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BRAITHWAITE'S   RETROSPECT
PRACTICAL MEDICINE AND SURGERY
                  CONTAINING

1 CONDENSED SUMMARY OF THE MOST IMPORTANT CASES J THEIR TREATMENT, AND At'
 THE REMEDIES AND OTHER USEFUL MATTERS EMBRACED IN THE FORTY VOLUMES--T *K
  WHOLE BEING ALPHABETICALLY CLASSIFIED, AND SUPPLIED WITH AN ADDENDA,
   COMPRISING A TABLE OF FRENCH WEIGHTS AND MEASURES, REDUCED TO ENGLISH
    STANDARD--A LIST OF INCOMPATIBLES--EXPLANATION OF THE PRINCIPAL
     ABBREVIATIONS OCCURRING IN PHARMACEUTICAI FORMULAE--A VOCA-
       BULARY OF LATIN WORDS MOST FREQUENTLY USED  IN PRESCRIP-
               TIONS, AND A COPIOUS INDEX.
BY WALTER S. WELLS, M.D.
VOL,. II.
        NEW YORK:
DICK k FITZGERALD, PUBLISHERS,
      18 Ann Street.
' £<> V 
V.  z
                   Kntbred according to Act of Congress, in  the year  1560, b/
                             WALTER  S.   WELLS,  M.D.,
In i*9 Offloe of the Clerk of the District Court of  the Ui.ued States, in and for the Bouinem lfestnc: t)
                                           New York. 
AN   EPITOME
                             o*

BRAITHWAITE'S    RETROSPECT.
■«*■
                       HYSTERIA.

            Oil of Valerian a Remedy in Nervous and Hysterical Affet-
            Gore relates the case of a lady, and accompanies his remarks
   .1 v         ng practical observations:]
   * viewed •» r case as one arising from a lesion of innervation of an ady-
npniic  character, out  of which the other morbid phenomena arose—the
di  nution in the animal temperature, the  absence of the pulse, and the
gt   d tremor, as the results of the circulation forsaking the periphery,
for u  impeded action in internal organs ; and the result of the treatment
entirely confirmed this view.
   A jar of warm water was applied to her feet, warm flannel to the sur-
face, and a teaspoonful of the following mixture in a wineglass  of water
every hour, until relief followed :
   Mist, camphorae;  spt. amraon. aromat,  aa.  §ij.; ol. ess.  valer., gtt.,
xxv.  M.
   She  got a little warm wine whey occasionally.   A restless feeling of
languor continuing, she got:
   Some warm leaf tea, and at nine o'clock a pill containing the eighth of
a  grain of morphine, one drop of oil of valerian, with some extract of
hyoscyamus.
   She slept well, and  when I called in the morning, I found her  quite en
livened at the idea of being  so  much sooner well of this attack than of
former ones, though she considered it more severe.
   [Speaking of another case, he says:]
   Soon after this time, I was called to the country to see a lady of wealth
and importance, who labored under many distressing nervous symptoms—
disturbed  rest, irregular bowels, impaired digestion, headaches, a partial
palsy of the left arm,  with nervous tvvitchings in the left side  of the face,
colicky  pains across  the abdomen, with much inflation of  the bowels.
Throughout the  continuance of  her  illness  the catamenia continued
undisturbed.  She was of a spare habit of body, aud every indication of
plethora absent.  The dyspeptic symptoms were those which first  called
for attention, out of which I conceived, the nervous disturbance arose;
but long after her bowels became  regular, the evacuations healthy, and
the appetite good, her nervous symptoms remaining unaltered,  sh'i vas 
4:                            HYSTERIA.
subjected to the influence of electricity, and of the following mixture she
took a small teaspoonful in half a tumbler of porter twice a day:
  Rhubarb root,  sliced, 3iij.;  chirayeta, 3ij.J coriander seeds,  bruised,
5iiss.; Bradishes' alkaline solution, §viij.                         .
  This was allowed to stand for ten days, and on being  filtered, sixteen
drops of oil of valerian were  added, which made a very good  antacid,
anti-spasmodic, tonic, aperient mixture, and from the use  of which sue
derived  much signal benefit.                                         A
  [It  will be observed that  in this case Mr. Gore used the chirayeta, and
as this lemedy is  not generally known, we would just remind the profes-
sion that in many cases  of indigestion, and  especially when accompanied
with an unpleasant  giddiness after eating, this will  be found a valuable
remedy.   The  following is a good way  of preparing and  taking the
infusion of chirayeta:  Add half  an  ounce of chirayeta  to one pint ot
boiling water; let it stand  closely covered  for  twelve  hours, and  then
strain it through a fine sieve, and  pour it into a wine bottle in which has
been  put  half an ounce of the subcarbonate of soda;  this  to be  well
shaken together.  A wineglassful of the infusion  to be taken three times
a day, one hour before  each meal.  A larger  quantity of the above, not
to be made at once, as it does not  keep good  for many days.  Mr.  Gore
ends his observations as follows:]
  In the abdominal pains, and in  that pain of the side  peculiar to mapy
young females, a combination  of aloes, assafoetida, and oil of  valerian,
proves exceedingly advantageous.
  I had one case of chorea, which, after a little  attention to the bowels,
derived  inestimable  benefit  from  a single drop of the oil, in  a lump of
sugar, three times a day.  After  about three weeks this  young woman
was quite restored.   It  occurs to  me that this would be a very suitable
remedy  to drop into a carious tooth accompanied  with pain, where inflam-
mation of the fang was absent, but having no opportunities to test this
since  the idea occurred to me, I can only give it as a suggestion.
                                                       Part ii., p. 54.

  Efficacy of Opium  Injections  in  Cases of Nervous  Excitement.—It
seems that both  tobacco  and opium, when  administered in the form of
an  injection, take even a more  powerful effect than  when  taken into
the stomach.  Dupuytren  explains this fact with respect to opium, by
supposing that in the stomach its  effects become  modified by the process
of  digestion, whereas,  when  administered by  the rectum  it  becomes
absorbed,  unaltered, into  the  system.   This  is well  illustrated  in  a
case  of nervous excitement,  published  by Dr. Maddock,  in  which
the  opium injection  was  used  with  remarkably good effects;  and
no  doubt, in  many cases  of nervous excitement, produced either by
disease or by operations, this remedy would be found valuable.
                                                       Part iv., p. 44

   Tobacco in Hysteria.—In a case  of hysteria, related  by Dr. J. H.
Thomson, where all the usual remedies  seemed comparatively useless"
tobacco leaves, soaked a few moments in hot water, and then spread over
the epigastric region of the patient, succeeded in arresting three consecu-
tive attacks.                                            part  vj^ ^ 82<

  Ioduret  of Silver—Suggested  in various painful hysterical  affections 
HYSTERIA.
5
in doses of from one-eighth of a grain to one or two grains, two or three
times a day, in the form of a pill.                        Part vii., p. 82.

