions to the Diagnosis and Treatment of severe
    Cases of Disease._ By Dr. A. HERMANN.)

The preface to this work explains that the author enjoys, at the
“Israelitenspital” of Pesth, a considerable field of experience, but is
less overburdened with cases than are many physicians of hospitals where
people of all creeds are received, and thus has time to study them
individually with the greater care. We gather that this volume, which is
the fruit of official labours during two years, is the first of a series
which it is intended to publish, and it fairly enough fulfils the
promise which the preface holds out. One of the most interesting parts
of the book is the observations on “tuberculous” affections of the
larynx. We must say, however, that the general treatment of the subject
of tuberculosis disappoints us, and certainly does not come up to the
standard of accurate and careful work which the author has set up for
himself. It shows few traces of that wide acquaintance with modern
pathological researches on its subject which is more than ever essential
to the clinical observer who would throw any light, even by means of the
most diligent labours, upon those matters which are really the
_quæstiones vexatæ_ in regard to the nature and treatment of the various
diseases commonly confounded under the name of tubercle. The last
chapter in the book contains an interesting account of the author’s
experience of the hypodermic injection of remedies. We observe with
surprise that he comes to conclusions very unfavourable to the
subcutaneous use of atropine, which he almost totally condemns. We
entirely agree with him in the statement that doses as high as half a
grain, or even less, will at times produce some cerebral and vaso-motor
symptoms, but the persistent use of much smaller quantities does, we
believe, meet with quite a different and a much higher measure of
success. On the other hand, the author speaks with the warmest praise of
the efficacy of hypodermic injection of morphia in all kinds of
neuralgias; for these diseases he declares that there is no remedy
comparable to it.


  _Annuaire de Thérapeutique, de Matière Médicale, de Pharmacie et de
    Toxicologie, pour 1869._ Par A. BOUCHARDAT.

M. Bouchardat’s well-known compact little yearly volumes are always
welcome, and always useful; and this year the _résumé_ includes a rather
unusual number of interesting matters. The first thing which deserves
notice is the recent researches on the therapeutic action of arsenic in
phthisis; a subject which we have for some time past desired to discuss
in this journal, but have been prevented by want of space and time. The
very able paper of M. Moutard-Martin, read before the Academy in
November last, called forth a report from M. Hérard, which speaks in
such strong eulogy of the remedy as used in the manner and under the
conditions laid down by M. Moutard-Martin, that we are considerably
surprised to observe the small amount of notice which has been given to
the subject in England. Arsenic has of course been long known as a tonic
more or less applicable to phthisis, as to other states of debility. But
the points so sharply brought out by the French author—the limitation of
the therapeutic action of arsenic to the non-febrile periods and cases,
and (on the other hand) its extraordinary efficacy within these limits,
in restoring flesh and strength and general health, and wonderfully
amending the state of the lungs themselves—are so important that they
demand the serious and immediate attention of English physicians. M.
Moutard-Martin employs the remedy in pills, as being more convenient
than the liquid form; each of these pills (_granules de dioscoride_)
contains a milligramme (·00156 of a grain) of arsenious acid, with manna
and honey.

Another matter which deserves notice, and had escaped ours, is the
experience of M. de Beaufort as to the efficacy of iodide of potassium
in diseases of the lachrymal apparatus. This observer began by applying
the treatment to comparatively recent and slight cases of obstruction of
the sac and nasal duct, the result of coryza, chronic conjunctivitis,
&c. Obtaining a speedy cure in several such cases, he proceeded to try
it even in instances where a tough fibrous stricture had existed for a
long time. Even in such apparently unlikely circumstances, he has twice
obtained success by the treatment. Where there is lachrymal fistula,
following an abscess of the sac, the iodide is also very useful, but its
employment should be accompanied by applications of tincture of iodine.

A matter of some consequence is the opinion of M. Regnault respecting
the comparative activity of various preparations of digitaline. In his
preface to the seventh edition of Soubeiran’s _Traité de Pharmacie_,
this author remarks on the serious difference which exists between
various samples of so-called digitaline. He declares that he finds
himself driven to employ exclusively the _granules_ of Hornolle and
Quevenne. Under the head of digitalis also we may notice the employment,
by MM. Dumesnil and Lailler, of a combination of opium (in the form of
_extrait gommeux_) with tincture of digitalis. This appears, according
to the authors, to have a calming effect upon the excitement and
sleeplessness of insane patients, with less tendency, at the same time,
to congestive effects than is the case when opium is given alone. They
say that not merely does it produce better immediate effects, but that
it can be more harmlessly continued after the original excitement has
calmed down than other narcotics. But they remark that as digitalis, in
therapeutic doses at least, has a well-known tendency to wear out the
susceptibility of the organism for it, it is best to suspend its use as
soon as may be. Two formulas are employed by the author:—

                             POTION NO. 1.

                   Extrait gommeux d’opium   ⅓ grain.
                   Tincture of digitalis   7½ minims.
                   Syrup                   1 ounce.
                   Distilled water         5 ounces.


                             POTION NO. 2.

                   Extrait gommeux d’opium   ⅔ grain.
                   Tincture of digitalis   15 minims.
                   Syrup                    1 ounce.
                   Distilled water          5 ounces.

According to circumstances, the stronger or the weaker of these two
prescriptions is the allotted potion for twenty-four hours. We have
recounted all this gravely, but must not be expected to preserve our
gravity to the last. Not even the respected name of M. Dumesnil can keep
down an irresistible tendency to laugh when we are seriously told that
7½ minims of tincture of digitalis, taken in two separate doses in the
course of twenty-four hours, will avert the mischievous excitement which
might otherwise be caused by ⅓ grain of extract of opium similarly
distributed! That neither potion No. 1 nor potion No. 2 can be
considered a dangerous narcotic we quite allow; but we fancy that must
be because there is so little opium in either of them, not because there
is so much digitalis. In fact, if we might be allowed to make a delicate
suggestion to our therapeutical brethren of _Outre-mer_, it is, that
just now they are going the least bit in the world crazy over digitalis
and its wonderful properties. However, we have nothing but praise for
such researches as those of MM. Oulmont and Hirtz, already noticed in
these pages.

A small matter worth noting is the suggestion of M. Hager as to the bad
effects of _impure glycerine_ which are occasionally met with. It
appears that certain glycerines, which are locally irritant when applied
to the skin, prove to contain formic and oxalic acid; the latter is more
especially the irritating agent.

Some interest attaches to a comparison instituted by M. Rabuteau between
the action of sulphate of _soda_ and that of sulphate of _lithia_. The
former diminishes or removes thirst and produces constipation; the
latter increases thirst considerably, and causes copious liquid stools
and watery vomiting. The soda salt _dries_ the alimentary canal, the
other thickens the blood and pours out its watery element in abundant
intestinal secretions.

The chlorides of sodium and lithium present analogous differences. The
former does not purge when introduced into the veins, though it does
purge when given internally in similarly large doses. Its ormolic
effects are like those of sulphate of soda. Iodide of sodium has similar
differences of effect, according as it is given by the veins or the
alimentary canal. In short, the purgative effects of salines would
appear to depend on the metallic and not on the metall_oid_ element
which they contain.

We must finish this hasty notice with a _résumé_ of M. Rabuteau’s
ingenious theory as to the cause of the constipation which so often
succeeds saline purgation. According to him, if the dose of the saline
be large almost the whole is directly eliminated by the alimentary
canal; if it be medium, a part passes into the blood; if it be small,
nearly the whole of it is absorbed into the blood. In the first case,
purgation is violent; in the second it is slight; in the third it is
_nil_, and there is even constipation. But as a certain quantity of the
medicine may have been absorbed, even when there has been powerful
purgation, there may be consecutive constipation from the presence in
the organism of the purgative salt, which slowly eliminates itself from
the intestinal surface. Rabuteau inclines to think, though it is
impossible to affirm, that not merely saline, but other purgatives, show
analogous differences of action.

In concluding our notice of this _Annuaire_, useful and interesting as
it is, we cannot but repeat the complaint we made last year. It is
astonishing to what an extent the accomplished editor has ignored some
of the most valuable therapeutic work done both in Germany and in
England. We venture to say that he would have done better to attend to
these matters, than to fill so many pages as he has done with a
reproduction of his own papers on the etiology of saccharine urine,
which is clearly beyond the proper work of his _Annuaire_.


  _De la Médication Antipyrétique. Thèse de Concours._ Par le Dr. A.
    FERRAND, Ancien Interne Lauréat des Concours des Hôpitaux, &c. &c.
    Paris: F. Savy, 1869. 8vo. pp. 90.

  (_On Antifebrile Medication._ By Dr. A. FERRAND.)

The author of this treatise is a really distinguished man in the _jeune
médecine_ of France; and it is with a natural interest that we turn
somewhat eagerly to the pages of his thesis to discover what are his
ideas as to the part which treatment can play in pyrexia. One can hardly
do better, in reviewing his work, than select the chapter on the
“Indications in Fever,” as a kind of test object, to judge the quality
of his work. Judged by this test, it must be pronounced very good. In a
quiet and thoughtful manner, M. Ferrand inquires into some of the
deepest problems of the physiology and chemistry of fever, and really
hits, as it seems to us, most if not all of the principal difficulties
which are troubling the minds of the most advanced pathologists and
clinical observers in Europe. That he does not pretend to solve all
these mysteries is no dispraise to him, but the reverse: at any rate it
may be fairly said that he has carefully considered all the doubtful
points by the light of the best observations in nearly every European
country. If we were inclined to make any exception to his accuracy and
completeness of information, it would be on the score of what he says,
or rather omits to say, respecting the _rôle_ played by
hydro-carbonaceous foods in alimentation. He seems to us to greatly
undervalue, if not to ignore, the incalculably important results of
recent researches in deciding the rank of non-azotised aliments in
_feeding_, and consequently in great part _disarming_, the destructive
force of pyrexial combustion. He assigns, as it appears to us, an
altogether exaggerated importance to the secondary effects of pyrexia
upon the nervous system: while at the same time he appears inadequately
impressed with the enormous destructive incidence of febrile action upon
the tissues. Upon this point M. Ferrand would surely do well to consult
the description of what passes in the organism in pyrexia which was
given by Professor Haughton in his admirable address before the British
Medical Association at Oxford. He seems to forget, what Professor
Haughton therein so ably showed, that a typhus fever or pneumonia
patient lying still on his back, and with scarcely anything moving
except the organs of vegetative life, and the deep chemistry of the
tissues, does in fact a heavier day’s work than any healthy
labourer!—heavier, that is, as regards the inevitable destruction of
tissue that must go to the maintenance of the most elementary and
necessary acts of life, in the absence of the power to assimilate
ordinary nutriment. It is this defect (as we think it) in his physiology
which makes M. Ferrand’s practical remarks on alcohol so very inferior
to those which he makes, in the practical therapeutic portion of his
work, upon other agents which he thinks appropriate to the treatment of
the febrile state. His account of Todd’s doctrine and school is indeed
extremely inadequate, and proves, for the hundredth time, how much that
remarkable teacher has been misunderstood by the majority of those who
have criticised his opinions, or supposed opinions. Here is a sentence,
for instance, of M. Ferrand’s, which is nearly as incorrect as it is
possible for a sentence to be—“Alcohol, for instance, is ... stimulant
and resolvent in small doses; but in larger and more continued doses it
becomes antipyretic.” That is precisely what alcohol does not do. Given
in large doses (relatively to the needs of the organism), it becomes
eminently pyretic. It need not always raise the temperature of those
parts to which we apply the thermometer; but, assuredly, given in such
doses as produce phenomena of intoxication, it does most directly
increase and give a mischievous impulse to the destructive processes
going on in the organism.