  Ergot of Rye.—Mr.  Nardo has found the internal  administration  of
ergot of rye, followed by the  rapid removal of the disease, depending on
atony of the nervous and  genital systems.
  His practice  consisted  in administering  about a scruple of .the ergot,
with sugar, in divided doses, each  day, intermitting the dose  every third
or fourth day.                                          Part vii., p. 90.
  Local Hysteria.—Dr. R. B. Todd, after  alluding to  the power of the
mind to create pain, or to perpetuate it after it had been excited by some
physical cause, observes:  I do not profess  to  give an  account of all the
forms that local hysteria may assume, so many and so various are they.  I
shall, however, briefly refer to the principal varieties that are  likely to be
met with in practice.
  Pain in the Side.—Among  the  most common forms of local hysteria
are those pains in the right or left side;  of these I believe the most fre-
quent is that on the left side; the pain is referred to a spot immediately
beneath the left mamma, corresponding very nearly to the situation of the
apex of the heart.   In most cases the pain is increased on pressure ; some-
times,  however, firm and steady pressure gives ease, and I have sometimes
observed patients to make pressure  themselves, in  order to obtain some
relief.   It is quite extraordinary what a common symptom this pain is, or
that on the right side. _ It  is  very frequently (that on  the left side espe-
cially) accompanied  with  leucorrhoea or some form  of uterine derange.
ment, so much so, that now, after I have learned that a young woman of
hysterical appearance complains of this pain, my next question invariably
refers  to the existence of leucorrhoea.  In some  instances  this pain is
always increased  on inspiration,  and is attended with a short but  fre-
quent  cough, without expectoration.  If there be any emaciation, or if
there has been phthisis  in the  family, the fears of the  patient's friends be-
come excited, lest this cough and  pain should be the forerunners of con-
sumption.  And it is not always easy to assure oneself that the irritation
of nascent tubercles may not have some  share in the  production of the
phenomena.
  Irritable Spine.—The irritable  spine is another form of local hysteria,
wiiich, if treated on erroneous principles, or if its real  nature be not de-
tected, may lead to  very  serious consequences.  This affection has been
deemed of sufficient importance by some practitioners,  to  merit its being
designated by the  special name  of spinal  irritation.  But this term is
highly objectionable. Many who have written upon  this subject have
striven, on very insufficient evidence, to show that the spinal cord itself is
at fault.  The truth,"however, is that  the  spinal irritation is but a symp-
tom of a general state,  a local  malady, depending  on  a constitutional
cause.   These cases are often mistaken for actual disease of the vertebra,
and patients have been  confined to the recumbent posture for its cure, a
mode of treatment admirably  calculated to perpetuate the real complaint.
It often happens that the  patient  has  difficulty in walking, and this is re-
garded as the consequence of  the spinal affection.   She at first finds her-
self  easily fatigued; the  pain in  her back is increased by  walking  or
standing;  she  gradually  becomes   disinclined  to  move,   and  gets
accustomed to the horizontal position, and, therefore, readily yields to 
6                            HYSTERIA.
any suggestions in favor of quiet, or reluctantly obeys the advice which
recommends an opposite plan.   The most acute pain is felt over a particu-
lar spot on the back.  Slight pressure will produce it,when the patient a
attention is alive to it; and firm pressure will often fail to create ™*J*e
her attention has been diverted from it.   But there is always a good aeai
of tenderness in the whole course of the spine  and  in other parts  also.
You will derive great assistance in  your attempts  to distinguish the real
nature of this affection, by attending to the nature  of the pain;  it is
always of that exaggerated kind which is characteristic  of hysterical  pain.
It is  much more acute than the pain which attends diseased vertebrae;
it is more superficial, so as often to appear, as I believe it is, seated in the
skin that covers the spinous processes.
  Local Pulsation.—We had  lately a  case  in which  this form of  local
hysteria was  very  well  marked; and it was accompanied with another
symptom not uncommon  in  hysterical persons.    This was a  strong
pulsation of  the  aorta  in the  epigastric  region,  simulating aneurism.
For  some  time  the pulsation  appeared so strong,  and was so circum-
scribed, that had  I not  known the  decidedly hysterical character of
the  patient's constitution,  I  should have  felt considerable  apprehen.
sion on  her account.  However, as her  strength  improved, and her
catamenia became  regular, these symptoms disappeared.
  Hysterical Affection  of Joints—The  profession  is much indebted
to Sir Benjamin  Brodie for having directed attention to the frequency
with which local  hysteria  manifests itself, especially  among the  higher
classes, in  the  form of affections  of  the large joints, simulating  those
diseases  with so  much  accuracy  that  practitioners  have  frequently
been misled by  it.  Sir  Benjamin states  the  remarkable  fact, which
no  one  is so well able  to ascertain  as a  surgeon  of his great  expe-
rience,  that  four-fifths of  the  supposed  cases  of joint-disease which
occur among the higher classes are hysterical.  This  statement ought
to impress us  strongly with  the importance of  being Avell acquainted
with the peculiar features of these hysterical affections of the joints.
   You will, of  course,  expect to find in  these  cases  indications of
the  hysterical  constitution;  globus;  perhaps,    occasional  hysterical
paroxysms;  general  irritability;  enfeebled  nutrition; pain easily  ex-
cited  on pressure  at various  parts of the  body ;  irregular  catamenia,
or  some uterine  disturbance.  The joints  which  are most frequently
affected are the hip and knee.  The patient  keeps  the  painful  joint
quite  at rest, being fearful of the  least disturbance.  When the  joint is
moved, she will call out with much more expression of pain than if  there
were  actual ulceration of the cartilages.   "There is always exceeding
tenderness," Sir Benjamin Brodie remarks, " connected with which, how-
ever, we may observe the remarkable circumstance, that gently touching
or pinching the integuments in such a way as  that the pressure cannot
affect the deep-seated  parts, will often be  productive of much more pain
than the handling of the limb in a more rude and careless way "  As
however, in  most hysterical affections,  if you  can  succeed in eno-a<nnc)
your patient's attention about  some other object, and thus directuW°her
thoughts from her own  sufferings, you will find that the  joint  can  ba
 moved with comparatively little or with no pain.
   Irritable Breast.—Another very serious form of painful hysterical affcc- 
HYSTERIA.
7
tion is the irritable breast.  It is  not  generally attended with swelling or
enlargement.  The  irritability is excessive, and the patient  shrinks quite
as much from superficial as from deep-seated pressure, and even before she
has been actually touched at all.   These characters, along with the evi-
dence of hysterical constitution, are sufficient to enable the attentive prac-
titioner to distinguish the real nature of the affection.
  Paralysis of the Bladder.—Hysterical paralysis of the  bladder is also
common, and much mischief may arise from neglect of constitutional treat-
ment, and too close attention to the local affection.  Sir Benjamin Brodie
lays down the rule, that in these cases the catheter should not  be had
recourse to; and the only exceptions to it are in  those  extreme cases in
which actual paralysis has taken place, and the bladder is likely to become
diseased, if not artificially relieved.  A similar want of power over  the
rectum  may occur in hysterical women.  I have  known women complain
that they were unable to expel the contents of the rectum, although they
were  conscious of fasces having passed into it.   With respect to many of
these cases  of hysterical paralysis, there is  much truth  in Sir B. Brodie's
remark, " that it is not that the muscles are incapable of obeying the act
of volition, but that the function of volition is suspended."
  Spasmodic  Affections.—Among the various forms of local hysteria, we
may class some singular spasmodic  affections, which often prove  exceed-
ingly troublesome ; for example :
  Laryngeal  Affection.—In the  woman  Collier,  whose  case I have
had occasion to refer to as an instance of paraplegia, we had an example
of a  spasmodic  affection  of the  muscles  of the larynx, very  much
resembling the spasmodic croup, or laryngismus stridulus, which occurs in
children.  This attack was always  preceded by depression of spirits  and
hysterical crying; the breathing became difficult, and both inspiration and
expiration were  attended with a stridulous noise ; there was also a loud
barking cough, which could be  heard at  a considerable distance.  The
attack passed off as the temporary excitement disappeared.
  Hysterical  Sobbing.—One of the most singular  cases I ever saw  was
that of a girl named Howe, aged  19, who was admitted  in consequence of
a peculiar spasmodic affection of the diaphragm, of a most severe kind, and
which, while it lasted, was most troublesome and  painful.
  At her admission, she stated that for the last three months she had been
very subject to leucorrhoea.  In  other respects,  she was in good health.
Her face has the  aspect of hysteria; the full upper lip is very well marked.
Four days before her admission, in taking down a bedstead, she fell  and
struck the right side of her abdomen.  In half an  hour she was seized with
a catching of  her breath, and with pain in the  right side of  the abdomen.
This continued for two or three hours, so as to  interrupt her  work,  and
then went off.  Her bowels were open at the time, but she is  of costive
habit.   In the evening, the catching of her breath and the pain returned;
it now  continued some time, so  that she  scarcely lay  down  during the
night.  Next  morning there  was great epigastric tenderness, and she  was
unable to bear the pressure of her stays.
  At our first visit, we found her affected with this catching of the breath,
It exactly resembled a violent fit of sobbing, unattended  with flow of tears.
There is a jerking movement of the neck from side to side with each sob,
but the limbs  are motionless.  Any excitement increases the sobbing.  It
was much increase I  by our visit, and subsided after we left.  The upper 
HYSTERIA.
extremities are now thrown into jerking movements, resembling those of
chorea, shortly after the sobbing begins.                           ,
  Her treatment consisted in free purging for the first few days, lest there
should be any lodgment in the intestinal canal, and  subsequently tonics.
Her attacks ceased, and as she remained quite free up to the 5th of April,
and her  health was much improved, she was discharged.  She was, how-
ever, readmitted on the 10th, with a recurrence of the paroxysms, without
any apparent cause.  They are accompanied with jerking movements of
the upper  limbs  and tremblings of the  lower ones, which give  her an
unsteady gait in walking.  Pressure excites or increases  the sobbing, par-
ticularly when applied on the right side; and if the pressure be continued,
the sobbing becomes excessively violent, and the whole body is thrown into
convulsive  movements.
  She  had followed a tonic treatment for a considerable time without any
benefit to  these paroxysms.  I determined  now to  try a  succession  of
blisters to  the epigastrium.   The first excited a very severe paroxysm;
however, by perseverance in the use of them,  she has not  only become able
to bear them, but the paroxysms have considerably diminished in frequency
and severity, so that now she can bear a good deal  of  pressure without
inducing  the sobbing.
  Sir B. Brodie has recorded a case very similar to this.
  Hysterical Sneezing.—Women are sometimes attacked with violent fitf
of sneezing, coming on  at particular periods and lasting for a considerable
time.   Of ray own knowledge, I am aware of but one instance of this, in a
newly married lady, in whom  the fits of sneezing used to come on early in
the morning.  There was, I had reason to believe in this  case, great disap.
pointment that the signs  of  pregnancy did not appear about the usual
time; and  it was curious that these attacks  should have come on  chiefly
when  the morning sickness would have shown itself in the early stage of
pregnancy.                                           Part viii., p. 59.

  Treatment.—The following formula  is very  highly lauded by Dr.
Debreyne:
  R P. camphorse, gss.; P. assafcetida, gss.;  extr. belladonnae, 9iv.; extr.
aquos.  opii, 9j.
  Mix and divide into 120 pills; commence with two at first per diem, and
gradually increase the dose to six in the 24 hours ;  they should always be
taken before food.   Occasionally a wineglassful of the infusion of valerian
<m- orange leaves may be given with much advantage along with each dose
of the pills.
  Dr. D. is in  the habit of administering them also for the cure of general
or  partial  nervous trembling, and of chorea.   Sometimes he exhibits
in the latter disease, the belladonna by itself; and, he savs, very generally
with success.  When it fails, he has recourse to cold bathing.
                                                      Part x.,jt). 25.
  Hysteria treated by the application of  Cold to the Region  of  the
 Uterus—-M. Butignot mentions the  case of a  young  wonvm eighteen
years of age, attacked for the first  time with hysteria, which hsted°seven
days   She  was quite  blind during this period, but remained perfectly
sensible.   There was permanent contraction  of the muscles of  the trunk
and extremities, with occasional convulsive  movements.   She  could onlv
swallow a few drops of liquid  at a time, and speak a few words in a low 
HYSTERIA.
9
voice.  Treatment was of no avail, soothing and antispasmodic remedies
did no good, but M. B. remarked on the fifth day that the paroxysm became
aggravated about noon; he immediately gave quinine, under which treat-
ment the symptoms gradually subsided.  The following year she was again
attacked as before, and from  pain in the  hypogastric region, with sup-
pressed catamenia, he was led to infer the existence of over-eXcitement in
the uterus.  He ceased all treatment, and applied cold compresses to the
lower part of the abdomen and upper part of the thighs.  In half an hour
the patient was relieved, and had no return of her symptoms.
                                                     Part xiii., p. 68.
  Hysteria.—M. Gendrin gives opium, in  large doses, commencing with
gr. v. daily, and increasing  to gr. x. or gr. xij.:  The appearance of an
hypnotic effect is a sign that the disease, and the tolerance of opium induced
by it, are on the decline, and the dose must then be lessened.
                                                      Part xv., p. 72.
   Treatment of Hysteria.—Occurring in a patient of plethoric habit, and
accompanied by cerebral symptoms : leech the  head, or cup between the
shoulders ; if this  is ineffectual, give two grains of digitalis-twice a day,
and put a blister  on the nape ;  for  the  convulsions of the voluntary
muscles, give half a grain of extract  of belladonna, every eight or twelve
hours.
  Produced by Accumulation in the Colon.—Clear out the bowels by the
repeated exhibition of pills composed of extract of jalap, compound extract
of colocynth, and compound rhubarb pill.
   Combined with  Pyrosis.—Give trisnitrate  of bismuth, with  a bitter
infusion.
   From Anwmia.—Give chalybeates.
   Hysterical spasms may be subdued by the inhalation of ether vapor, or
chloroform.                                          Part xvi.,  p. 90.
   Observations on Hysteria.—Referring to cases in which  females have
become outrageously excited,  Mr.  Corfe says :
   Now, all attempts to pacify such persons  by ordinary means, as by  argu-
ment, by medicine, or by reasoning, are fruitless; they are like  eels for
wriggling, and like bulls for fierceness  and strength;  our only alternative
is to fix them on the stretcher, and strap them there, mount a chair placed
on each side of the head, and  keep up a constant stream of cold water on
the face; and the more they scream the more cold water they are obliged
to gulp down their throat, until the globus is conquered, the head cooled,
the passions subdued, and, when they really find that we give them  more
in proportion to the screaming, they become calm and sue for pity.
                                                     Part  xvii., p. 58.

   Belladonna  in Hysteria.—Marked benefit is derived from belladonna,
given as  follows:  Take of camphor, 12 grammes (about 5hj. and gr. y.);
assafcetida, 12  grammes; extract  of belladonna, 4 grammes (about 5j.);
aqueous extract of opium,  1  gramme (about gr. xvss.) ; sirup' of gum,
enough to make 120 pills.  Give one pill the first day, two on the second,
and gradually increase the dose to six pills daily.       Part xxi., p. 11.
   Treatment of Cerebral Hysteria.—Employ as a prophylactic  and cura-
tive agent in this affection, the persevering and systematic  application^
 electro-galvanism to the abdominal and pelvic regions, in combination 
10                         INDIAN  HEMP.
with other means.  Amongst the adjuvants that should be administered
concurrently with its use, Dr. Laycock  mentions tar in  small doses,, tne
introduction of which we owe to Professor Simpson, and which is in itseu
an excellent remedy for habitual constipation,  without the aid  01 eieciro-
  i              j     ■             r                Part xxn., p. 82.
galvanism.                                                    ,r
   Colchicum in Hysteria and Chorea.—Thirty drops of the  tincture of
colchicum, taken every eight hours, was followed by complete relief.  In
chorea, also, the same remedy has proved valuable.      Part xxv., p. dOO.
  Hysteric Hemiplegia.—This may be known from hemiplegia depending
on disease of the thalamus  opticus and  corpus  striatum by its occurring
generally  in  young  subjects, by the  muscles  of  the  face  not  being
affected, and by loss of sensation preponderating over loss of motion. The
best treatment is steel and valerian.  (Prof. Gull.)     Part xxxiv., p. 28.
                     INDIAN  HEMP-
  Indian Hemp.—There are few  medicines which  have excited more
interest than  Indian Hemp, and few medicines of known medicinal powers
have so often and so signally failed to fulfill the hopes  respecting it.  The
reason of this seems to be that the preparations which have been used by
different  experimenters have not been alike.  One  man has used the sim-
ple  tincture of the seed, another the tincture of  the resin, and another
the  resin itself.   Again, one preparation may be very useful in India, but
the  same, when brought to this country, may be  so deteriorated  as to be
useless.  Dr. O'Shaughnessy may have found the resin of the  plant pow-
erful in India, while it is necessary, when used in this  country, to make  a
tincture of the resin, prepared in India from hemp,  collected at the proper
season.  Mr. Donovan, from numerous  experiments  on  his  own person,
and on others, especially recommends the tincture of the  resin as superior
tp all the other  preparations of this drug.  The resin itself seems  to be
totally insoluble in watery liquids, and it should therefore be  made into  a
tincture.   The  pilular form will  often pass undissolved through the ali-
mentary  canal.   This  is corroborated by the fact that Mr. R.'b'Shauo-h-
nessy found that one drachm of the tincture, which contains  three grams
of the resin, had a much  more  powerful effect  than five grains of the
latter.  Mr. Donovan prepares his  tincture of the resin  by mixing two
grams of the resin with one drachm of rectified  spirit; and of this he
gives at first from eight to fifteen minims in a very small quantity of nroof
spirit. If the draught be mixed with water, the  resin will be ranidlv nrpl
cipitated and adhere to the vessel, and will thus escape being swallowed

  Indian Hemp as an Oxytoctc.-This  seems to be a valuable  oxytocic
remedy.   Several  cases are sriven bv  Dr  a,.;,f;    viuiaoie  oxytocic
powerful effects.  The cxtr&ZX^venlTZ^T^^ ^
this form the hemp is rather uncertam.   jChe fon" r™ °f ^'i^ ?
emulsion, made by rubbing a scruple of the p^1?!  recommended is the
drachm of olive oil, to wlfich mayb.added  hatfan  n ^ T^V"  *
and seven and  a half ounces of distilled Ziev   TZ TT  °f- mucil»S«.
the best form, of the strength of three gnK'of ^fi^to^SSuS 
INFANTS.
11
 of rectified spirit.   The dose of the extract is from one to six  grains, of
 the tincture ten to thirty drops.  To promote uterine contraction, less
 than thirty drops is of little service.  In tetanus one or two drachms must
 be Slven-                                           Part xxiv., p. 320.

                               ---•-%-•—


                         INFANTS.
   Nursery Treatment  of.—No other kind  of  milk to be given to an
 infant in addition to the milk of the mother or wet-nurse.  The less rock-
 ing the better.   When asleep, to be  laid upon its right side.  The best
 food is "Lemann's biscuit-powder," soaked for twelve hours in cold spring
 water, then boiled  for half an hour, not simmered, or it will turn sour.
 Very  little sugar to be added to the food, and then only at the time when
 given.
   Sweets, of every kind, are most injurious, producing acidity, flatulency,
 and indigestfon,  sores in the  mouth, and disordered secretions.   An infant
 will take  medicine the more  readily if made lukewarm in a cup placed in
 hot water, adding  a very little  sugar when given.   The warm bath (at
 ninety-four degrees of heat,  not less, for ten minutes, every other night)
 is a valuable remedy in many cases of habitual sickness or constipation.
   "Soothing-sirup," sedatives,  and  anodynes,  of every kind, are most
 prejudicial.  They  stop  the  secretions. A very small dose of laudanum
 given  to  an infant may produce coma and  death.  When an infant is
 weaned, which is generally advisable at the age of nine months, it  is of
 the utmost importance that  it be fed with the milk of one cow, and one
 only (a milch cow), mixed with "Lemann's biscuit-poAvder " (prepared as
 before directed), and very little sugar.
   Solid meat is not generally required until an infant is fifteen  months of
 age, and then to  be given sparingly, and cut very fine.   Roasted mutton,
 or broiled mutton-chop (without  fat), is  the best meat;  next to  that,
 tender lean beef or lamb ; then fowl, which  is better than chicken ; no
 pork or veal;  no pastry; no  cheese ;  the less  butter the better.   An infant
 should not be  put  upon its  feet soon, especially while teething, or indis-
posed.  Avoid over-feeding  at all times, more particularly during teeth-
 ing.  It is very likely to produce indigestion and disordered secretions,
 the usual  primary causes of  convulsions, various eruptive complaints, and
 inflammatory affections of the head, throat, and chest. .  Part vii., p. 90.
   Hint on  the Feeding of Children.—Nurses in general, who  have the
 charge of young infants brought up by the hand, have an invincible objec-
 tion to thin food, as the object is to make the child look as fat and hearty
 as jjossible, and we  have to struggle against this  prejudice  sometimes in
 cases even of imminent danger.
   In most of these cases we find the alvine dejections to consist of a thick,
pasty mass, without a proper admixture of bile, constipation being a fre-
quent accompaniment; and  it is not till the secretions become less con-
sistent, and of a better color, that we observe decided  signs of ameliora-
tion as to the  spasmodic attacks.  The generality of authors who  have
written on this subject allude to  this state of bowels.  Dr. Underwood
mentions,  that he has known  some of  the largest and finest infants he had
ever seen, die suddenly within the month, immediately after the nurse had 
INFANTS.
 boasted  of their having taken " three  boatfuls of victuals."   There are
 numerous  cases, also, of general convulsions occurring  soon  after being
 fed with thick food.  In a family in which twelve children were succes-
 sively subject to this disease, they were  all fed by hand, principally owing
 to the mother having sore nipples.                    Part xvl-> P: 293'
  Diet of  Infants.—We have had a considerable experience in. directing
 and  observing minutely the  rearing of infants upon  a  substitute for
 mother's milk.  We never allow a healthy infant, for the first two months,
 to have any other food as a substitute for its  mother's  milk than cow's
 milk diluted with two-thirds of water, and well sweetened with fine sugar.
 Of this  fare  we sanction an unlimited supply, at intervals of from  one
 and a half  to two hours during the day, and three or four hours at night,
 provided it be sucked from a teat.  Upon this simple fare, we have seen
 children grow up in the plenitude of health and strength.  If the food be
 as thin as we have described, no evil  can arise from  over-feeding ; and by
 allowing an interval to  elapse between the times of feeding, digestion
goes on better, and  fretfulness is averted. To weak or scrofulous infants,
the addition of a little mutton suet is good, or the same benefit may be
obtained by giving two teaspoonfuls  of  cod-liver oil daily.   Oatmeal, and
all farinaceous foods, are unsuitable and unnatural for the first two months,
and are  certain to induce fits of feverishness and griping pains.  After the
second month,  rusk, melted down in the  sweetened  milk  and water,  is
useful; but the food must  still be thin, and sucked from a teat by the
infant.  The exertion of  sucking is, for many reasons, very salutary.
                                                  Part xxviii., p. 291.
  Prolonged Retention of Life by  Infants who have not Breathed.—■
The long period during which life may, under  certain circumstances, be
retained by the infant who has never breathed, is a  fact full of  interest to
the physiologist, the medical jurist, and the accoucheur.  The experiments
of Legallois show that, in the mammalia, the foetus which has not breathed
 can resist death from submersion much longer than the foetus in  which
 respiration has  been carried on.  Puppies and  kittens, immediately after
 birth, may be kept under water for twenty-eight minutes with  impunity
 when five days old,  they perish after sixteen minutes' submersion • and'
 when fifteen days old, they die as rapidly as other  warm-blooded animals
 of any age, from deprivation of air.  The human still-born foetus can pro
 bably live  longer without  respiration than any other  mammalian foetus
 The following cases are collected in the "GazetteHebdomadaire" for Dp'
 cember 1st, 1824, from  different sources.  They are  very striking arid
 very suggestive to the practical accoucheur.                      °'
  A woman  aged  25  who had tried  to conceal  her  pre-nancv was
 delivered when seated on a tub    The infant, born without Iny sSns of
 life, was buried in a sand-pit, and, after remaining there for hilf on  hi
 was removed, and lived.  This case is described %^ Dr Weese  n  «1, ^
 " Badisch.  Ann. f. Staatsarz," x. 2.              y       eeSe ln  1845' in
  In 1850, a  young woman was tried by the tribunals of Berlin who hnd
 buried her new-born male infant, believing it to be dead   Aft  l!  i
 the infant was disinterred, and recalled to life.            Aftei an hour>
  T  Pa servant, aged  23, was delivered in a  stable  wh«m l   •
 agamst the wall, alone, and in a state of unconsciousness aw\if1DS
 lour, a.  m.  When she came to herself, she found the St on the tolt 
INFLAMMATION.                         13
having a spade lying  upon it, with its cutting edge turned to the body.
She took the infant, which was perfectly cold, believing it to be dead, and,
with the placenta attached, wrapped  it up in her apron, and buried it in
the garden.  Suspicions arose that she had been confined : she confessed ;
and at half past nine the infant was dug up from a depth of thirty centi-
metres.   It was found lying on its face, with the placenta under the abdo-
men.  Though cold, apparently dead, and pulseless, the  cord was  tied.
For two hours, P., a surgeon, used means to reanimate it, when at last it
began to breathe  feebly, gradual signs of life became more evident, and it
cried.   Some  slight wounds were observed  on its body: wounds in the
neck, which did not bleed at first, bled when- the infant was restored.  It
took the  breast  greedily.   On the 17th and 18th, the wounds  suppu-
rated ; and on the 19th, it died of convulsions.  The physicians intrusted
with the judicial autopsy,  reported that it  had been  inhumed before it
breathed; and that it had not breathed till  after it was exhumed; and
that the statement of the  mother was possibly true.   She was therefore
acquitted of the charge of infanticide, but was found guilty of concealment
of pregnancy.                                       Part xxxi.,p. 213.
  Defective Assimilation  in Infants.—This disease, which is the most
frequent and  fatal of all infantile disorders, is almost always the result
of want of breast-milk,  and the use of injudicious food.   Fatty acids,
and  already artificially digested animal  and  occasionally vegetable  sub-
stances, and especially breast-milk,  must be supplied.   It is a very good
plan to  mix human and cow's  milk.    Simple juice of meat is very useful.
The remedies of use are phosphate of soda,  producing an emulsion with
fats, thus allowing of their assimilation ;  chloride of potassium to dissolve
carbonate of lime; phosphate of lime,  to enable the blood to take up more
carbonic acid, and thus hold in solution more  carbonate of lime (these
substances severally strengthening muscular  and bony tissue).  Nitrate of
silver and  sulphate of copper are  the best remedies for the diarrhoea.
Wine is also required even in large quantities.Dr. Routh.Partf xl., p. 57.
                       INFLAMMATION.
  Hints on the Treatment of Inflammation.—Dr. Watson enters into
the treatment of inflammation, and places his chief reliance on blood-let-
ting, copiously used  at the commencement  of  the disease.  Respecting
venesection from the external jugular vein, he says:
  There is a distinct  and  peculiar danger attending the incision of this
vein, that, namely, of admitting air  into it.   You perhaps are aware that
if air enters a large vein near  the heart, and passes on to that organ, it
kills outright.
  [When on the subject of mercury  in the treatment of inflammatory dis-
eases, he offers the following valuable hints:]
  Patients  who are kept under the influence of mercury grow pale as well
as thin: and Dr. Farre, who has paid great attention to the effects of this
drug, remedial and injurious, holds that it rapidly destroys red blood:  as
effectually as it may be destroyed by venesection.
  But  the great remedial  property  of mercury is that of stopping, con- 
14                         INFLAMMATION.
trolling, or altogether preventing the  effusion of coagulable lymph ; of
bridling adhesive inflammation.                             ,    „oiinior
  In common adhesive inflammation, whether of «erons °r *he  ®XkJ'
tissues; whenever, in fact, you have reason to suppose  *»* ^fS^J
lymph is effused,  or about to- be  effused, and mischief is likely to lesult
from its presence, then you may expect muchbenefit from the proper ad-
ministration of mercury;  as an auxiliary, however, to blood-letting, not
as a substitute for it.
   TSpeaking of antimony, Dr. Watson says:]      #       m
  Antimony, as far as my own observation goes, is admirably  suited to
cases of active  inflammation, in  which mercury would either  be not so
useful, or could not be brought  to bear.  It is m inflammation of the
mucous membrane of the air passages that antimony is so signally beneficial.
  On the other hand, antimony does not appear to be nearly so valuable a
remedy as mercury, when serous membranes are inflamed.
  As to the form in which the  antimony should be exhibited, I apprehend
that we shall all come at last to freshly  dissolved tartar emetic.
                                                      Part  hi., p. 32.