We have no wish, however, to leave an unfavourable impression of M.
Ferrand’s very able pamphlet on our readers’ minds. On the contrary, we
refer them with confidence to the work as a repository of a large amount
of accurate and careful thought and observation on the nature and the
remedies of the pyrexial state.


  _A Practical Treatise on Perimetritis and Parametritis._ By J.
    MATTHEWS DUNCAN. Edinburgh: Adam and Charles Black. 1869.

Though we have nothing to do with the pathology of this work, it may be
as well to explain the meaning of the terms employed in the title, so
that the value of the author’s therapeutics may be the better
understood. Objecting to such expressions as pelvic cellulitis and
inflammation of the uterine appendages, Dr. Duncan adopts in part the
phraseology of Virchow, and employs the words perimetritis and
parametritis, the former to signify inflammation of the uterine
peritoneum, and the latter to imply inflammation of the cellular tissue
in connexion with the uterus. With the justification of such a
terminology we need not concern ourselves, but we may express a regret
that so much of the author’s observations are confined to the natural
history of these affections, and so little to the all-important problem
of treatment. In a work extending over nearly 250 pages, one expects to
find therapeutics represented by a greater space than that included in
about a sheet of printed matter. Our disappointment, too, is enhanced
when we find the author, in many instances, limiting himself to the
vaguest of generalities, and, while sceptical as to opinions which do
not coincide with his own ideas, credulous to a high degree on some
points of traditional medicine. The only methods of treatment on which
Dr. Duncan at all dwells are those of leeching and poulticing—save that,
in a few words on internal remedies, he urges the use of mercury to
produce slight salivation, and rejects, what many think so valuable, the
employment of opium. He is strong on the subject of poulticing, and his
statements are in accordance both with practical experience and _à
priori_ reasoning. He impresses seriously on his readers the importance,
during the acute stage, of keeping up the poultices constantly night and
day. As to blood-letting, his practice is definite, though his arguments
from physiology in support of it are, we must confess, insufficient for
us. Local leeching is, in his opinion, vastly superior in its effects to
more distant venesection; and doubtless there is much good in the
practice of applying a few leeches over the groin or to the perineum.
But the following argument in favour of the former plan of distant
blood-letting strikes us as being of that painfully unprecise character
which unhappily is so much associated with medical research:—

“The profession in this country at least has lost all faith in this
treatment, as well as in the corresponding doctrine regarding
venesection of special veins of the upper extremity in disorders of the
head. But enough remains in the well-known and, it appears to me,
well-founded belief in the value and efficacy of the pediluvium in
menstrual affections to prevent us from regarding these therapeutics as
absurd; and, although not dreamt of in our modern and too
self-sufficient medical philosophy, yet laws of sympathy between distant
parts may be discovered which will explain and inculcate some such
remedial measure, which now appears to be unreasonable.”

How, in the name of all that is “positive” in medical science, is
therapeutics to advance an inch while philosophers reason to truth in
this fashion? It would not be more absurd for a chemist to support a
gratuitous speculation on the faith of a future recognition of
phlogiston, than for an intelligent practitioner to establish a
therapeutical fact by argument such as that which Dr. Duncan employs.
When the author confines himself to telling us under what circumstances
blood-letting should be adopted, he gives us the result of a valuable
and wide clinical experience; but his hypotheses are, we confess, too
much for us. We cannot understand why Dr. Duncan completely overlooks
the subject of restoratives and tonics in perimetritis and parametritis;
and we should be glad to hear his reason for ignoring such very
important agents in the treatment of these affections.


  _The Atlas of Venereal Diseases._ By M. A. CULLERIER. Translated from
    the French, by F. J. BUMSTEAD, M.D. Philadelphia: Henry C. Lea,
    1868.

We wish for once that our province was not restricted to methods of
treatment, in order that we might say something of the exquisite
coloured plates in this fine volume; for the work is essentially one to
aid in diagnosis rather than to detail means of cure. The Atlas, which
Dr. Bumstead has not only translated, but very materially added to from
his own stores of knowledge, is in every respect a most useful work for
the practitioner, who is often called on to diagnose an affection which
in the absence of a truthful history may appear either syphilitic or not
in nature. With the aid of these handsome plates, there need be little
difficulty in the identification of a syphilide. It must not be
supposed, however, that therapeutics are neglected, or sacrificed to
etiology. Both author and editor give us a very full account of the
remedies now in vogue, and of their own clinical observations. We have
not seen anything on the subject of the hypodermic employment of
mercury, but the internal administration of the salts of mercury and
iodide of potassium is of course enjoined. Indeed, the chapters on the
treatment of syphilis are not the best. The section devoted to the
remedial measures to be attempted in gonorrhœa strikes us as being
copious and well arranged, and contains some sound, practical
commentaries by the editor, who disapproves of the porte-caustique and
other heroic modes, and recommends the use of an extremely weak
injection of nitrate of silver (gr. ⅙ to the ℥j.) every three or four
hours. His suggestions as to general treatment are equally judicious. In
every respect this Atlas will be found most useful for reference by the
busy practitioner.


  _The Medical Formulary, &c._ By B. ELLIS. Twelfth Edition, revised by
    ALBERT H. SMITH, M.D. Philadelphia: Lea, 1868.

The aim of this work is to supply the young physician with the means of
writing “elegant and judicious” prescriptions; and if we may judge by
its success, the book must be one which meets a want. But we cannot help
saying that the habit of writing “elegant and judicious” prescriptions
is one of the barbarisms of the practice of ancient times which we
should gladly see consigned to oblivion. It fosters charlatanism, and
utterly retards all efforts to found a rational system of therapeutics.
How can any logical induction, or any generalization of the slightest
value be drawn as to the remedial effect of drugs administered after the
mode laid down in such books as the “Formulary?” Without pausing to
consider a recipe for pills which are “elegantly” and alliteratively
styled “Chapman’s peristaltic persuader,” let us ask what can be the
judiciousness of the following marvellous concoction of substances?—


      _Elixir of Cinchona._

 ℞          Quiniæ sulphatis, gr. xxv.

              Quinidiæ sulphatis,

              Cinchoniæ sulphatis, āā gr. x.

              Sacchari, ℥xx.

              Olei anisi,

              Olei fœniculi, āā gtt. ij.

              Olei cinnamonii Zeylandici, gtt. vj.

              Olei cari, gtt. j.

              Olei aurantii, ♏︎xl.

              Spiritus Curaçoæ, f. ℥vj.

              Alcoholis deodorati,

              Aquæ rosæ,

              Aquæ, āā Oj.

              Caramel, ℨiij.

                    Misce secundem artem!


  _Conservative Surgery, with Reports of Cases._ By ALBERT G. WALTER,
    M.D. Pittsburg: Johnston.

This is a very verbose treatise on the mode of dealing with lacerated
wounds, &c. The author recommends free incisions along the whole length
of the limb, and the subsequent application of poultices and
fomentations, assisted by general and local supporting measures. As is
usual in such cases, he cites a vast series of cases, which, as is
equally usual, might be cited in evidence of a very large number of
different and conflicting propositions. There is some sense in the
author’s practice, but a terrible deal of nonsense in certain of his
physiological speculations.




                          Clinic of the Month.


=The Pressure and Ligature Methods of treating Aneurism.=—In the course
of a lecture on aneurism of the femoral artery Mr. Paget, adverting to
these two methods, speaks of them thus: “Taking large numbers of cases
of aneurism together, they are very nearly balanced, on the one side for
pressure, and on the other for ligature. In favour of pressure there is
the experience of the surgeons in Dublin. They seem to have a much
larger number of aneurisms, especially of aneurisms of the popliteal
artery, to treat than we have in England, and they have certainly a
large amount of success. I have no doubt this is in part due to a
well-arranged system, and to the house-surgeons and dressers acquiring a
more special skill than we have yet achieved. On the other hand, there
is the remarkable success attained by surgeons who have constantly
practised, with great skill, the ligature. The success of Mr. Syme in
the ligature of the femoral artery for popliteal aneurism has been so
great that any one who might fairly expect to attain nearly the same
measure of skill would undoubtedly follow the ligature rather than the
pressure. I would prefer, however, to leave the subject open for your
own observation, and say, endeavour to ascertain, as far as you may be
able, which are the cases for the ligature and which are those in which
pressure is more likely to lead to a good result. And in many cases in
respect of which you are doubtful, pressure may be tried first and the
ligature afterwards.” (See _Lancet_, April 24.)