  Blood-letting in  Inflammation.—In commenting  on  the  practice of
bleeding in the erect posture in inflammation, and then giving a large dose
of opium to prevent reaction, Dr. Craigie  believes it will often be found to
give rise to a great fallacy; the faintness thus produced being often merely
mental, and  always too temporary and  too  trifling to facilitate the re-
moval of the congested blood  from the vessels of an important organ 01
membrane in a state of intense inflammation;  except,  perhaps, when the
disease is in the head, eyes, or upper parts of the body, in which case, the
erect position must certainly be the most proper, and during venesection,
must cause the  greatest drain of blood  from the parts.     Part hi., p. 39,

   Use of Poultices in Inflammations of the  Great  Cavities.—Nothing
is more remarkable in the practice of physic in France, than the constant
use of cataplasms in the treatment of inflammations of the great  cavities.
The moment inflammation is  supposed to exist in the chest or abdomen,
 the first order given is to apply cataplasms.
   In the bronchial  irritation  .attendant  upon the exanthematous fevers
 poultices to the chest  are universally employed ; and where any want of
 energy appears  to exist  in the  system, preventing  the coming out of
 eruption, cataplasms,  consisting  of the usual linseed  meal, with the addi-
 tion of a very  small quantity,  say a twelfth or fifteenth  part of  mustard
 meal (not flour), are  applied  to the  feet,  and maintained for days to-
 gether ; thus keeping up both the temperature of the extremities and
 gently stimulating  the skin   The same mixture is also, when  necessary,
 applied to the calves of the legs and thighs.
   Pleurodynia   diaphragmitis,  and many'other affections of a painful
 nature,  are  likewise treated  by poultices; and it is certain, that their
 effects are often, in such cases, very satisfactory.         pa^t ^   p 42

    Opium  in Acute Internal Inflammations.-Recommended by Dr R
 Clmstison, particularly in inflammations  of the mucous membranes.
                                                       Part in.,  p. 45.
   Hemostasis.—A  substitute for blood-letting in  casP* of inflow,   *•
  Vide Art. "Congestive Fever."            g       eS ot mflammation. 
INFLUENZA.                            15
  Nitrate of Potash.—In large doses, suggested in inflammatory affections.
                                                        Part \x.,p. 19.
  Treatment of Chronic Inflammation.—[Chronic inflammation generally
indicates a scrofulous diathesis, and we must direct  our treatment to the
constitution, and employ alteratives  if any medicines  are  used;  but im-
proved diet, change of air, and removal to the sea-side, will often be suffi-
cient.  Mr. Cooper observes:]
  In chronic inflammation of the joints, glands, and in the formation of
indolent  tumors, and even those of a specific character, as fungus and scir-
rhus—which go  on increasing  insidiously and almost without pain—too
active means prove highly injurious, and small doses of bichloride of mer-
cury, with sarsaparilla, or Plummer's pill with hyoscyamus  at night, seem
to be the best remedies,  assisted by generous  diet and free air.   Our Lon-
don hospitals are the Avorst possible places for such patients  to be  sent to.
Mercury in these cases is not given with the same view as in  syphilis, to
act specifically, but merely to act gently upon the chylopoietic viscera, and
is given  in very small doses: and so soon, therefore, as the secretions are
restored, the mercury should be withheld  and iodine prescribed.  The
formula which I usually order it in is as follows:
  R Iodini, gr. ss.;  potass, iodidi, 3ss.; sirup. papav.,-§ss.; infus. gent, co.,
gviij.  M.  Capt. cochl. larga ij. bis quotidie, with tepid applications to the
chronic swellings, either  warm water dressings or the following lotions, if
the Avarmth does not prove  agreeable to the patient's feelings :  R Ammon.
hydrochlor., 3j.; sp. vini rect., liq. ammon. acetat. aa. gij.; aquae destillat.,
§iv. M. ft. lotio.
  Friction, steaming and bandaging, will, each of them, in certain cases,
prove  advantageous, as  Avell as a variety of  stimulating applications; as,
for instance, equal  parts of  camphor  and soap  liniments, with a  small
quantity of tincture of opium, often prove of great service.
                                                     Part xvi., p. 307.

                               —•-•-•---
                         INFLUENZA.
   Opium.—Dr. Christison finds opium of the most use in inflammations ol
the mucous membranes, especially coryza, catarrh, influenza and dysentery.
H» would cure coryza at once by causing the  patient to avoid  all meals
after dinner, to use liquid sparingly, and by giving a full dose of muriate
of morphia or Battley's solution at  bedtime ; and breakfast before getting
up the next morning. It seems necessary, hoAvever, that the remedy should,
be administered early in the attack. "Febrile catarrh too may be checked
abruptly in  the same way, if patient and  physician are lucky enough to
meet during the first or second day at farthest."
  Dr. Christison  has repeatedly seen epidemic influenza  thus checked at
the outset—the local inflammation vanishing, while the strange  lassitude,
listlessness and ennui, so characteristic of this disorder, went on  as usual
for some days during convalescence.                      Part hi., p. 45.
  Ipecacuan—Suggested in influenza.   Proportion, one or  two scruples
of ipecacuan to five or seven ounces of water.  Dose—Half an ounce every
*-wo or three hours.                                    Part viii., p. 22. 
16
INSANITY.
   Eupatorium Perfoliatum in Influenza—Manner of Admmist, ation.--
In the severest cases, where it was determined to treat the  disease with
the herb alone, the patient, after  being  covered  in  bed, was induced to
swallow a wineglassful of the infusion, prepared by infusing an  ounce of
the dried leave?in a pint of boiling water, warm,  every  half hour.   After
the fourth or fifth dose, considerable nausea, sometimes vomiting, with free
diaphoresis, ensued, and there was an  immediate amelioration ot  all the
symptoms.  Along with the nausea, free expectoration  commenced; and
after the former symptom had subsided, the patient was freed from every
annoyance, and remained in every respect comfortable.  Sufficient to keep
up the impression  on the system, the  infusion Avas hoav  given only every
third  or fourth hour in the same dose.   The bowels Avere generally opened
in about six hours after the commencement of the treatment, and afterward
continued in a lax condition.  Toward the evening of the second day, and
particularly if the patient  had been  guilty  of imprudent exposure, the
symptoms frequently returned, and it was necessary to repeat the  course
adopted at first.   But generally the medicine, continued  as directed, kept
the symptoms completely in check, and the patient Avas  out on the fourth
day.  In cases where the treatment Avas commenced with calomel, etc., the
infusion, to secure  its diaphoretic and  expectorant effects, was introduced
on the second day in Avineglassful doses every  second hour. To correct the
debilitating effects of the disease, frequently remaining after all  its acute
and more violent symptoms had subsided, a Avineglassful  of the cold infu-
sion Avas directed three times a day.
  The treatment of the disease in old persons, or in other cases where there
was a marked tendency to prostration, was commenced in the same man-
ner.   As soon as the effects already mentioned as  occurring were induced,
the cold substituted for the Avarm infusion Avas directed in the same dose
every second hour, to be continued, gradually lessening the period through-
out the disease, unless the violent symptoms  returned, Avhen it was to  be
discontinued until the same course wras repeated  with the Avarm infusion,
and then resumed.  (Dr. Peebles.)                        Part x., p. 33.
                         INSANITY.
  Seclusion, as employed at Hanwell, in the Treatment of the Insane —In
the management of the insane, seclusion of the patient  is advised during
the period of the paroxysm, or fit of passion.  To acquire the confidence of
the patient, by kmd  and soothing treatment, is considered  indispensable
and nothing aviII so  much  oppose its acquisition as brutal, or even  hn
patient usage during  the paroxysm.                      part ^    63

  Non-restraint  System in the Management of the Insane.-The annear
ance and general state of the patients in the wards of Hanwell, the order"
activity and cheerfulness  which pervade the asylum, and the rapid  subsi-
dence of the wildness oi new patients, are all alleged  bv T»,  n    n
proofs of the superiority of the" gentle' plan of trSment.7 R occaSlW
happens that patients are brought into the asylum  in spvp J. «T*   • J
They are immediately set free;  nor is the restraint^ Z  on  *eS*™mis-
the patient remains quiet.                         er put °n  aSain; yet
                                                      Part vii., p. 87. 
INSANITY.
17
  Injurious Influence of Tobacco in Insanity.— Vide Art. " Tobacco."

  Insanity produced  by the  use of Chloroform during Labor.—[At a
meeting of the Westminster Medical Society, a few months ago,]
  Dr. Webster related the folloAving case, communicated to him by a pro-
fessional friend, in consequence of perusing in "The Lancet",a report  of
the three similar instances he had mentioned at a previous meeting of the
Society.  Only one drachm of chloroform, sprinkled  upon a handkerchief,
was used ;  but the effect it produced Avas so sudden  and violent, that the
patient, after  inhaling, remained quite insensible, Avhich greatly alarmed
the attendants; Avith the insensibility there Avas likewise deadly paleness
of the countenance; however, she sloAvly rallied, but  had a painful and
protracted labor.  During several days subsequently, the lady continued
in a very nervous  condition, although not  then  actually incoherent; but
she soon became  so  furiously maniacal as to  require coercion  by a strait-
waistcoat.   After being insane during many months,  the patient gradually
recovered  her reason,  and ultimately got convalescent.
                                                      Part xxi., p. 361.
  Medical Jurisprudence of Insanity.—A careful  distinction, says Dr.
Jameson, must be made between diseases having mental symptoms, and
diseases of the mind;  betAvixt madness and such affections as hypochon-
driasis and hysteria.  Hypochondriasis consists of illusions and hallucina-
tions regarding one's bodily sensations, and is, therefore, not insanity  until
these become deep-seated and permanent delusions, compelling to irrational
conduct.   Hysteria, hypochondriasis, and various other  affections, Avhich
often precede, cause, and accompany insanity, are not diseases of the mind,
but, more  strictly speaking, diseases having mental symptoms, until  by
generating delusions they pass into insanity, and  afterward continue  as
complications of the  disorder which they have  created.  Thus, Ave  have
hysterical  mania,  which is not hysteria merely, but hysteria and mania
combined; so also there is hypochondriacal monomania, wdiich is not hypo-
chondriasis alone,  but  hypochondriasis and insanity together.
  Simple  defect of  intellectual power, intellectual dullness, must not  be
confounded Avith  the  imbecility  which constitutes  a variety of insanity,
Avhich is not merely  a feeble intensity of mind, but a positive deficiency  of
faculties.   Wherever there is a feeble exercise  of attention, or defective
memory, there will be imperfect  comparison  and resulting inaccuracy  of
judgment; but not from these, or similar causes, any necessary tendency
to be governed by delusions.   In all cases of imbecility included in the
term unsoundness  of mind, there  are both emotional and  intellectual  defi-
ciency, a loss of control over conduct, and from the  antecedence of judg-
ment being in  some  part defective or diseased, a liability to confound the
actual with the unreal.  Delusion is  not a prominent characteristic, hoAV-
ever, for in such cases feebleness is the type of  all  the mental manifesta-
tions, whether healthy or disordered.
  Eccentricity has also to be distinguished from insanity.  All the insane
are eccentric  in  their  ideas,  their  language, or their conduct; but the
merely eccentric have but a A'oluntary resemblance to the insane.  Eccen-
tricities differ from lunacies, in not arising from a loss, but from an undue
exercise of, the faculty of judgment; very often from a  vanity or self-
respect in the individual, that  leads him to prefer his own judgment to  all
other judgment, experience and  authority.  They  offend against custom
     VOL. n.—2 
18
INSANITY.
and experience more than against reason.  The eccentric, if he cannot grv e
a satisfactory reason for his outre conduct, can at least  assign an intelli-
gible motive: the lunatic has no explanation to afford that does not involve
In absurdity.  A certain individual behaves in all respects  like other men,
unless that he constantly walks about Avithout a hat, or any other artificial
covering for his head.  When questioned upon this point of disagreement
with the custom  of his neighbors, he says that nature did  not intend the
head to have any other protection than what  she herself bad afforded, that
a bare  head is more becoming, that he feels himself in every way more
comfortable as he is, and that he is certain that he will live longer m con-
sequence of acting in this rational Avay.  In two instances m which lunatics
adopted the same habit, the causes assigned  by them were of a very dif-
ferent description.  One  did not  have  his head covered,  because it had
grown so large that he could not get a cap to fit it; and the other Avas so
annoyed by certain mischievous tormentors of an invisible kind drumming
upon the crown of his hat, that in general he  preferred to carry it in hia
hand.  The eccentric man had a  rule of conduct, the  result of his  own
narrow judgment; the two lunatics Avere impelled by fancies  upon which
their judgment was entirely inoperative.  Lord Monboddo, insisting  that
the human family were  originally adorned Avith tails, shoAved himself an
eccentric theorist; had he asserted  that they  actually  retained them, he
would have had an insane delusion, instead of a philosophic crotchet.   He
would have had a false perception on which his judgment Avas inoperative,
whereas he Avas guided by his judgment to a strange conclusion.
  Eccentricities no more constitute insanity,  than idiosyncrasies constitute
disease ; and as  these  are competent with a sound state of body, so  are
those with eAren  a vigorous judgment.  For example:  There was an old
man well known  in London in the  last  century, Avho was of an  ungainly
appearance, and  subject to occasional attacks of hereditary melancholy.
So inconsistent Avas he in his habits,  that sometimes he practised great ab-
stemiousness, and at other times  devoured  huge meals, Avith brutish
slovenliness and voracity : sometimes he would persist in drinking nothing
stronger than water, but occasionally he drank Avine by tumblerfuls.   His
income Avas far from large, and not of a certain amount, yet he kept a set
of old men and women about his house, Avhose bickerings and disagree-
ments  now and  then drove him  out of doors.  He Avas  in general very
loquacious, but had been knoAvn to sit in company and drink a dozen  cups
of tea without speaking a syllable.  When not engaged discoursing it  Avas
his custom  to  keep muttering  to  himself.  In Avalking he  performed
strange  gesticulations with his limbs, and Avould not go in at a door, un-
less he could effect his  entry in a certain preconceived  number  of steps>
and so as to introduce himself on a particular foot, turning back, and re-
commencing, until he succeeded as he desired.  There Avas a row'of posts
near his house, which he would not pass without touching singly and if
he found that he had omitted one in the series, he retraced his steps to
remedy the neglect.  He hoarded  up  orange skins for some  mysterious
purpose which he would never divulge.   He suffered remorse of conscience
for once having  taken milk with his coffee on Good Friday  He believed
in  ghosts, and  went  ghost-hunting in  Cock-lane;  and  he  maintained
that he had heard his  mother calling upon him by name from the other
world.  Yet Dr. Johnson was so far from insane, that his  judgment com-
manded respect and admiration everywhere, and by the common consent 
INSANITY.
19
of em'iMat contemporaries he  was the most vigorous thinker and the
greatest tfage of his time.
  There are, however, instances of eccentric conduct resulting from abuse
of the  imagination, which verge closely upon madness, and occasionally
pass into it.  The distinction is, that the individual's voluntary power over
his  thoughts is  capable  of bringing the comparing fiiculty.into efficient
operation,  Avhen  he chooses duly to exert his will.  Thomas Hood speaks
of one  Avho, in consequence  of exciting his fancy by German tales of
diablerie, used  to fly upstairs  at his utmost speed from the street door to
the attics,  because a sort of Avager with the devil came  into his head, that
he Avould gain the top before counting a certain number, or forfeit eternal
happiness.  ^ Every one possibly experiences  moods Avhich  differ in no re-
spect from insanity, than that they are neither permanent nor independent
of the will.  These may be common in imaginative minds, but instead of
being  indulged,  they should be guarded against and restrained,  for,
though they exist at first by sufferance of the will,  they sometimes gain a
strength that defies control, and  triumphs over the reason.  Hoffman, a
master in fantastic fiction, suffered so much from intemperate abuse of the
imaginative faculty, that solitude became terrible to him.   He was never
quit of a  mysterious sense of danger;  things the most cheerful became
incongruously associated with thoughts the most dreadful, while monsters
and  spectres, Avhich he himself had created, tyrannized over  his reason.
To appease his terrors, he  had frequently to summon his Avife from bed to
sit  by him as he studied at night.  He Avas constantly on the verge of in-
sanity, and died of spinal disease, his mind being tortured by his fancy to
the last hour of his existence.
  Often it is not an easy matter to draw a distinction between insanity
and moral depravity.  In  every case of mental alienation there is disorder
of moral as well as of intellectual manifestations.   The moral disturbance
is usually the earliest developed feature of the malady, frequently it is the
most prominent, and occasionally no other is distinguished; so that the
bad have been liable to pass as mad, and the mad for bad, according to
the philosophy  and fashion  of the time.  There is no problem in laAv, medi-
cine, and ethics, of greater social importance, or of more difficult solution,
than the discrimination of insanity and vice.  A wicked deed may be the
result  of an undeveloped  moral sense, as for example in  a child or an
idiot; it may be the  consequence of such extremity of passion as impels to
instinctive, instead of deliberative action; and it may be the indication of
a conscience enfeebled by voluntary neglect, and the habitual gratification
of evil desires.   Any of these states may be simulated by disease; but  it
is Avith the last  two only that the jurist will have difficulty ; for in all cases
of insanity in which the moral sense  is non-existent, the  powers of the
understanding are also either undeveloped or destroyed. No hideousness
of depiavity can amount to proof of insanity, unsupported by evidence of
a judgment incapacitated, or a Avill fettered, by disease.  In those cases
of mental disorder in Avhich the emotions are perverted, and where there
is no clear proof of deranged intellect, cases Avhich do from time to time
occur, the  presumption of  insanity, in  regard to a criminal  action, has to
be upheld by evidence of suspension of the Avill.   The actions of an indi-
vidual  in such a state ought  to  be impulsive, involuntary, and irreconcil-
able  with the idea of a healthy state of the emotional faculties.
                                                     Part xxii.,^?. 358. 
20
INSANITY.
  Medical Treatment of Insanity.—{The following is a brief outline of
Dr.  WiusloAv's views  on the  pathology and medical treatment  of in-
sanity :]                                                      ,    ~.
  It is necessary that we should, before being able to appreciate the elf ect
of medical treatment, entertain just and enlightened views as to the cura-
bility of insanity.  I noAV speak from a somewhat enlarged experience,
from much consideration of the matter, and I have no hesitation in affirm-
ing that, if brought Avithin the sphere of medical treatment in the earlier
stages, or even Avithin a few months of the attack, insanity, unless the re-
sult  of severe physical  injury to the head, or connected with a peculiar
conformation of  chest and  cranium, and a  hereditary  liathesis,  is as
easily curable as any other form of bodily disease for the treatment of
which we apply the resources of our art.  It is a lamentable error to sup-
pose, and a dangerous, a false, and unhappy doctrine to promulgate, that
the disordered affections of  the mind are not amenable to the recognized
principles of medical science.   The  vast  amount of incurable cases of
insanity which  crowd the Avards  of  our national and private asylums,
is pregnant Avith important  truths.   In  the  history  of  these  un-
happy persons—those  lost and ruined minds—we read recorded the  sad,
melancholy, and lamentable  results of either a total neglect of all efficient
curative  treatment at a period when it might  have arrested the  onward
advance of the cerebral mischief, and maintained reason upon her seat; or
of the use  of injudicious and  unjustifiable  measures under the mistaken
notions of the nature and pathology of the disease.   In no  class of affec-
tions is it so  imperatively necessary to inculcate the importance of early
and  prompt treatment, as in the disorders of the brain affecting the mani-
festations of the mind.   I do not maintain that our curative agents are of
no avail when the disease has passed beyond what  is designated the " cur-
able stage." My experience irresistibly leads to the conclusion that we
have often in our power the means of curing insanity, even alter it has
been of some years' duration, if we obtain a thorough appreciation of the
physical  and mental aspects  of the case, and  perseveringly and continually
apply remedial measures for its removal; but I cannot dwell too strongly
upon the vital  necessity of  the early and prompt  exhibition of  curative
means in the incipient stage of mental derangement.
  I  believe  insanity (I am now referring to persistent insanity, not to those
transient and evanescent forms of disturbed mind  occasionally witnessed)
to be the result of a specific morbid action of the hemispherical ganglia,
ranging from irritation, passive and active congestion, up to positive and
unmistakable inflammatory action.  This state of the brain may be con-
fined to  one or two of the six layers composing the hemispherical o-ano-lia •
but all the layers are  generally more  or  less implicated,  in conjunction
with the tubular fibres passing from the hemispheres through the vehicular
neurine.  This specific  inflammation, from  its incipient to the more ad-
 vanced stage is often associated with great vital and nervous depression.
It is, like analogous inflammation of other structures,  not  often accompa-
 nied by much  constitutional  or febrile disturbance, unless it  loses ita
specific features, and  approximates in its character to the inflammation of
active cerebntis or meningitis.   This state of the hemispherical ^india is
frequently conjoined with active sanguineous  circulation and collation
both of the substance of the  brain and its  investing membran >s~  The
 morbid cerebral  pathological  phenomena-viz., the opacity of  hi'arach 
INSANITY.
21
noid, the thickening of the dura mater, its  adhesions  to the cranium, the
depositions so often observed upon  the  convoluted surface of the hemi-
spheres, and  on the meninges, the hypertrophy, scirrhus, the cancerous
affections, the induration, the depositions of bony matter  in the  cerebral
vessels and on the  dura mater, the serous fluids in  and  the  ulcerations
upon the surface of the ventricles, the alterations in the size, consistence,
color, and chemical  composition of the vesicular neurine  and fibrous por-
tion of the brain—are all, in my opinion, the results, the sequelae, more or
less, of that specific inflammatory condition of the hemispherical ganglia
to which I have referred.   It does not necessarily'follow that the fons et
origo mali of insanity is invariably to be traced to the brain.  The pre-
liminary morbid action and irritation are ofted  situated in the heart, the
stomach, the liver, the bowels, the lungs, or the kidneys,  the brain being
secondarily affected; nevertheless, in all cases inducing actual insanity, the
hemispherical ganglia  are  involved in the morbid action.  The most re-
cent pathological doctrine propounded to explain the  phenomena of insa-
nity—-I refer to the  views of a recent writer—that derangement of mind
is the effect of "loss of nervous tone,'1'' and that this loss of nervous tone is
" caused by a premature and abnormal exhaustibiUty of  the vital powers
of the sensorium "—conveys to my mind no  clear, definite, or precise
pathological idea.   It is true that Ave often have, in these  affections of the
brain and disorders of the mind, " loss of nervous tone," and " exhaustion
of vital power;" but, to my conception, these are but  the effects of a prior
morbid condition of the encephalon, the seguelcc of specific inflammation
of the hemispherical ganglia.  To  argue  that  insanity is invariably and
exclusively the result of" loss of nervous tone," is to confound cause and
effect, the post hoc with the propter hoc ; and would, as regards therapeu-
tical measures, act as an ignis fatuus, alluring us as pathologists from th6
right and legitimate  path.  I feel anxious that my views upon this im-
portant subject should  be  clearly enunciated, and not open to misconcep-
tion.   I think much mischief has arisen from a  belief in  the existence of
active ordinary cerebral inflammation in cases of insanity, for it has led to
the adoption of treatment most destructive to life, and has seriously inter-
fered. Avith the permanent  restoration of the  reasoning powers.  Never-
theless, insanity is occasionally complicated with acute cerebral symptoms
sufficient  to justify us in the cautious use of somewhat active measures for
its removal.   We must avoid the fatal error of a too rapid process of gene-
ralization, and be careful of not looking to symptoms instead of to the
disease itself, and of permitting ingenious  and well constructed  a priori
theories of the nature of insanity to dazzle our  imaginations and abstract
the mind  from the steady and patient investigation of pathological science
and individual cases of disease.   If we  allow our judgment to be warped
by the inflammatory theory on the  one side (I am now speaking of ordi-
nary, not of specific inflammation), and conclude that the excitement of
mania is to be subdued by copious  depletion or  the administration of anti-
phlogistic measures—or if, on the  other hand, we adopt the speculative
opinions of those who  believe that, in every case of insanity, irrespectively
of its origin, its progress, or its character, thsre exists "mere loss of ner-
vous tone," caused by " a  premature abnormal  exhaustibiUty of the vital
powers of the sensorium "—how lamentably shall we  be  misled  as to the
real character of insanity, and in the application of our therapeutic agents I
These circumscribed and partial views  of  the pathology  of insanity often 
22
INSANITY.
lead to serious solecisms in practice.  In ninety per cent, of the cases o)
acute mania there is found in the brain and its meninges a state ot sangui
neous  congestion, particularly of the hemispherical ganglia, combined
with alterations in the grey nervous matter.  In forming an opinion ot the
tions  have subsided, and the disease has assumed a chronic form, before
the patient is examined and  placed under treatment; consequently many
deductions recorded by pathologists have been based  upon  the  study of
chronic, and not of acute mania.   A large percentage of the cases, before
admission into our national asylums, have passed through the primary and
acute stages, and have probably been subjected to  medical treatment
This fact must never be  lost sight of in forming our opinion, not only of
the nature of the disease itself, but of the medical treatment necessary for
its cure.   In  private practice  the acute forms of insanity are often  met
with ; but even Avith the advantages which the physician can command, of
investigating the earlier stages of deranged mind, he often discovers that
the mental affection has been allowed to exist and slowly progress for a
considerable period, no treatment, either  medical or  moral, having been
adopted for its removal.  In the incipient form  of insanity, particularly
when it manifests itself in plethoric  constitutions, has been  sudden in its
development, is the  result  of  physical  causes, and is connected with the
retrocession of gout, or is rheumatic in its character, there can be no doubt
the nature of the  changes  induced  in  the brain is more allied to  that of
inflammation  than that of nervous exhaustion.  The attacks from the slow
and insidious operation of moral causes are less likely to be  accompanied
by  active  symptoms.  In  many instances  the  maniacal excitement  is
asthenic  or atonic in its character, resembling  the delirium of the last
stages of typhus fever.
  The most simple classification of insanity, the one best adapted for useful
and practical purposes, is its division into the acute and chronic forms ; the
insanity ushered in by excitement or by depression into mania and melan-
cholia—amentia and dementia.   The  minute divisions and subdivisions,
the complicated and confused classification to be found in books, may serve
the ostentatious purposes of those desirous of making  pompous display of
scientific  lore,  but 1 think they have tended to bewilder and obscure the
understanding  of the student, and lead the man in search of practical truth
from the investigation of the disease itself to the mere study of its symp-
toms, and to the  consideration  of unessential points and shades  of differ-
ence  Adhering to this division of the subject, each form should be  viewed
in relation to  its complications, as well as to its associated diseases  Anion*
the former are epilepsy, suicide, homicide, paraplegia,  hemiplegia, and
general paralysis.  Ihe associated disease implicate the lungs, heart, liver,
stomach, boAvels, kidney, bladder, and  skin
  Before speaking of the preliminary examination of the patient supposed
to be insane,  and the prognosis in cases of insanity, I would  premise  tint
those inexperienced in the examination of this class of cases^wouTd often
arrive at false and inaccurate conclusions, if they were not cognizant of the
tact, that the insane often describe sensations which they htve never ev
perienced,and  call attention to important symptoms which have no exis
tcnce except  m their oavu morbid imaginations!   A patient will ten  you 
INBANTTY.
23
 that he has a racking headache, or great  pain and  tenderness in the epi-
 gastric region, both symptoms being the fanciful creations of  his diseased
 mind.  This is particularly the case in the hysterical forms of insanity, in
 Avhich there always exists a disposition to pervert the truth, and exagge-
 rate the symptoms.  Again, serious bodily disease maybe present, the patient
 not being sufficiently  conscious to comprehend the nature  of the questions
 asked,  or able to give intelligible replies to the anxious interrogatories of
 the physician.  Insanity often masks,  effectually obscures, other organic
 affections, the greater  malady overpowering the  lesser disease.  When
 Lear, Kent, and the Fool are standing alone upon the Avild heath, exposed
 to the merciless pelting  of the tempest, Kent feelingly implores the king to
 seek shelter from the  "tyranny of the open night"  in an adjoining hovel;
 it is then that Lear gives expression to the psychological truth just referred
 to:

                ** Thou tfaink'st 'tis much that this oontentioua storm
                  Iiwades us to the skin ; so 'tis to thee;
                  But wliere the greater malady isfoced,
                  The leaser is scarce felt;
                                    The tempest in my mind
                  Doth from my senses take all feeling else
                  Save what beats there."

 Disease of the brain may destroy all apparent consciousness of pain, and
 keep in abeyance the outward and appreciable manifestations of other im-
 portant indications of organic mischief  Extensive diseases of the stomach,
 lungs, kidneys, bowels,  uterus and  heart  have been known to have pro-
 gressed to a fearful extent Avithout any obvious  recognizable indication of
 the existence of such affections.   Insanity appears ' occasionally to modify
 the physiognomy and symptomatology of ordinary  diseases, and to  give
 them peculiar and specific characteristic features.
   Again, it is necessary for the physician to Avateh the operation of medi-
 cine in  masking important diseases.  The  different forms  of narcotics, if
 given in heroic doses,  often mislead us in  our estimate of the nature  of
 bodily diseases not directly connected AA'ith the mental affection.  The most
 essential preliminary matters of inquiry have relation to the age, tempera-
 ment, and previous  occupation, and condition in life  of the  patient.  It
 will be  necessary to ascertain the character and duration of the attack ; to
 ascertain  Avhether it has resulted from moral or physical causes ; if of sud-
 den, insidious, or of slow groAvth;  Avhether it has a hereditary origin, or
 is the effect of a  mental  shock, or of mechanical  injury; Avhether it is the
 first attack ; and  if not, in what features it differs from previous paroxysms.
 It will also be our duty  to inquire Avhether it is complicated with epilepsy,
 paraplegia, or hemiplegia, suicidal  or  homicidal impulses.  If any prior
 treatment  has been adopted, we must  ascertain its nature;  Avhether the
 patient  has suffered  from gout, heart disease, rheumatism, cutaneous affec-
 tion, or syphilis.   It is important in cases of females  to obtain accurate in-
formation in relation to the condition of the uterine functions, and to ascer-
tain the state of the moral affections.  We should also inquire whether the
patient  has been  suspected of habits of self-abuse.  Having obtained accu-
rate information upon these essential points, our  own personal observation
will aid us in  ascertaining the character of the  mental disturbance; the
 configuration of the head, chest, and abdomen; the gait of the  patient, the 
24
INSANITY.
 degree of sensibility and volitional poAver manifested; the state of the 10
 tina, the pulse, the urine, and  temperature of the scalp  and body gener-
 ally ; the condition of the skin and chylopoietic viscera;  the action of the
 heart, lungs, and nature of any existing disease of the uterus.  If a patient
 complains of any local mischief, hoAveArer imaginary it may appear to be at
 the time, it is essentially necessary that we should clearly satisfy our minds
 upon the point before dismissing  it as  not  entitled to serious investiga-
 tion.   A patient once bitterly  complained of retention of urine; upon ex-
 amination the bladder was found to be distended, and the man had passed
 uo urine for twenty-four hours.  I was about to introduce a catheter, Avhen
 the patient burst into a fit of laughter, and immediately emptied his blad-
 der.  Esquirol relates a case of  a  merchant,  Avho, whilst  suffering  from
 melancholia, declared that some  foreign body Avas  sticking in huVthroat.
 No notice Avas taken  of this supposed fanciful idea.  The patient died, and
 an ulcer was discovered at the upper third of the oesophagus. A patient
 complained of devils being in bis  stomach and bowels, and declared that
 they were acted upon by electric or magnetic agencies. After death he was
 found to have  scirrhus of the stomach, and  chronic inflammation of the
 bowels.  A patient refused to eat; he said he could not swallow his  food
 without great pain.  As he had exhibited other symptoms of a disposition
 to suicide, it was thought by myself and others, that his obstinate refusal
 of food was associated with ideas of self-destruction.  He died, and at the
 post-mortem examination a stricture in the pylorus was discovered. These
 illustrations, and  they could  easily be extended,  will  prove the impor-
 tance of paying minute  attention  to  particular  delusions, Avith the view
 of  ascertaining Avhether they have not  a particular and actual physical
 origin.
  The prognosis in cases of insanity will mainly depend upon the duration
 of the attack, its character and origin, and the diathesis of the patient.
 The prognosis is generally unfavorable if the  disease is hereditary—if the
 symptoms are similar in character to those exhibited by other members of
 the family when insane.  Insanity, accompanied  by acute excitement, is,
 ceteris paribus  more easy of cure than when it has been of slow and ira!
 dual growth, and is marked by great mental depression.  The prognosis is
 favorable in cases of puerperal  mania; it is unfavorable when there exists
 a want of symmetry between the  two sides  of the head, with small ante-
 rior, and large posterior  cerebral  development.  Any great ineoua itv in
 the crania  conformat on would be a suspicious  indication?  Th^ existence
 of any malformation m the development of the chest is also an unfe™£
 ble sign, and would induce us to  give a guarded  prognosis    Dr Darwb
 says, when a person becomes  insane, who has a small fimiiJ^ i:i~i    I
 absorb his attention, his prospect of recovorv t W    i,  y °^ chlld,ren to
 that the maniacal hallucination ismoi eTowerfnfth   i ™ *• fStablifheu8
 usually interest us most.  The prognosis KlS  ^T* ^ whlch
 under the morbid delusion that they are  nohon^     f When patlentS are
fering internally from peculiar sensation,P  £ r ^ and1a,re ^n^ntly suf-
ditficult to eradicate th in other ZXT'  Religious delusions are more
tient will materially guide us  in foS^ESST  ^ ?«* &the ^~
tes says the insane are not curable afte^the tor^J™^'  HiPPocra-
tains the greater portion recover between th1    ¥**'> Es(*Ulroi Iaaia"
Haslam, between the  ages of ten and tWenW  g  if U'?nt? ?nd tbirt^
                                     wenty.  As a principle, we may 
INSANITY.
25
conclude that the  probability of recovery in any given  case is in propor-
tion to the  early age, physical condition, and duration  of  the attack.
When a patient has youth and a good constitution to aid  him, and is ad-
vantageously placed,  having at  command  remedial  measures, and is
excluded from all irritating circumstances, the prognosis may be favorable.
I have seen patients after the advanced age of sixty and seventy  recover;
and cases  of cure are upon  record where insanity has existed  for ten,
fifteen, and twenty years.  In forming our prognosis, it is important  to
ascertain the educational training of the  patient.   Has he been  in  the
habit of exercising great self-control? Has  his mind been Avell  disci-
plined ?  Has he kept in abeyance the passions, or have the motions and
impulses of his nature obtained  the mastery over him ?   He who  has been
taught to practise self-denial and self-control in early life, is, cmteris pari-
bus, in a more favorable position for recovery than he Avho has permitted
himself to  be the willing and obedient slave of eArery passion and caprice.
Insanity, accompanied Avith criminal propensities, is said to be incurable;
because, as Ideler urges, such patients " cannot bear the torments of their
consciences, and relapse into the stupefaction of insanity to liee  from the
consciousness of their guilt."  The  prognosis is unfavorable when the in-
sanity is comjilicated Avith organic  disease of the  heart and lungs, with
deafness, and paralysis in any of its  forms.  Lesions of the motor power
are very unfavorable indications.  Great impairment of mind,  accompa-
nied with delusions of an exalted character, and associated with paralysis,
is generally incurable.  Esquirol says, epilepsy, if associated with insanity,
places the patient beyond all prospect of cure.  I should be loth  to  adopt
this sweeping  condemnation.   I have seen cases  of epilepsy, combined
with mental derangement, recover; although, I admit, they constitute a
difficult class of cases to manage.
   [As it would be impossible to describe in detail the  particular class of
remedial agents adapted to each class of deranged minds, in the succeed-
ing lecture the  subject  has  been generalized,  the  most  prominent
kinds of insanity, and the difficulties of their management, only being  dis-
cussed.]
   In regard to the treatment of acute mania, the  important and  much-
litigated question  at issue among practitioners of all countries, is that re-
lating to the propriety of depletion.  Whilst  some practitioners of great
repute and enlarged experience fearlessly  recommend copious general de-
pletion for the treatment of insanity, and refer  to  cases  in which this
practice has been attended Avith the  happiest results, others, equally emi-
nent, and as much entitled to our  respect, denounce the lancet as a most
fatally dangerous weapon, and shudder at  the suggestion  of abstracting,
even locally, the smallest quantity of blood.  In avoiding Scylla,  we must
be cautious of being  impelled  into Charybdis.  The error consists in a
vain effort to  discover a uniform  rule of treatment, and  attempting  to
propound some specific mode of procedure adapted to all cases.  He who
maintains that blood-letting is never to be adopted  in  the treatment of
mania, Avithout reference to its character, its origin, the peculiar constitu-
tion of the patient, and the existence of local physical morbid, conditions,
which may be materially modifying the disease, and giving.active develop-
ment to delusive impressions, is not a safe  practitioner.  ^ Neither would I
confide in  the judgment of the physician who would, in  every case  of 
26
INSANITY.
violent maniacal excitement,  attempt to tranquillize the patient by either