=Treatment of Atonic Dyspepsia.=—Dr. Thorowgood, in a paper just
published, refers to the existence of torpor of the colon as a
complication in cases of this kind. In treating cases of dyspepsia
occurring in those who work hard with their brains and have but little
“tone” about the stomach and bowels, he is convinced that the more we
refrain from the administration of purgatives the better. At one time he
used to think that when the tongue was crusted a purgative could not be
amiss; but to whatever degree this holds good with strong country people
and over-fed townspeople, it does not apply to those who have feeble
appetite and who work hard. In these cases he has seen an acid mixture
or a chalybeate do more service in cleaning the tongue and promoting
digestion than alkalies or aperients. If the colon be filled with
scybalæ, the best evacuant is a table-spoonful of castor-oil in
peppermint water. When the constipation takes on a less or more
obstinate character, he uses a saline chalybeate in imitation of the
saline chalybeate waters of Kissingen, Harrogate, &c. In addition he
gives a zinc pill, with extract of henbane, at night. But he avoids the
use of opium. (See _Lancet_, April 24.)


=Anaemia and Chlorosis treated by Nickel and Manganese.=—Dr. Broadbent
lately read a paper before the Clinical Society (April 9th), in which,
on the principle that chemical substances closely allied have similar
action, he recommended manganese and nickel as substitutes for iron in
the treatment of chorea. He recorded various cases, in some of which
good results appeared to follow this method.


=Operation for Chronic Inversion of Uterus.=—At the meeting of the Royal
Medical and Chirurgical Society, on the 13th of April, Dr. Barnes read a
paper, in which he described a new operation for the relief of chronic
inversion of the uterus. He gave the statistics of the different methods
now in use. He stated that the ligature and excision were open to the
double objection that, besides being very hazardous to life, success was
only achieved at the expense of mutilating the patient. Forcible taxis
was a violent and often fatal proceeding. Sustained elastic pressure had
given remarkable results, but cases would occur where the constricted
cervix uteri would resist simple pressure. He then described a case of
inversion of six months’ standing, which had resisted elastic pressure
kept up for five days, and in which he resorted to a plan then
practised, he believed, for the first time, of making three longitudinal
incisions into the os uteri, so as to relax the circular fibres; taxis
then applied quickly succeeded, and the woman made an excellent
recovery. He proposed, therefore, as the best proceeding where simple
sustained elastic pressure fails, to make an incision on either side of
the os uteri, and then to re-apply the elastic pressure, as being safer
from the risk of laceration than the taxis. (See _British Medical
Journal_, April 24.)


=A Presse-artère for Compression of the Arteries=, which may be found
useful in some cases, has been described by Mr. B. Wills Richardson, of
Dublin. The tubular _presse-artère_ which he has invented is intended
only for immediate compression, but it was used with good result in the
amputation of the fore-arm. The new instrument is composed of two parts.
(1) A fine silver or a fine German silver tube. To the upper end of this
tube a small milled button is soldered. The button facilitates the
turning or screwing of the tube by the fingers of the surgeon. A female
screw is formed upon the upper half of the inside of the tube. (2) A
steel stem having two jaws at its lower end. These jaws are perfectly
smooth on their opposed as well as on their outer surfaces, and free
from any cutting edge. They are so arranged as to open and close
parallel to each other. At the upper end of the stem there is a handle
nut. It is hexagonal only in the present instrument; but, for
recognition in wounds, the handle nut of the _presse-artère_ intended
for large arteries should have some other form when more than one
instrument is in use. The nut is fitted to the stem by means of a square
mortise to prevent it from turning on the stem during the screwing or
unscrewing of the tube. The handle nut is secured in its position by a
smaller but screw nut. The upper half of the stem has a male screw cut
upon it, and is adapted to the female screw on the inside of the tube.
The inventor claims the following advantages for this piece of
apparatus:—(1) The smallness of the space it occupies. (2) Facility of
application and removal. (3) Accurate graduation of the compression by
means of the fine screw arrangement. (See _Medical Times_, April 24.)


=Catgut in the Ligature of Arteries.=—In a communication to the
_Lancet_, Professor Lister, after giving numerous pathological details,
refers to the practical importance of catgut as a ligature. He states
that by applying a ligature of animal tissue antiseptically upon an
artery, whether tightly or gently, we virtually surround it with a ring
of living tissue and strengthen the vessel where we obstruct it. This
antiseptic animal ligature consists of catgut steeped in carbolic acid
and oil. And with such a ligature Professor Lister says he should now
“without hesitation undertake ligature of the innominate, believing it
to be a very safe proceeding.” He thus expresses himself as to the
necessary qualities of the ligature:—“The method which I have found to
answer best is to keep the gut steeped in a solution of carbolic acid in
five parts of olive oil, with a very small quantity of water diffused
through it.” A larger proportion of the acid would impair the tenacity
of the thread. If a mere oily solution is employed, the gut remains
rigid, the oil not entering at all into its substance. But a very small
quantity of water, such as the acid enables the oil to dissolve, renders
the gut supple without making it materially weaker or thicker. And,
curiously enough, the presence of this small amount of water in the oily
solution gradually brings about a change in the gut, indicated by a deep
brown colour; after which it may be placed in a watery solution for a
long time without swelling, as a portion prepared in a simple oily
solution does. This is a great convenience; for an oily solution is
unpleasant to work with during an operation, and exposure to the air
soon renders gut suppled with water rigid from drying. But when it has
been treated in the way above recommended, it may be transferred to a
watery solution at the commencement of an operation, and so kept supple
without having its strength or thickness altered. “For tying an arterial
trunk in its continuity, catgut as thick when dry as ordinary purse-silk
will be found best. But for ordinary wounds, where, if one ligature
happens to break, another can be easily applied, much finer kinds may be
employed, and are convenient from their smaller bulk.” (See _Lancet_,
April 3.)


=The Advantages of Tracheotomy.=—Mr. T. R. Jessop corroborates the views
expressed in our last Number by Mr. A. E. Durham. He gives some very
remarkable cases, showing the great usefulness of the operation. Indeed,
one case was a veritable resuscitation of life. (Ibid.)


=Arsenic a Cause of Shingles.=—The very important problem as to whether
arsenic, when continuously administered, is productive of shingles, is
again discussed by Mr. Hutchinson. Mr. Hutchinson does not assert the
fact to be more than a coincidence, but he relates several very
interesting cases in which the prolonged use of arsenic was followed by
shingles. (See _Medical Times_, April 17.)


=The Treatment of Diabetes.=—Dr. Basham records some cases of diabetes
treated very successfully with alkalies and the phosphatic salts of
ammonia, and he expresses an opinion very favourable to this method of
treatment. The following is the prescription employed:—Phosphate of
ammonia and carbonate of ammonia of each ten grains, aromatic spirit of
ammonia half a drachm, water an ounce, added to the juice of a fresh
lemon, and taken three times a day. This line of treatment was continued
for four months, with the results tabulated below:—

                                                      Mean      Sugar
                                                    sp. gr.    per oz.
 September (began phosphatic salts)                   1037    18 grains.
 October                                              1040    18 grains.
 November (great increase of urates)                  1036    6 grains.
 December 4th (large proportion of urea and
   urates)                                            1018     ½ grain.
 December 28th (urea and urates in excess, a large
   crop of crystals of oxalate of lime after
   cooling)                                           1024       Nil.
 January 26, 1869 (same as above)                     1026       Nil.

(See _British Medical Journal_, April 10.)


=Silver-wire Ligatures for the Pedicle in Ovariotomy.=—Dr. Marion Sims
calls attention to a recent case in which he performed ovariotomy, in
order to explain his method of dealing with the pedicle. In the
particular instance the walls of the abdomen were so thick, and the
pedicle was so short, that it would have been impossible to secure it in
the usual way by the clamp externally. In such cases he has always held
that the pedicle is best secured with silver-wire ligatures and dropped
back into the pelvic cavity. “If the pedicle be small, it is enough to
transfix it with a double silver-wire and secure the two halves by
firmly twisting the wires on opposite sides.” If it be broad, it
requires a number of separate wires. This case required eight deep
silver sutures for closing the external wound, care being taken to pass
them through the divided edges of the peritoneal coat. A piece of lint,
wet with carbolic lotion, was laid over the wound, and secured by a
bandage, and a large compress of cotton wadding. The urine was drawn off
for three days. There was no constitutional disturbance, and the patient
was convalescent from the moment of the operation. (See _British Medical
Journal_, April 10.)


=Perchloride of Iron in Post-partum Hæmorrhage.=—Mr. Hugh Norris
corroborates the testimony of the various obstetricians who have spoken
so favourably of this styptic. Injections of strong solution of the salt
instantly arrest the hæmorrhage in this dangerous class of cases. He
noticed also that the perchloride has a peculiar corrugating effect on
the superficial muscular fibres, as well as on the mucous surfaces. He
has noticed in less than five minutes after injection that the sphincter
vaginæ, which had previously allowed the passage of the hand, became so
contracted that it barely admitted a single finger. From this he
concludes that one of its beneficial effects in these cases is the
contraction of the muscular fibres of the uterus. He lays down the
following conclusions in reference to this preparation:—(1) We possess
no topical styptic in efficacy at all approaching the perchloride of
iron; its effects being certain, perfect, and instantaneous. (2) In
_post-partum_ hæmorrhages, a solution of this salt, applied in the form
of an intrauterine injection, is of the utmost value both in immediately
arresting the flow of blood and also in causing a permanent contraction
of the recently emptied uterus. Its presence in the cavity of the uterus
_post-partum_ is not only not injurious, but on the contrary, from its
well-known antiseptic properties, may frequently be productive of
positive benefit in more ways than one. Mr. Norris employs a saturated
(?) solution of the perchloride. All clots must first be removed, and
the long tube of the syringe should be introduced thoroughly into the
uterus before injection. (Ibid.)


=The Cure and Prevention of Scurvy.=—In a paper in the _Lancet_, Mr.
Archer Farr starts a doctrine which is yet, we think, to be proved, viz.
that scurvy is not caused by the absence of certain alkalies and the
presence of others. Indeed, he refers scurvy to the absence on
ship-board of proper flesh-food, and he thinks that by supplying flesh
in thoroughly good condition scurvy may be avoided. Lime-juice acts, he
says, by taking the place of the gastric juice and digesting the food,
and thus promoting the nutrition of the body (!). (See _Lancet_, March
27.)