gfo^i°rf^Sr^en the symptoms are acute, the_ patient  young
and plethoric, the habitual secretions suppressed, the head hot and painful,
the eyes intolerant of light, the conjunctiva}  injected   the pupils  con-
tracted, the pulse rapid and hard, and the paroxysm sudden in its develop-
ment, one general bleeding will  often arrest the progress of the cerebral
mischief,  greatly facilitate the  application of other remedies,  and  ulti-
mately promote recovery.  In proportion  as  the symptoms of  ordinary
insanity approach  those of phrenitis, shall we be justified m  the  use of
general depletion.   Although it is only occasionally, m instances present-
m<r peculiar characteristic features—cases occurring in the higher ranks of
life where the patient has been in the habit of living above par, and is ot
a sanguineous temperament—that we are justified in  having recourse to
the lancet, there is a large class of recent cases  presenting themselves in
the asylums for the insane, both public and private, in the treatment of
Avhich we should be guilty of culpable  and cruel negligence, if Ave Avere
to omit to relieve the cerebral  symptoms by means of the local abstrac-
tion of blood.   It is the fashion and caprice of the day to recklessly decry
the application of cupping-glasses or of leeches in the treatment of in-
sanity, in consequence, I think, of the  slavish  deference shown  to the
opinion of a feAv French  pathologists of eminence, who have, by their in-
discriminate denunciation of all  depletion, frightened us into submission,
and compelled us to do violence to our OAvn judgment.  The  local ab-
straction of blood is, in the hands of the discreet  and judicious  practi-
tioner, a powerful  curative agent; and yet it is the practice of some men,
and men, too,  of position, to discard altogether the remedy.
  I Avill briefly refer to the kind of case in Avhich the local abstraction of
blood will  be found most beneficial, if proper regard  be had to the  tem-
perament, constitutional condition, and the local circumstances modifying
the character  of the attack.  In  insanity,  when  the exacerbations occur
at the  menstrual  period, ceteris  paribus,  leeches  to  the  A'ulva  and
thighs, Avith the use of foot-bath, and the exhibition of aloetic purgatives,
will be  attended  by  the   most  favorable  results.   In  irregular  and
obstructed menstruation, the local  abstraction of blood  wdll be  very ser-
viceable.   In suppressed hemorrhoids, leeches to the neighborhood of the
sphincter ani will  greatly benefit in unloading the hemorrhoidal vessels,
and relieve the brain of undue excitement.  In  cases of nymphomania,
leeches to the vulva are indicated, and have been known to greatly bene-
fit.  In cases  of intermittent insanity,  the paroxysm may often  be cut
short by relieving the overloaded state of the vessels  of the head by
means of cupping or the application of leeches.  In some instances I have
tried Dr. Wigan's plan, and have applied leeches to  the Schneiderian
membrane, particularly for the treatment of insanitv of early life, and
connected with conduct evidently the effect of cerebral irritation.  Ihavc
seen this mode of procedure of essential benefit in persons of plethoric
constitution and of sanguineous temperament.  Occasionally the insanity
is found to be associated Avith active visceral disease, or Avith hypertrophy
and  other affections of the heart.   Under these circumstances when
there exists great tenderness over the region of any of the visceral  or-ans,
and we are satisfied, by a careful stethoscopic examination, that hypertro!
phy of the heart is present, leeches applied over the seat of the local mis 
INSANITY.
27
chief, conjoined Avith other appropriate treatment, Avill materially aid us in
subduing the maniacal affection.  In cases of illusions of hearing, or of
vision, it will often be necessary to apply leeches  behind the earsfor over
the superciliary ridges.  I have known* this practice entirely remove the
morbid illusions Avhich had been embittering the person's life.
  But apart  entirely from the local  affections to Avhich I have  referred,
for the treatment of idiopathic insanity, apparently without any complica-
tions, or modified by any of the associated diseases, the careful  and tem-
perate local  abstraction of blood, Avhen general depletion is inadmissible,
Avill often materially shorten the duration of an attack of insanity, and re-
store the mind to a healthy condition.  I am anxious to record my favor-
able opinion of this mode of treatment, because I have Avitnessed so many
Bad results from an opposite timid and reprehensible neglect of the means
placed within our power for the treatment of the varied forms and degrees
of mental  derangement.  Sad consequences have undoubtedly  followed
the indiscriminate use  of depletory  measures; the  presence  of violent
mental excitement has occasionally led the  practitioner to the conclusion
that the disease Avas of an active character;  and  in  the attempt to allay
the undue cerebral  excitement by means  of antiphlogistic  measures, the
patient has sunk into incurable and hopeless dementia.  But recognizing
an anaimic class of cases, Avhere great excitement is often associated Avith
loss of nervous and A'ital poAver, Ave must be cautious in permitting serious
disease to be creeping stealthily on in the brain, no effort being made to
relieve the congested  cerebral vessels or inflamed tissue,  until serious
disorganization has taken place in the delicate structure of the  vesicular
matter, and the patient is forever lost.  In the treatment  of acute mania,
the remedy next  in  importance to cautious depletion is that of prolonged
hot baths.  To Dr. Brierre de Boismont,  of Paris, at wdiose excellent in-
stitution  I first Avitnessed  the application  of this remedial  agent, the
profession is indebted  for reviving a practice which had long fallen  into
disrepute.   In treatment of acute mania, the prolonged hot baths Avill be
found of  the most  essential service.    Dr.  Brierre  de Boismont has
recorded the history of sixty-one of seventy-two cases that were subjected
to this mode of treatment.  Three-fourths of this number were cured in  a
week, and the remainder in a fortnight.  The  patients remain from eight
to ten and fifteen  hours in Avarm  baths, whilst a current  of cold Avater is
continually poured over the head; the temperature of these  baths is from
82° to 80° Fahr.;  the affusions 60° Fahr.   Among the therapeutic effects
of these baths, Dr. B.  de Boismont reckons a diminution of the circula-
tion and respiration, relaxation of the skin, alleviation of thirst, the intro-
duction of a considerable quantity of Avater into  the  economy,  an abun
dant  discharge of limpid urine, a tendency to sleep, a state of repose
This mode of treatment is said to be ineffectual in cases of periodic inter-
mittent mania, in mania beginning with great mental impairment, or asso-
ciated Avith  epilepsy  or general  paralysis.  The  result  of  my  own
experience of  this  plan of treatment has  produced a Arery favorable
impression upon my  mind, and I think it is entitled to a fair trial in all our
public asylums Avhere they admit acute and recent cases.
  In some forms of  acute mania it is desirable, as a substitute for deple-
tion, to diminish the activity of the circulation by the exhibition of nau-
seating doses of the tartrate of antimony; it may be serviceably combined
with the tinctures of digitalis and hyoscyamus.  This remedy,  however, 
23                            INSANITY.

requires careful watching, as it often has been .1™°^ *°.Judd£^c^
the vital powers to a low ebb, and extinguish life.   K^**!?™^^
ficial in proportion to  the recent character of  the case and  the positive
acU ity ofthe cerebral circulation.  The tincture of digitalis was formerly
in great repute as an anti-maniacal remedy; the experience of late yeais
hasgr.ct  encouraged us in administering it in the doses^prescribed by some
of the old write™; nevertheless, it is a useful agent, and occasionally pioves
a valuable auxiliary in the hand of the  practitioner who carefully watches