=Treatment of the Vomiting of Pregnancy.=—Mr. John Harrisson recommends
that in these cases hypodermic injection of morphia be tried. He gives
the report of a very decided and serious case, in which nearly every
conceivable remedy had been employed in vain. He then tried the
subcutaneous injection of acetate of morphia, in doses of one-sixth of a
grain, three times a day, and this instantly arrested the vomiting. (See
_British Medical Journal_, April 3.)




              Extracts from British and Foreign Journals.


=Carbolate of Soda as a Remedy for Itch.=—Dr. Zimmermann, of Braunfels,
remarks that no one who sees much of itch will deny that we are without
any remedy which acts with the certainty of a specific. In private
practice, where we cannot readily obtain the proper baths, frictional
manipulations, &c., cases are apt to be very inveterate. The popularity
of petroleum and Peru balsam is due chiefly to their being neither very
disagreeable nor very troublesome in the use; but petroleum has not
justified its reputation,[12] while Peru balsam, which really is very
valuable, especially in recent and in children’s cases, is unfortunately
very costly. Zimmermann is inclined to hope that in carbolate of soda he
has found a remedy that will cure scabies, _tuto_, _cito et jucunde_,
though his experience is not yet sufficient for absolute proof. He
employs a solution of 160 to 320 grains of the salt in about 7 ounces of
water; this is to be well rubbed into the affected parts thrice daily.
In two or three days every case of Zimmermann’s, even the inveterate
ones, has been completely cured, and this without any annoyance or
interruption of the patient’s ordinary business. There is no irritative
erythema of any consequence from the frictions. Carbolate of soda may be
used as a disinfectant and deodoriser; for this purpose 16 to 32 grains
to 7 ounces of water is sufficient. (_Der Praktische Arzt. März._)


=On the Contra-indications of Anæsthesia.=—M. Gosselin considers that
alcoholism renders patients very unfit for taking chloroform, and thinks
that to all persons above 50 years of age, and given to intemperance,
chloroformisation should be forbidden; or at any rate only applied with
the greatest caution, and never for a long time together. Professor
Nagel, of Vienna, has recently opposed this wholesale condemnation. In
delirium tremens, chloroform narcosis is often very useful, especially
where it is necessary to set fractures. The severest delirium, on which
large doses of opium produce no effect, has been repeatedly calmed by
chloroformisation in Nagel’s own practice. Alcoholism only so far
contra-indicates anæsthetics, that in refractory subjects it is
necessary to push the agent in such large doses that, even with the
greatest care, there is a risk of asphyxia.

An even more positive contra-indication to chloroform is found by
Gosselin in the case of stupor following severe wounds. No one will
dispute that narcotisation is at first entirely out of the question; it
only remains doubtful for how long a time after the injury it is unsafe
to give chloroform for operative purposes. Gosselin is for total
exclusion, since even after the apparent departure of stupor, a kind of
concealed shock to the system may still exist, and would render
anæsthesia dangerous. He also thinks that in recent dislocations,
especially of the shoulder, chloroform is not only usually needless, but
contra-indicated by the fact that the patient’s want of sensibility may
permit such force to be used as may inflict severe injuries upon the
nerve trunks; and even in old dislocations chloroform should not be used
till other means have been tried. This contra-indication, also, is
opposed by Nagel, who brings a large amount of experience to controvert
it; it even happens, sometimes, that the muscular tone can be
sufficiently relaxed for the reduction without any loss of
consciousness. The chief contra-indication to chloroformisation which
Nagel admits is the pre-occurrence of long-standing or considerable
(arterial) hæmorrhage, and advanced age, especially if there be also
heart or lung disease, vascular degeneration, emphysema, &c., also the
fact that the operation might cause blood to enter the larynx; and in
hernia, because of the tendency to vomit. He recommends the greatest
care in giving it to refractory patients, who struggle, scream, and hold
their breath. The danger of asphyxia increases every moment, and it is
necessary to have ready the means of throwing in a stream of pure air or
of oxygen, through the _nose_, sprinkling the patient with cold water at
the same time. Nagel has also observed that the restlessness and
oppression produced by half-felt pain in incomplete narcosis, and the
consequently insufficient respirations, may produce an even fatal
exhaustion. Narcosis should therefore be properly kept up as long as it
is wanted. (_Der Praktische Arzt._)

[It is very necessary that we should study the opinions of foreign
physicians and surgeons as to the dangers of anæsthesia. At the same
time, I think it right to protest here that the cautions given even by
Nagel, and still more those which Gosselin inculcates (with two
exceptions), are to me inexplicable. At least they can only be
understood upon the supposition that the means of inducing anæsthesia
which are employed by these authorities are extremely inefficient and
improper. A former very large experience of chloroform administration,
some years ago, impressed me with the confident belief that if
chloroform be given with proper care and with a Snow’s, or still better
a Clover’s apparatus, there is really no danger whatever in its use,
except in two cases—that of shock after severe injury, and that of
delirium tremens. I cannot admit that a patient who is in a fit
condition to undergo a surgical operation at all is placed in any worse
position for supporting the shock of it by the fact that he has been
chloroformised, if this has been skilfully done—the case of severe shock
from injury always excepted.—F. E. ANSTIE.]


=Subcutaneous Injection of Mercury in Syphilis.=—Dr. A. Stöhr records a
series of clinical observations on this method of treatment, which are
very interesting. He considers that the subcutaneous injection of the
bichloride is the most effective and direct means of producing the
curative effects of mercury which has ever been applied. Stöhr employed
the treatment for 96 patients; in almost all the cases it was carefully
ascertained that no specific treatment had been previously adopted. His
cases included a larger relative proportion of inveterate syphilis than
those treated by Lewin in his researches, described by M. Bricheteau in
the _Practitioner_ for March. Stöhr considers that the hypodermic method
is not needed for the milder forms of syphilis. Old and obstinate cases,
on the other hand, in which inunction or other forms of mercurialisation
have been vainly tried, are particularly appropriate for a trial of the
subcutaneous method. It is especially indicated in such cases as those
of iritis and of dangerous laryngeal affections, in which it is
important to produce a very rapid effect; also in severe and extensive
syphilitic skin affections, in which inunction cannot be applied.
Syphilis of the bones and periosteum, and syphilitic gummata, are but
little influenced by hypodermic mercurialisation. In cases accompanied
by severe marasmus, the hypodermic use of mercury is contra-indicated.
It is also inappropriate to the treatment of those persons who have to
be treated as _out_patients of a hospital. Stöhr employs a solution of
corrosive sublimate in distilled water: he had at first tried a solution
in glycerine, but this did not prove practically convenient. The dose
ordinarily used was ⅛ of a grain; the daily employment of this only
slowly produces ptyalism. When ¼ grain doses were used daily, the
slighter symptoms of ptyalism never failed to occur by the third or
fourth day, and the severer phenomena by the eighth or ninth; so that,
with few exceptions, the administration of 2 or 2½ grains in this way
produced such a strong development of salivation that the treatment had
to be interrupted. (_Deutsches Archiv f. klin. Med._ V. 3 and 4.)


=The Treatment of Diabetes.=—Dr. Leube gives an elaborate report of two
cases of diabetes in which he made the most careful daily observations
of the quantity of water, of sugar, &c. He arrives at the following
therapeutic conclusions:—Pure meat diet (with only _almond_ bread) was
the most powerful means of reducing the sugar excretion. Of drugs which
were tried, _arsenic_ had by far the most remarkable effect in reducing
the sugar. Saikowsky discovered, some three years ago, that the
continuous administration of arsenic for several days to animals
entirely removed all glycogen from the liver; and that then neither
puncture of the fourth ventricle nor curara poisoning would produce
diabetes at all. Leube made the therapeutical application of the drug
which these experiments suggest. He administered Fowler’s solution in
doses equivalent to about ⅓ grain of arsenic daily. The effects were
most striking during the period when the patients were taking a _mixed_
diet. With mixed diet, and without arsenic, the daily average of sugar
was 570 grammes in one case; arsenic reduced it to 352 grammes, on the
average of 79 day and night observations; and substantially the same
result was obtained in the other case. The use of this drug would appear
to promise results of real importance. (_Deutsches Archiv f. klin. Med._
V. 3 and 4.)


=A German Criticism of Lister’s Treatment of Abscesses.=—Dr. W. Rosco
publishes a very sharp critique on this plan of treatment, which has
lately become so fashionable. He analyses minutely the sixteen cases
which were published in the _Archiv f. Heilkunde_ (and reported in the
_Practitioner_ for July 1868), and maintains that the results obtained
were not more favourable, if so favourable, as those which are often
obtained without any use of carbolic acid. Rosco maintains that there
are two weighty objections to the too free and indiscriminating use of
this treatment for abscesses. In the first place, there is a danger that
surgeons, trusting blindly to the antiseptic action of the carbolic acid
dressing, will open cold abscesses either unnecessarily early, or even
in cases where incision is altogether improper. Secondly, the caustic or
irritant action of the acid will occasionally produce mischievous
effects. But the main point of his argument is directed to the
demonstration, that even the most brilliant results which have been
obtained in England, and published by Lister and others in the columns
of the _Lancet_, are by no means conclusive in showing that the carbolic
acid was really the curative agent. He observes, moreover, that although
in England the treatment has been most extensively tried everywhere, the
majority of hospital surgeons appear very sceptical about it.
Undoubtedly Lister’s method deserves every attention, and should be
tried in appropriate cases, but the inquiry should not be made with too
much credulity, but with prudent doubt. (_Archiv f. Heilkunde_, 2,
1869.)


=Electricity in the Diseases of Children.=—Dr. Ullersperger gives a good
summary of existing knowledge as to the uses of electricity in the
paralyses of common and special sensation, and of motion, in children.
The paper is a useful one, but does not contain any original matter on
which it is necessary to comment here. (_Journ. of Kinderkrankheiten_,
and Jan. Feb. 1869.)


=Liebig’s Food for Infants.=—Dr. Kjelberg related to the _Gesellschaft
schwedischer Aerzte_ his experience of the use of Liebig’s food for
infants as a remedy. Six cases of diarrhœa occurred in the Children’s
Hospital among infants of from 1½ to 2 years; five of them had already
been treated with medicine without effect. A thin broth made from the
“food” was given them as their only nourishment, and all medicine was
discontinued. The motions at once assumed a better appearance. In one
case, which had no previous treatment, the effect of the exclusive use
of Liebig’s food was very striking. Kjelberg says that he had used the
treatment in two cases of children, private patients, in whom not
diarrhœa, but obstinate constipation was the malady. The children were
still suckled, while the food was administered. The peristaltic function
of the bowels rapidly became normal and regular. Kjelberg thinks that
Liebig’s food possesses the capacity of _regulating_ the activity of the
intestinal canal. (_Ibid._)


=Hypodermic Injection of Ergotin in the Treatment of
Aneurism.=—Professor Langenbeck writes an important paper on this
subject. From the well-known influence of ergot in provoking
contractions of the organic muscular film of the uterus, he was led to
think that a similar stimulation might be produced by it, with
beneficial effect, in the muscular coats of arteries in cases of
aneurism. The first case in which he employed it was one of subclavian
aneurism in a man aged 45. The tumour was treated in the first place on
Jacobson’s plan, with the repeated application of moxas, and a great
diminution of all the symptoms took place, and lasted for three years;
but the pulsation continued. In consequence (as the patient thought) of
an excessive summer heat, a relapse took place, the tumour enlarged
greatly, and all the old symptoms returned. Three centigrammes of
aqueous extract of secale were injected over the tumour, with great
relief to the pain and consequent insomnia. Between January 6 and
February 17 about 30 grains of ergotin were injected, with the effect of
so greatly relieving the symptoms of pressure in veins, that the pain
and paralysis of the arm and hand were diminished to a remarkable
extent. The pulsations of the aneurism were also sensibly weakened, and
the tumour somewhat sunken. In a second case—one of aneurism of the
radial, about an inch and a quarter above the wrist, and which had
existed for many years—about 1/4th of a grain of aqueous extract of
secale (dissolved in seven times its bulk of half and half glycerine and
sp. rectif.) was injected into the skin above the tumour, and on the
following day the tumour appeared to have vanished. The cure became
permanent, and the only trouble was a local erythematous inflammation
which lasted some days. Langenbeck discovers that it was natural that a
more powerful effect should be produced by the remedy in radial than in
subclavian aneurism, since the radial artery is more copiously furnished
with muscular fibres than the subclavian. (_Berlin Klin. Wachensch._ 12,
1869.)


=Pruritus of the Skin of the External Auditory Meatus.=—Dr. J. Gueber
describes under this name, not the itching and eczema of the ear so
often left after scabies, but a special affection, first named as above
by Hebra, in which the itching is the _only_ symptom. It occurs most
frequently in middle age, and in persons who, from one reason or
another, have a defective circulation. There are frequently periodical
exacerbations of the irritation. Gueber recommends, as a palliative,
applications of water and oily matters for radical cure, repeated
painting with a strong solution of nitrate of silver, till inflammatory
reaction is set up. Along with this, however, there must of course be a
suitable rational treatment, according to the special indications which
present themselves. (_Allgem. Wien. Med. Zeitg._ 52, 1869.)


=New Remedies.=—Dr. G. W. Lawrence, writing to the _Philadelphia Medical
and Surgical Reporter_, states that the following substances, whose
qualities he briefly describes, have been recently tried by him in
practice:—_Quiniæ Iodo-Sulphas_. It has proved to be a desirable
alterative and tonic, serviceable in consecutive syphilis, scrofula,
cachexia, neuralgia, some forms of paralysis, and in debilitated
conditions of the general system. Given in pill form, or mixed with
syrup of sassafras bark or blended with elixir of Calisaya bark.—_Iodide
of Antimony._ An alterative, used chiefly in skin diseases, those forms
arising from constitutional ills and secretory disturbances. Prescribed
with aromatic syrup of dulcamara. He has recently used iodide of
antimony as an anaphrodisiac with satisfactory results. He combined it
with lupulin, and gave it in pills every six hours.—_Iodide of
Manganese._ Alterative, administered generally with the iodide, or some
other desirable preparation of iron, or with quiniæ iodo-sulphas, in
anæmia and chloro-anæmia, with resin podophyllin, in chronic splenic and
hepatic derangements. In the alterative agency of manganese, he fancied
that a determined action is exercised on the ganglionic system of
nerves.—_Glycerole Pyrophosphate of Iron._ In the formula pure glycerine
is substituted for sugar, or simple syrup; each fluid ounce (with
glycerine) contains sixteen grains of pyro-phosphate of iron. This new
preparation is unchangeable, and is one of the most palatable of that
family of tonics. He employs it usually as an eutrophic in that spanæmic
condition of the system so frequently provoked by the protracted use and
abuse of iodides and bromides of potassium. He also uses it when
indicated, in progressive paralysis, motor ataxia, in threatening a
supposed incipient _ramollissement_ of the brain and spinal marrow.


=Carbolate of Lime in Pertussis.=—Dr. Snow, of Providence, has suggested
the use of carbolate of lime in hooping-cough, and in all cases it has
apparently produced a marked effect in diminishing the frequency and
severity of the paroxysms. Small quantities of the carbolate of lime are
placed in saucers in the room where the child sleeps; merely sufficient
to make the odour perceptible. (_New York Medical Record._)


=Bromide of Potassium and Antimony in Puerperal Convulsions.=—Dr. T. N.
Simmons reports the history of a case of puerperal convulsions, in which
the efficacy of these remedies was evident. A primipara, while in
labour, with the head of the child in the inferior strait, was seized
with a violent convulsion, which was followed by four others, with an
interval of about 15 minutes between each. Chloroform proving of no
benefit, bromide of potassium was administered, beginning with a dose of
40 grains in combination with half a grain of antimony. In combination
with the bromide one-half grain of the antimony was given every hour and
a half or two hours, until three grains of the antimony were taken.
After the first dose there was a return of four paroxysms. The first
occurred within an hour, the second in two hours, the third between
three and four hours, and the fourth in eight hours. Their intensity and
duration were also diminished in the order of their recurrence.
Convalescence was rapid. (_N. O. Journal of Medicine._)


=An Acidulated Solution of Pepsine as a Solvent for False Membrane in
Diphtheria.=—Dr. W. H. Doughty has communicated to the _Richmond and
Louisville Medical Journal_ an article upon this subject, with a history
of a case in which he was entirely satisfied with the efficacy of
pepsine in diphtheria. The patient was about 25 years of age, of feeble
general health from intermittent fever. He presented himself with sore
throat. For the affection cauterization was resorted to, and a gargle of
chlorate of potash ordered. The throat became very much inflamed and
swollen, and the glands about the neck enlarged. About the fourth day
exudation of membrane was observed under the tongue, a portion of which
was removed with forceps. The swelling increased, and the membrane
continued to re-form. Quinine and stimulants were freely used, with
inhalations of lime-water. On the fifth day commenced the application of
pepsine to the membrane, keeping up the same general treatment. Pepsine
was used in the following proportion: ℞ pepsine ℨj; acid muriatic,
dilute, gtt. x; water q. s. ad ℥iij.: M. and filter. This was applied by
means of a hair pencil continuously. A few hours from the commencement
of the application, “the mouth, as far as visible, is cleaner and
better.” On the next day the patient feels better; no appearance of
exudation; mouth is clean, but continues to discharge broken-down opaque
masses from the throat, and thinks he must have suffocated but for the
solution employed. The breathing is comparatively easy and cough less.
Patient died on the seventh day, of asthma.


=Impermeable Dressings in Eczema.=—In an article on this subject in Mr.
Erasmus Wilson’s “Journal,” Mr. Alfred Pullar makes the following
remarks on the value of this mode of dressing:—“The method of local
treatment first brought into notice by Professor Hardy at the Saint
Louis Hospital in Paris, consists in covering the diseased parts
completely with vulcanized india-rubber cloth (_toile caoutchouquée_).
The material used for this purpose is ordinary cotton cloth covered with
a solution of caoutchouc and subsequently vulcanised: by this means it
is rendered impermeable to watery fluids, and acquires on one side a
smooth surface. The therapeutical effects resulting from a covering such
as that described would seem to depend essentially upon two
conditions:—_First_, the exclusion of the air. As it has been proved by
experience that the influence of the atmosphere increases the
inflammation of the diseased surface, its complete exclusion fulfils an
important indication in the treatment: this is accomplished by the
india-rubber covering, which also protects the abnormally sensitive skin
from variations of temperature. _Second_, the retention of the
secretions of the skin. These—exuded in considerable quantity, and
_unchanged_ by the atmosphere—are retained in contact with the skin, and
seem to act by relaxing the inflamed structures. Whilst visiting Hardy’s
wards at the Saint Louis Hospital, I had the privilege of seeing several
cases of eczema treated by this means (these cases being chiefly eczema
of the limbs in old people). The impermeable dressing was so applied as
to cover completely the affected parts, and was removed, from time to
time, in order to be cleaned and re-applied. Under this treatment, the
painful symptoms of the disease were greatly relieved; and the morbid
surface gradually assumed a more healthy appearance.” (_Journal of
Cutaneous Medicine_, April.)


=Tetanus treated with Calabar Bean.=—Drs. Boslin and Curron (_Chicago
Medical Journal_) have treated a case of acute traumatic tetanus of
violent character with large doses of morphia and calabar bean. For a
portion of the time, a grain and a half of morphia and three grains of
the powdered bean in glycerine were given every hour, with the manifest
effect of quieting the patient and relieving the spasm. The patient
recovered.


=The Therapeutics of Bismuth.=—In the _California Medical Gazette_, Dr.
W. F. Mac Nutt has a paper on “Some of the Uses of Bismuth,” in which he
states that he finds this drug more valuable than it is often supposed
to be. Some of his ideas on its therapeutics are novel. “I believe,” he
says, “that bismuth not only destroys the sulphuretted hydrogen present
in the bowels, but is an antiseptic to albuminous matters, preventing
their putrid decomposition. That bismuth destroys the sulphuretted
hydrogen present in the bowels, is proved by the fact that if
administered for a few hours in considerable quantity the flatulence
disappears; and if a dose of oil is given, the evacuations are as black
as tar, where the evacuations were natural or clay-coloured before the
bismuth was given. It is the chemical action of the gas upon the bismuth
which gives the evacuations their black colour. But a small portion of
bismuth, when given in powder and in doses from gr. v to gr. xx, is
dissolved in the stomach and absorbed. The remainder passes undissolved
into the bowels, and while it may have some local anæsthetic action on
the bowels as on the stomach, it will be comparatively inert unless
there be sulphuretted hydrogen present. Its action on the sulphuretted
hydrogen is more particularly demonstrated when given for chronic
diarrhœa. Some have attributed to bismuth astringent, tonic, and
sedative properties, on account of their success with it in chronic
diarrhœa. Others have given it for the same disease without the
slightest benefit, and consequently have denied that it has astringent,
or sedative, or tonic properties. While the fact is, that in cases of
diarrhœa that are caused or kept up by the poisonous effect of
sulphuretted hydrogen, I have given bismuth, combined with a few grains
of Dover’s powder, with more real benefit to the disease than any drug I
could administer. Opium alone is useless, or worse. Charcoal, by
absorbing the gas, has been, next to bismuth, the most beneficial.
Chambers on ‘Indigestions’ says that it is ‘rare to find sulphuretted
hydrogen or hydro-sulphate of ammonia excreted without watery or soft
pultaceous stools. They appear to be purgative poisons.’ They are not
always purgative poisons.”


=Physiological Action of Absinthe.=—The following are the conclusions
which M. Magnan laid before the French Academy of Sciences, and which
have given rise to some discussion in the weekly journals:—1. The
epileptic or epileptiform accidents in alcoholism—or, in other words,
alcoholic epilepsy—are of a radically different nature, according as the
alcoholism is acute or chronic. 2. In acute alcoholism the epilepsy is
under the complete influence of an external agent, of a poison
(absinthe) which of itself alone causes the epileptic attack; it is
epilepsy by “intoxication.” 3. The alcoholic epileptics exhibit the
ordinary features of simple alcoholic cases, and also superadded
phenomena, among which the epileptic attack is dominant. 4. These two
groups of symptoms (the alcoholic symptoms and alcoholic convulsions),
united in the same subject, have a relation to the twofold nature of the
poison (absinthe), whose elements are absinthe and alcohol. 5. In
chronic alcoholism the epileptic or epileptiform accidents are under the
direct control of organic modifications which take place in the patient.
The excess of liquids, in gradually altering the tissues, renders them
capable, under the influence of various causes, of producing by
themselves convulsive epileptiform phenomena, accidents analogous to
those that we see take place in other patients in certain cases of
lesions of the nervous centres (general paralysis, tumours of the brain,
&c.) (_Comptes Rendus_, April 5.)




                         Notes and Queries.[13]


THE DOSE OF ATROPIA FOR SUBCUTANEOUS INJECTION.—I wish to answer the
query of Dr. Sisson in the _Practitioner_ of last month with every
caution, but I have formed a strong opinion on the subject in question.
A “Country Practitioner,” who wrote to this journal in February, states
that he used to give hypodermic injections of more than ⅕ grain of
atropia daily, to the same patient, for years. Now I stated in my paper
in this journal (July 1868), that such doses as these are utterly
unsafe, and I retain that opinion. Supposing that the sulphate of
atropia was good, which it is very possible it was not in the “Country
Practitioner’s” case, I can affirm, from my own knowledge, that there
are many patients to whom such a dose would be dangerous and probably
fatal, if it were really fairly introduced into the subcutaneous tissue.
_I have seen uncomfortable atropism from the injection of less than
1/100 grain_: a case occurred to me only a week or two since. It is
therefore unadvisable to begin, at any rate, with large doses. With a
large experience of subcutaneous injection, I am enabled to say with
confidence that 1/60 or 1/50 grain doses are what are best borne by the
majority of persons; that sometimes, but not often, it is necessary to
go as far as 1/30 grain; and that not unfrequently patients will not
bear as much as the 1/60 without uncomfortable atropism. Hence my
recommendation to practitioners to commence, experimentally, with such a
small quantity as the 1/120 grain.—F. E. ANSTIE.


STRYCHNIA AS A REMEDY IN A SEVERE CASE OF NERVOUS HYPERÆSTHESIA.—Mr. H.
A. Allbutt, of Leeds, writes to us:—“The following case may be of some
interest to the readers of the _Practitioner_, as in some of its
symptoms it presented some curious phenomena. Mrs. A——, a married lady,
about thirty-six years of age, consulted me in last November for
lameness, and great pain and difficulty in walking, with obscure pains
in her back and sides, severe palpitation, restless nights, loss of
appetite, and great nervousness. She often, too, complained of dimness
of vision, and the thumb was at times flexed across the palm of the hand
in a spasmodic manner. In addition to these symptoms, she suffered from
prolapsus uteri and menorrhagia. The difficulty and pain in walking
were, however, the most prominent features of the case. She could not
raise her feet the height of a step, and her locomotion was most
curious, consisting of a sort of corkscrew motion, or twisting of the
foot and thigh each step that was taken. This had been going on for
three years, sometimes better and sometimes worse, but on the whole she
was gradually getting worse. I learned from her that when younger she
had been of a strong, healthy nature, and suffered from little illness
till her marriage. She seems to have suffered severely during her
various confinements from floodings, &c., and from the time of her last
confinement she has been affected more or less in the manner described.
In regard to the cause of this condition, I am of opinion that her
nervous system had been much weakened, and thrown into an excitable
condition by the shocks of labour and by the floodings at those times.
In this opinion I was borne out by Dr. Allbutt, of Leeds, who saw the
case with me. The treatment at first consisted of the various
preparations of steel, of which I found the ferri ammon. cit., combined
with bromide of potassium, to be the best. Tannic acid pessaries were
also ordered to be introduced into the vagina for the relief of the
prolapsus uteri, and a hypodermic injection of morphia was given every
night for three weeks. Under the influence of these remedies she
improved in her general health, and the lameness was improved in a
slight degree; in fact, she seemed to arrive at a certain standard of
health and to advance no further. I was now induced to try strychnia, in
the form of pills, combined with carbonate of iron. The dose was 1/20
gr. twice a day. The effects were marvellous. The lameness is fast
disappearing, and she is able to walk out of doors, which she has not
done for fifteen months. I firmly believe she will be quite cured if the
treatment is persevered in.”


MURIATE OF AMMONIA AS A REMEDY.—Dr. Cholmeley has kindly sent us a note,
the manuscript of which, by an unfortunate accident, has been mislaid.
The substance of his remarks is as follows:—He confirms the observations
of Dr. Anstie, in a paper in the December number of the _Practitioner_,
as to the great efficacy of the muriate of ammonia as a remedy for
neuralgic and myalgic pain. But Dr. Cholmeley goes on to say, that with
regard to a matter on which Dr. Anstie spoke more doubtfully,—the
efficacy, namely, which certain authors have ascribed to this drug as an
emmenagogue,—he has formed from a large experience a decided opinion in
favour of the utility of this medicine. He is convinced that in a very
large number of cases of absent or suppressed menstruation, muriate of
ammonia acts in a very direct and powerful manner in establishing or
restoring the flux. Dr. Cholmeley has now experimented with the muriate,
in doses of 10 to 20 grains, in so large a number of hospital and
dispensary patients, that he cannot suppose there is any room for
fallacy in this conclusion.

[Since the date at which the paper referred to by Dr. Cholmeley was
written, we have had occasion to employ the muriate of ammonia in two
cases of amenorrhœa, with apparently very striking and direct results of
a curative kind. As yet, however, we must confess ourselves unable to
lay down any definite rule as to the class of cases to which it is
applicable with the best chance of success, beyond a general idea that
it acts best in persons not anæmic, but possessing a weak and mobile
nervous system.—EDS. PRACT.]


ETHER SPRAY IN OPERATIONS ABOUT THE ANUS.—Dr. John Barclay, of Banff,
writes to us as follows:—“I write to corroborate what was written by Mr.
Alexander Bruce, in the _Practitioner_ for last month, concerning the
employment of ether spray in operations about the verge of the anus. I
have experience of it in two cases. The first was the slitting up of a
hæmorrhoid containing a clot, and when the ether spray was directed on
the part the patient screamed in intense agony, comparing it to nothing
else than the introduction of a red-hot iron. The pile was opened
without it, and the patient said the cutting was as nothing compared
with the spray. The second case was very similar to this, and the result
here was the same. So that I never dream now of recommending the
freezing by ether in operations in that region. I may remark that it is
a curious thing ice never seems to give pain when so employed.”


TREATMENT OF HÆMORRHOIDS.—Mr. J. Christophers, of Wadebridge, Cornwall,
sends us the following note:—“The pain and risk attending operations for
the removal of hæmorrhoids, whether by knife, ligature, cautery, or
caustic, render valuable any less heroic mode of treatment, whereby the
necessity for using the means alluded to may be dispensed with, or even
rendered less frequent. The term hæmorrhoid or pile being used to
signify a tumour caused by enlarged or varicose veins at the lower part
of the rectum, the definition of the disease would seem to indicate its
treatment—pressure and support. The benefit resulting from pressure on
tumours, and from pressure and support applied to varicose veins
situated on the surface of the body, is manifold and manifest. The same
good results often attended pressure internally applied in cases of
hæmorrhoids, and frequently in cases of prolapsus also. Occasionally
after having introduced the finger into the rectum, in cases of
hæmorrhoids, for the purpose of exploration, I have heard with surprise
the patient affirm that the examination had temporarily relieved the
severity of his pain. Continuous pressure exercised by means of the
rectum plug, of a size, form, and material suited to these cases, in
many instances, affords immediate relief, and often effects ultimate
cure; the rectum plug being nothing more than a simple cone or peg,
terminating in a short stem or disk, having a hole bored through its
long diameter formed of metal, ivory, wood, membrane, or of other
material capable of inflation. Any of these substances answer the
purpose, some being suited to one kind of case, some to another. Those
formed of wood have in my hands answered well, and have often achieved a
success that has exceeded my expectations. The shape and size best
suited to individual cases experience soon teaches. A not unfrequent
obstacle in treating cases by the rectum plug will be found to consist
in the intolerance by the rectum in some patients at first of its
presence; perseverance in its use gradually and surely overcomes this
difficulty. After a short probation all discomfort ceases, and the plug
can be worn by day and by night, sitting, riding, walking, or standing,
with the best results, and that not only in cases of hæmorrhoids, but in
bad cases of prolapsus also. So much is this the case that many who have
worn a rectum plug, though with difficulty at the beginning, give up its
use, even when the malady that demanded its application is cured, with
reluctance and regret, saying that they derive comfort and support from
its presence. These circumstances induce me to think that this safe and
simple means of treating hæmorrhoids has been too much neglected, and
for this reason I venture to bring it under the notice of the
_Practitioner_.”




                           Bibliography.[14]


Les Eaux thermales de Mont-Doré dans leurs Applications à la
Thérapeutique médicale. Par M. Mascarel.

Prophylaxie Internationale des Maladies vénériennes. Par MM. Croq et
Rollett.

Considérations sur les Résultats de la Paracentèse dans la Pleurésie
purulente. Par le Docteur A. Attionent.

Du Collodion riciné appliqué en badigeon sur toute la Surface du Ventre,
considéré comme Agent de Calorification générale et comme Moyen héroïque
de Traitement dans le Cholérine, le Choléra, etc. Par M. A. Drouet.

Études sur quelques Points d’Hygiène hospitalière. Par M. G. Chantreuil.

Traitement du Croup par les Inhalations de Vapeurs humides de Sulfure,
de Mercure. Par M. le Docteur Abeille.

De la Médication antipyrétique. Par M. le Docteur A. Ferrand.

Mémoire sur les Dissolvants et les Désagrégéants des Produits
pseudo-membraneux et sur l’Emploi du Brome dans les Affections
pseudo-membraneuse. Par M. le Docteur Ch. Ozanham.

De l’Administration de Quinite dans les Fièvres d’Accès comme succédané
du Sulfate de Quinine. Par M. le Docteur Halmagrand.

Monatsschrift für Ohrenheilkunde. 3 Jahrg. 1869.

Klinische Beiträge zur Psychiatrie. Von Prof. Dr. Lombroso.

Zeitung allgemeine balneologische. Herausgegeben von Dr. H. Kisch.

Die Transfusion des Blutes in physiologischer und medicinischer
Beziehung. Von Belina-Swiontkowski.

-----

Footnote 1:

  _Boston Medical and Surgical Journal_, May 21, 1868.

Footnote 2:

  “The Restorative Treatment of Pneumonia.” Third Edition. Edinburgh:
  Black, 1866.

Footnote 3:

  _British Medical Journal_, December 28, 1867.

Footnote 4:

  _British Medical Journal_, February 22, 1868.

Footnote 5:

  See also some Lectures on Pneumonia by Dr. Waters, of Liverpool
  (_British Medical Journal_, October 1867), whose views and treatment,
  allied to those of Dr. Sieveking—I hope he will excuse me for
  thinking—are very unsatisfactory, when compared with the results
  obtained by a restorative practice.

Footnote 6:

  _Practitioner_, November 1868.

Footnote 7:

  Read at the third Quarterly Meeting of the Medico-Psychological
  Association, held at the Royal Medico-Chirurgical Society, April 29,
  1869.

Footnote 8:

  Extract from Nineteenth Annual Report of the Somerset Asylum:—“One
  female maniac, C. L., aged 35, single, most obscene in her conduct and
  language, noisy, destructive, and dirty, got rapidly well after the
  employment of the hypodermic injection of a solution containing half a
  grain of acetate of morphia.”

  Extract from Twentieth Annual Report of the Somerset Asylum:—“The
  hypodermic injection of about half a grain of acetate of morphia in
  ♏︎x. of distilled water has been useful in cases of maniacal
  excitement with sleeplessness.”

Footnote 9:

  The gas used in the following instances was supplied to me by Barth,
  of London, and administered in his apparatus. I would wish, in this
  place, to thank Dr. Birch, of Kensington, for introducing it to my
  notice, and for his kind communications on the subject of this paper.

Footnote 10:

  In estimating the value of oxygen in these cases of phthisis we must
  bear in mind the mechanical effect of deep and steady inspiration
  through a long tube; this, _per se_, has a tendency to expand the lung
  vesicles and to hasten the healing of cavities, as has been fairly
  shown by Ramadge, in spite of his absurdities.

Footnote 11:

  Cf. Birch on “Action, &c. of Oxygen,” 2d edit. p. 33.

Footnote 12:

  Our own experience is very favourable to petroleum.—EDS. PRACT.

Footnote 13:

  The Editors, being desirous of making this department a useful medium
  of communication between practitioners, will be glad to receive short
  notes on theoretical or practical points in therapeutics,—brief
  jottings on those numerous queries which suggest themselves from time
  to time to a medical man as he “goes his rounds,” but which he has
  neither the time nor, in some cases, the opportunity of answering. The
  Editors do not pledge themselves to reply to every question addressed
  to them, but they hope to make the “department” the means of supplying
  the information required; and this they can only effect by the hearty
  assistance of their readers.

Footnote 14:

  Any of the foreign works may be procured by application to Messrs.
  Dulau, of Soho Square, W.C.; or Williams & Norgate, of Henrietta
  Street, Covent Garden, W.C.

------------------------------------------------------------------------




                          TRANSCRIBER’S NOTES


 1. Silently corrected typographical errors and variations in spelling.
 2. Retained anachronistic, non-standard, and uncertain spellings as
      printed.
 3. Footnotes have been re-indexed using numbers and collected together
      at the end of the last chapter.
 4. Enclosed italics font in _underscores_.





End of the Project Gutenberg EBook of The Practitioner. May, 1869., by Various

*** END OF THIS PROJECT GUTENBERG EBOOK THE PRACTITIONER. MAY, 1869. ***

***** This file should be named 59682-0.txt or 59682-0.zip *****
This and all associated files of various formats will be found in:
        http://www.gutenberg.org/5/9/6/8/59682/

Produced by Richard Tonsing and the Online Distributed
Proofreading Team at http://www.pgdp.net (This file was
produced from images generously made available by The
Internet Archive)

Updated editions will replace the previous one--the old editions will
be renamed.

Creating the works from print editions not protected by U.S. copyright
law means that no one owns a United States copyright in these works,
so the Foundation (and you!) can copy and distribute it in the United
States without permission and without paying copyright
royalties. Special rules, set forth in the General Terms of Use part
of this license, apply to copying and distributing Project
Gutenberg-tm electronic works to protect the PROJECT GUTENBERG-tm
concept and trademark. Project Gutenberg is a registered trademark,
and may not be used if you charge for the eBooks, unless you receive
specific permission. If you do not charge anything for copies of this
eBook, complying with the rules is very easy. You may use this eBook
for nearly any purpose such as creation of derivative works, reports,
performances and research. They may be modified and printed and given
away--you may do practically ANYTHING in the United States with eBooks
not protected by U.S. copyright law. Redistribution is subject to the
trademark license, especially commercial redistribution.

START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE
PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg-tm mission of promoting the free
distribution of electronic works, by using or distributing this work
(or any other work associated in any way with the phrase "Project
Gutenberg"), you agree to comply with all the terms of the Full
Project Gutenberg-tm License available with this file or online at
www.gutenberg.org/license.

Section 1. General Terms of Use and Redistributing Project
Gutenberg-tm electronic works

1.A. By reading or using any part of this Project Gutenberg-tm
electronic work, you indicate that you have read, understand, agree to
and accept all the terms of this license and intellectual property
(trademark/copyright) agreement. If you do not agree to abide by all
the terms of this agreement, you must cease using and return or
destroy all copies of Project Gutenberg-tm electronic works in your
possession. If you paid a fee for obtaining a copy of or access to a
Project Gutenberg-tm electronic work and you do not agree to be bound
by the terms of this agreement, you may obtain a refund from the
person or entity to whom you paid the fee as set forth in paragraph
1.E.8.

1.B. "Project Gutenberg" is a registered trademark. It may only be
used on or associated in any way with an electronic work by people who
agree to be bound by the terms of this agreement. There are a few
things that you can do with most Project Gutenberg-tm electronic works
even without complying with the full terms of this agreement. See
paragraph 1.C below. There are a lot of things you can do with Project
Gutenberg-tm electronic works if you follow the terms of this
agreement and help preserve free future access to Project Gutenberg-tm
electronic works. See paragraph 1.E below.

1.C. The Project Gutenberg Literary Archive Foundation ("the
Foundation" or PGLAF), owns a compilation copyright in the collection
of Project Gutenberg-tm electronic works. Nearly all the individual
works in the collection are in the public domain in the United
States. If an individual work is unprotected by copyright law in the
United States and you are located in the United States, we do not
claim a right to prevent you from copying, distributing, performing,
displaying or creating derivative works based on the work as long as
all references to Project Gutenberg are removed. Of course, we hope
that you will support the Project Gutenberg-tm mission of promoting
free access to electronic works by freely sharing Project Gutenberg-tm
works in compliance with the terms of this agreement for keeping the
Project Gutenberg-tm name associated with the work. You can easily
comply with the terms of this agreement by keeping this work in the
same format with its attached full Project Gutenberg-tm License when
you share it without charge with others.

1.D. The copyright laws of the place where you are located also govern
what you can do with this work. Copyright laws in most countries are
in a constant state of change. If you are outside the United States,
check the laws of your country in addition to the terms of this
agreement before downloading, copying, displaying, performing,
distributing or creating derivative works based on this work or any
other Project Gutenberg-tm work. The Foundation makes no
representations concerning the copyright status of any work in any
country outside the United States.

1.E. Unless you have removed all references to Project Gutenberg:

1.E.1. The following sentence, with active links to, or other
immediate access to, the full Project Gutenberg-tm License must appear
prominently whenever any copy of a Project Gutenberg-tm work (any work
on which the phrase "Project Gutenberg" appears, or with which the
phrase "Project Gutenberg" is associated) is accessed, displayed,
performed, viewed, copied or distributed:

  This eBook is for the use of anyone anywhere in the United States and
  most other parts of the world at no cost and with almost no
  restrictions whatsoever. You may copy it, give it away or re-use it
  under the terms of the Project Gutenberg License included with this
  eBook or online at www.gutenberg.org. If you are not located in the
  United States, you'll have to check the laws of the country where you
  are located before using this ebook.

1.E.2. If an individual Project Gutenberg-tm electronic work is
derived from texts not protected by U.S. copyright law (does not
contain a notice indicating that it is posted with permission of the
copyright holder), the work can be copied and distributed to anyone in
the United States without paying any fees or charges. If you are
redistributing or providing access to a work with the phrase "Project
Gutenberg" associated with or appearing on the work, you must comply
either with the requirements of paragraphs 1.E.1 through 1.E.7 or
obtain permission for the use of the work and the Project Gutenberg-tm
trademark as set forth in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg-tm electronic work is posted
with the permission of the copyright holder, your use and distribution
must comply with both paragraphs 1.E.1 through 1.E.7 and any
additional terms imposed by the copyright holder. Additional terms
will be linked to the Project Gutenberg-tm License for all works
posted with the permission of the copyright holder found at the
beginning of this work.

1.E.4. Do not unlink or detach or remove the full Project Gutenberg-tm
License terms from this work, or any files containing a part of this
work or any other work associated with Project Gutenberg-tm.

1.E.5. Do not copy, display, perform, distribute or redistribute this
electronic work, or any part of this electronic work, without
prominently displaying the sentence set forth in paragraph 1.E.1 with
active links or immediate access to the full terms of the Project
Gutenberg-tm License.

1.E.6. You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form, including
any word processing or hypertext form. However, if you provide access
to or distribute copies of a Project Gutenberg-tm work in a format
other than "Plain Vanilla ASCII" or other format used in the official
version posted on the official Project Gutenberg-tm web site
(www.gutenberg.org), you must, at no additional cost, fee or expense
to the user, provide a copy, a means of exporting a copy, or a means
of obtaining a copy upon request, of the work in its original "Plain
Vanilla ASCII" or other form. Any alternate format must include the
full Project Gutenberg-tm License as specified in paragraph 1.E.1.

1.E.7. Do not charge a fee for access to, viewing, displaying,
performing, copying or distributing any Project Gutenberg-tm works
unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8. You may charge a reasonable fee for copies of or providing
access to or distributing Project Gutenberg-tm electronic works
provided that

* You pay a royalty fee of 20% of the gross profits you derive from
  the use of Project Gutenberg-tm works calculated using the method
  you already use to calculate your applicable taxes. The fee is owed
  to the owner of the Project Gutenberg-tm trademark, but he has
  agreed to donate royalties under this paragraph to the Project
  Gutenberg Literary Archive Foundation. Royalty payments must be paid
  within 60 days following each date on which you prepare (or are
  legally required to prepare) your periodic tax returns. Royalty
  payments should be clearly marked as such and sent to the Project
  Gutenberg Literary Archive Foundation at the address specified in
  Section 4, "Information about donations to the Project Gutenberg
  Literary Archive Foundation."

* You provide a full refund of any money paid by a user who notifies
  you in writing (or by e-mail) within 30 days of receipt that s/he
  does not agree to the terms of the full Project Gutenberg-tm
  License. You must require such a user to return or destroy all
  copies of the works possessed in a physical medium and discontinue
  all use of and all access to other copies of Project Gutenberg-tm
  works.

* You provide, in accordance with paragraph 1.F.3, a full refund of
  any money paid for a work or a replacement copy, if a defect in the
  electronic work is discovered and reported to you within 90 days of
  receipt of the work.

* You comply with all other terms of this agreement for free
  distribution of Project Gutenberg-tm works.

1.E.9. If you wish to charge a fee or distribute a Project
Gutenberg-tm electronic work or group of works on different terms than
are set forth in this agreement, you must obtain permission in writing
from both the Project Gutenberg Literary Archive Foundation and The
Project Gutenberg Trademark LLC, the owner of the Project Gutenberg-tm
trademark. Contact the Foundation as set forth in Section 3 below.

1.F.

1.F.1. Project Gutenberg volunteers and employees expend considerable
effort to identify, do copyright research on, transcribe and proofread
works not protected by U.S. copyright law in creating the Project
Gutenberg-tm collection. Despite these efforts, Project Gutenberg-tm
electronic works, and the medium on which they may be stored, may
contain "Defects," such as, but not limited to, incomplete, inaccurate
or corrupt data, transcription errors, a copyright or other
intellectual property infringement, a defective or damaged disk or
other medium, a computer virus, or computer codes that damage or
cannot be read by your equipment.

1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right
of Replacement or Refund" described in paragraph 1.F.3, the Project
Gutenberg Literary Archive Foundation, the owner of the Project
Gutenberg-tm trademark, and any other party distributing a Project
Gutenberg-tm electronic work under this agreement, disclaim all
liability to you for damages, costs and expenses, including legal
fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE
PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE FOUNDATION, THE
TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE
LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR
INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH
DAMAGE.

1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a
defect in this electronic work within 90 days of receiving it, you can
receive a refund of the money (if any) you paid for it by sending a
written explanation to the person you received the work from. If you
received the work on a physical medium, you must return the medium
with your written explanation. The person or entity that provided you
with the defective work may elect to provide a replacement copy in
lieu of a refund. If you received the work electronically, the person
or entity providing it to you may choose to give you a second
opportunity to receive the work electronically in lieu of a refund. If
the second copy is also defective, you may demand a refund in writing
without further opportunities to fix the problem.

1.F.4. Except for the limited right of replacement or refund set forth
in paragraph 1.F.3, this work is provided to you 'AS-IS', WITH NO
OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT
LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE.

1.F.5. Some states do not allow disclaimers of certain implied
warranties or the exclusion or limitation of certain types of
damages. If any disclaimer or limitation set forth in this agreement
violates the law of the state applicable to this agreement, the
agreement shall be interpreted to make the maximum disclaimer or
limitation permitted by the applicable state law. The invalidity or
unenforceability of any provision of this agreement shall not void the
remaining provisions.

1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation, the
trademark owner, any agent or employee of the Foundation, anyone
providing copies of Project Gutenberg-tm electronic works in
accordance with this agreement, and any volunteers associated with the
production, promotion and distribution of Project Gutenberg-tm
electronic works, harmless from all liability, costs and expenses,
including legal fees, that arise directly or indirectly from any of
the following which you do or cause to occur: (a) distribution of this
or any Project Gutenberg-tm work, (b) alteration, modification, or
additions or deletions to any Project Gutenberg-tm work, and (c) any
Defect you cause.

Section 2. Information about the Mission of Project Gutenberg-tm

Project Gutenberg-tm is synonymous with the free distribution of
electronic works in formats readable by the widest variety of
computers including obsolete, old, middle-aged and new computers. It
exists because of the efforts of hundreds of volunteers and donations
from people in all walks of life.

Volunteers and financial support to provide volunteers with the
assistance they need are critical to reaching Project Gutenberg-tm's
goals and ensuring that the Project Gutenberg-tm collection will
remain freely available for generations to come. In 2001, the Project
Gutenberg Literary Archive Foundation was created to provide a secure
and permanent future for Project Gutenberg-tm and future
generations. To learn more about the Project Gutenberg Literary
Archive Foundation and how your efforts and donations can help, see
Sections 3 and 4 and the Foundation information page at
www.gutenberg.org



Section 3. Information about the Project Gutenberg Literary Archive Foundation

The Project Gutenberg Literary Archive Foundation is a non profit
501(c)(3) educational corporation organized under the laws of the
state of Mississippi and granted tax exempt status by the Internal
Revenue Service. The Foundation's EIN or federal tax identification
number is 64-6221541. Contributions to the Project Gutenberg Literary
Archive Foundation are tax deductible to the full extent permitted by
U.S. federal laws and your state's laws.

The Foundation's principal office is in Fairbanks, Alaska, with the
mailing address: PO Box 750175, Fairbanks, AK 99775, but its
volunteers and employees are scattered throughout numerous
locations. Its business office is located at 809 North 1500 West, Salt
Lake City, UT 84116, (801) 596-1887. Email contact links and up to
date contact information can be found at the Foundation's web site and
official page at www.gutenberg.org/contact

For additional contact information:

    Dr. Gregory B. Newby
    Chief Executive and Director
    gbnewby@pglaf.org

Section 4. Information about Donations to the Project Gutenberg
Literary Archive Foundation

Project Gutenberg-tm depends upon and cannot survive without wide
spread public support and donations to carry out its mission of
increasing the number of public domain and licensed works that can be
freely distributed in machine readable form accessible by the widest
array of equipment including outdated equipment. Many small donations
($1 to $5,000) are particularly important to maintaining tax exempt
status with the IRS.

The Foundation is committed to complying with the laws regulating
charities and charitable donations in all 50 states of the United
States. Compliance requirements are not uniform and it takes a
considerable effort, much paperwork and many fees to meet and keep up
with these requirements. We do not solicit donations in locations
where we have not received written confirmation of compliance. To SEND
DONATIONS or determine the status of compliance for any particular
state visit www.gutenberg.org/donate

While we cannot and do not solicit contributions from states where we
have not met the solicitation requirements, we know of no prohibition
against accepting unsolicited donations from donors in such states who
approach us with offers to donate.

International donations are gratefully accepted, but we cannot make
any statements concerning tax treatment of donations received from
outside the United States. U.S. laws alone swamp our small staff.

Please check the Project Gutenberg Web pages for current donation
methods and addresses. Donations are accepted in a number of other
ways including checks, online payments and credit card donations. To
donate, please visit: www.gutenberg.org/donate

Section 5. General Information About Project Gutenberg-tm electronic works.

Professor Michael S. Hart was the originator of the Project
Gutenberg-tm concept of a library of electronic works that could be
freely shared with anyone. For forty years, he produced and
distributed Project Gutenberg-tm eBooks with only a loose network of
volunteer support.

Project Gutenberg-tm eBooks are often created from several printed
editions, all of which are confirmed as not protected by copyright in
the U.S. unless a copyright notice is included. Thus, we do not
necessarily keep eBooks in compliance with any particular paper
edition.

Most people start at our Web site which has the main PG search
facility: www.gutenberg.org

This Web site includes information about Project Gutenberg-tm,
including how to make donations to the Project Gutenberg Literary
Archive Foundation, how to help produce our new eBooks, and how to
subscribe to our email newsletter to hear about new eBooks.