^VorThrcure of the acute forms of insanity, the douche bath has been
much lauded ; but this remedy is  now rarely used in British asylums.  1
have occasionally seen benefit derived from its exhibition, but it requires
great caution in its use.  A patient has been subjected whilst in a  parox-
ysm of acute delirium, to the douche bath, and has sunk almost immediately
into incurable idiocy !  The physical shock has occasionally been known to
produce a  good  moral  impression.  For illustration:  a patient imagined
himself emperor of the world, and would not allow any one to address him
by any other title.   The immediate application  of the douche bath
destroyed his idea of royal dignity, and he Avas willing to admit that he
had never been, nor Avas at any time a  regal personage. A few hours sub-
sequently, the delusive impression returned in all its  original  force ;  the
douche bath was again had recourse to, and a second time the morbid im-
pression vanished; by a series of baths  he was restored to  sanity, and after
his complete recovery, when the particulars of his case Avere placed before
him, he observed, " Why did you not Avhip me, and beat this nonsense
out of my head ? I Avonder how you could have borne Avith my folly, or I
have been guilty of such contemptible arrogance and obstinacy."  As a
substitute lor the douche, the shower-bath is often used Avith great benefit,
particularly in certain forms of melancholia, associated Avith nervous de-
pression and general debility.  In cases of melancholia, or other kinds of
chronic insanity  connected Avith a congested state of the liver, the nitro-
muriatic bath Avill occasionally do much good.  In a few instances I have
noticed marked  benefit from Bertolini's sedative bath, composed of hen-
bane, two  pounds, and equal parts  of hemlock, and cherry laurel  leaves,
well infused in a sufficient quantity of hot Avater.  But the simple hot-bath
 in certain conditions of the nervous system, particularly in some forms of
 suicidal mania, is of the utmost  benefit.  A warm bath a short period
 before  retiring to rest, bathing the head at the same time with cold water,
 particularly if the scalp be  unnaturally hot, will often insure  a quiet and
 composed night when no description of sedative, however potent its charac-
 ter and dose, would influence the system.
   In the early stages  of  insanity, and throughout its Avhole  course, the
 bowels are often in an obstinately constipated  condition.  The concentra-
 tion of nervous  energy in  the brain appears to interfere  Avith that supply
 Avhich  should proceed to other  structures; consequently there appears to
 be a want of healthy sensibility in the mucous membrane of the  bowels,
 and an interruption to the peristaltic action of the intestinal canal.   There
 is no class of agents which act so certainly and effectually in relieving the
 mind when under the influence  of depressing  emotion, as cathartics. &The
 ancients considered hellebore as a specific in certain forms of melancholia.
 In the hands of modern practitioners, it has  not been found to merit the
  high encomiums which have been passed upon it.  It is important in every 
INSANITY.
20
case of insanity, but particularly in the acute stages of mental derange-
ment, to act powerfully upon the bowels by means of a succession of brisk
cathartics.   The bowels  are often found gorged with fecal matter, and
immediate  relief often follows the administration of two or three doses of
calomel and colocynth, or of croton-oil.  It Avill "often be necessary to assist
the operation of the cathartics by means of  enemata.   In hysterical  and
some other forms  of insanity, there is ahvays a disposition on the part of
the  patient resolutely to resist  the calls of nature, and,  knowing  this
peculairity, we must carefully watch the condition of the bowels, otherwise
serious mechanical obstructions may ensue, followed by intractable diseases
of the  rectum.   Insanity is often  associated Avith gastric and intestinal dis-
ease, Avith an irritable condition of the mucous membrane of the  alimentary
canal; and, in  such cases, although it is  important to relieve  the boAvels
and prevent them from being constipated, we must bear in mind that the
injudicious exhibition of irritating drastic cathartics may aggravate the
mental disease, by increasing the gastric  and  intestinal  irritation,  and
thus do permanent and  irremediable  mischief.   Much injury  may arise
from the indiscriminate  and injudicious administration  of cathartics.  In
insanity associated with menstrual obstructions, it will be  necessary to
exhibit the class of purgatives known  to act specifically  upon the  lower
bowel; consequently aloetic cathartics, such  as  the compound decoction
of aloes, are found of most service in these cases.  In plethoric habits, Avhen
there  is a  marked determination of blood to the head, no medicine will
relieve so  speedily as active doses of the compound powder of jalap.
   In the treatment of insanity, the class of medicines termed sedative play
an  important  part.   If  exhibited Avith  judgment, the  most  gratifying
results often follow their continuous and persevering administration.  The
sedative treatment of insanity is  a subject of itself, and I quite despair of
touching even "upon the  confines  of many interesting and important points
involved in the consideration of this division of my lecture.  In insanity
unassociated Avith active cerebral  circulation, congestion, or paralysis, or
after the head symptoms have been relieved by the local abstraction of
blood  and the administration of appropriate medicine, the exhibition of
sedatives Avill be followed by the most  beneficial results.   In recent  cases
they are generally inadmissible, except in delirium tremens and puerperal
insanity, and other forms of derangement analogous in their pathological
character and symptoms to these affections.  In chronic insanity, in melan-
cholia unconnected Avith abdominal repletion, or visceral disease, the  per-
severing use of sedatives in various combinations Avill often  reestablish
sanity, Avhen no other course of treatment is likely to be successful in dis-
pelling the illusive impressions,  or  raising the  drooping  and desponding
spirits.  Battley's solution, the tincture of opium, the ineconite, acetate,
and hydrochlorate of morphia, the preparations of hyoscyamus, coniuin,
stramonium, camphor, hops, aconite, ether, chloroform, hydrocyanic acid,
Indian hemp, are  all  of great and essential  service if administered with
judgment and  sagacity."   In suicidal  insanity, when local cerebral conges-
tion is absent, and the general health and secretions are in  good condition,
the  meconite  and hydrochlorate  of morphia   often act  like a  charm,
uninterruptedly andperseveringly given until the nervous  system is com-
pletely under its hifluence.   I have Avitnessed the most distressing attacks
of suicidal mania yield  to  this treatment, Avhen every other system has
failed.   I could cite  the particulars of numerous  cases of  this form of 
30
INSANITY.
 insanity radically cured by the occasional local abstraction of blood from
 the head, the administration of alteratives, the warm bath, and sedatives.
 In the use of this  powerful  curative agent, our success will often depend
 upon a ready adaptation of the kind of sedative to the description of case
 in which  it may be deemed admissible, and a judicious combination of
 various kinds of sedatives.  I do net think Ave pay sufficient attention to
 such  combinations.  I have often seen an  apparently incurable and un
 manageable  case  yield to several  kinds  of sedatives combined, when it
 resisted the operation of any one or two.   The extract of conium is often
 of service in cases of insanity combined  Avith epilepsy; conjoined  with
 mineral tonics, conium is occasionally of benefit, particularly in melancholia
 connected Avith chronic diseases of the digestive organs and with neuralgia.
 In cases of uterine irritation, I have seen great good result from the com
 bination of hops, camphor, and hyoscyamus.  In illusions of vision, bella-
 donna, commencing with quarter-grain doses, will be found a useful remedy.
 In insanity complicated with dysmenorrhoea, the combination of camphor
 Avith hyoscyamus,  opium, or conium, may be given Avith great advantage.
 The hydrochlorate of morphia, in union with dilute hydrochloric acid, is
 said to be useful in cases Avhere the sedative treatment is desirable.  I am
 often in the habit of exhibiting sedatives and tonics in a state of combina-
 tion, particularly conium with iron, opium with quinine, or Avith the infu-
 sion or compound  decoction of cinchona.  In debility, Avith  irritability of
 the nervous system, accompanied by restlessness, Battley's  solution, Avith
 the preparations of cinchona, will often proAre of great benefit.  The tinc-
 ture of sumbul I have  occasionally administered, and I think Avith advan-
tage, in paroxysmal or convulsive forms of insanity.  I have given to the
extent of one or two drachms for a dose.  In hysterical derangement, the
tincture of Indian hemp will  occasionally allay the excitement, and produce
sleep more rapidly than any other form of sedative.  The valerianate of
 zinc has not answered the expectations of those Avho have spoken so  highly
 of its medicinal virtues.  Tincture of opium Avith camphor, and the tartrate
 of antimony,  is an  excellent combination in cases of doubtful  cerebral con-
 gestion.   Tincture of hops in doses of from one to four drachms, it will be
 necessary  to give Avhen  no other formulae are admissible.  As a mild form
 of sedative, compound ipecacuanha powder is occasionally recommended;
 but a good substitute for Dover's powder is a pill composed of opium,
 ipecacuanha,  and soap.
  In treating the more chronic forms of insanity, particularly melancholia,
 it will be  essential to bear in mind that they are difficult of cure, because,
 owing to the slow, obscure, and insidious  character of  the disease, the
 mental  affection has been of some duration before the attention  of the
 practitioner has been directed to  its existence.   As this form of derange-
 ment generally exhibits itself in trifling perversions of the affections and
 propensities leading to little  acts  of extravagance  and irregularity of
 conduct, associated with great depression, we  often  find the attack has
 existed some years before a necessity is  felt for any medical  advice or
 treatment-perhaps a suicidal propensity has manifested itself, this  bein«
 the first apparent overt act of the insanity                          «^"0
  It is necessary, before  suggesting any'course of treatment  in  melan-
 choha to  ascertain whether  any latent visceral disease be  present  Occa-
 sionally the  local irritation will be  found  either in the  liver  or the
 stomach and bowels, and in women the uterine functions are frequently 
INSANITY.
81
disordered.  In the religious and  other forms of melancholia in  females,
the delusive ideas are often associated with uterine irritation; and  under
such circumstances, if actual physical derangement of an active character
exists in this organ, the  best treatment wilf be, the application of leeches
to the neighborhood of uterus, combined Avith warm hip-baths, sedatives,
and  mineral tonics.  In cases  of melancholia, the  digestive functions are
often much vitiated, the circulation languid, the skin cold and flaccid; and
these symptoms being conjoined Avith a general loss of physical tone, such
patients require generous diet, good air, gentle exercise, and  occasional
stimuli.  When dyspeptic symptoms are combined with an inactive state
of the bowels, I have often administered the compound tincture of  guaia-
cum with great benefit.   It is  important to Avatch the particular features
in these cases,  and to improve the general health by the  exhibition of mild
alteratives and vegetable tonics, Avith alkalies.  I have occasionally admi-
nistered, Avith  success, in this form of insanity, apparently associated Avith
an  abnormal  condition  of the  nutrition of the  brain, cod-liver  oil, with
preparations of iron.
  My time will not admit of my submitting  for your approval the treat-
ment best  adapted for those forms of mental disease associated  Avith an
atrophied or softened condition of the nervous matter.   I think more is to
be done for the  cure of these cases than  the  writings of medical men
would lead the student to suppose, particularly if the disease  be seen  and
subjected  to treatment in the  early stages.   I have recorded the details
of several instances of cerebral disease, exhibiting  all the legitimate  fea-
tures of ramollissement, and yielding to the persevering  administration of
the  preparations  of iron, phosphorus, zinc,  and  strychnia, combined Avith
generous living, and the occasional application of a leech behind  the  ear,
should indications of cerebral congestion be present.  I  have also derived
benefit in these cases from the use of the milder forms  of mercury, asso-
ciated Avith cinchona.  In cases of impairment of the mind, loss of memory,
defective power of attention,  occasional paroxysm  of  mental paralysis,
unconnected Avith lesions of the motor poAver, I have found a solution of
the acetate of strychnine, and a solution of the  phosphate of strychnine,
of great advantage.
  In some chronic forms of insanity, in dementia, and persistent monoma-
nia, connected, as it  was supposed, with morbid  thickening of the dura
mater, and Avith interstitial infiltration of the membranes, as  Avell as Avith
exudations upon its surface, I have occasionally had the  head shaved, and
haAre perseveringly rubbed OA*er the scalp a  strong  ointment of the iodide
of potassium combined Avith  strychnine.   In other  instances  I have kept
the head painted Avith the mixture of iodine.  I have seen marked benefit
from this mode of treatment.  In  several cases Avhere  the mental  symp-
toms  Avere  supposed to  be  associated  with  effusions of  serum, I have
ordered the iodine to be applied externally, at the same  time exhibiting
minute doses of calomel, or mercury with chalk, to slightly affect the  sys-
tem :  this,  conjoined with occasional tonics, diuretics, and  stimuli to sup-
port the vital powers and enable the patient to undergo  this treatment, is
occasionally productive of considerable benefit, in cases apparently placed
quite beyond the reach of improvement in cure.
  I have only briefly spoken of two distressing, and often  unmanageable
forms of insanity—viz., of suicidal mania, and of  those cases Avhere the
patient obstinately refuses to take  either  food or  medicine.  In  insanity 
82
INSANITY.
associated Avith suicidal tendencies, it will be important to ascertain whe-
ther any  cerebral congestion exist, as  such is  often  the case.   A lew
leeches  applied to the head, followed by an  active cathartic, will  relieve
the local irritation, and often dissipate the idea of self-destruction.   In the
absence of any positive active cerebral symptoms, the prolonged hot bath,
and the persevering exhibition of some form of sedative, is the best treat-
ment to be adopted.   I have seen the suicidal impulse removed after the
administration of a few doses of  belladonna;  but the meconite and hydro-
chlorate of morphia, if given for a sufficient  length  of time, will, in the
great majority of cases, distinct from actual incurable visceral or cerebral
disease, effect a cure.  Occasionally the shoAver-bath, and counter-irritation
in the  vicinity of the  head, Avill aid us in reestablishing health.   Cases
sometimes present themselves where the patient determinedly refuses  to
take either  food or medicine.   This character of case gives those Avho
have the care of the insane  much  anxiety.  The refusal  of food  maybe
connected with determination to destroy life, or it may be associated with
delusive impressions.  I  am inclined to believe  that  in  the majority  of
these cases the symptom  is the result of some local mischief remote from
the  brain, and  sympathetically affecting the organ of  thought.   Upon
examination Ave  often find, in  these cases, great gastric derangement,
obstinate  constipation, considerable  tenderness upon pressure in the epi-
gastric region, hepatic disease, the tongue foul, breath offensive, and other
symptoms of derangement of the chylopoietic viscera.  The determination
to resist  nourishment arises, un'der such circumstances, from  a positive
loathing of food—a want of all inclination for it.  I haAre seen cases of
this description, wdiere it has been deemed necessary, in order to  prolong
life, to  introduce food forcibly into the stomach, speedily  cured  by the
adoption  of means  for  improving  the  state  of the general health and
digestive  organs.   Mild alteratives, vegetable  tonics, blisters over the
region of the stomach, if the patient complain of pain in  that region upon
pressure,  the warm and shoAver-bath—is the  most successful treatment to
adopt  in  cases connected with  obvious  visceral  derangement.  Instances
sometimes occur, where  the refusal of food is clearly traceable to  a delu-
sive impression—a hallucination of taste, which makes  everything appear
to the  patient  bitter, disgusting,  and  poisonous.  The  unhappy patient
imagines  that he is commanded, either by good or evil spirits, not to eat.
These unhappy persons must be treated upon general  principles, and  the
remedies be adapted to the peculiar character  of each individual case.
Under such hallucinations  of taste, patients often swallow the most  ex-
traordinary articles.  The  case  of a lunatic is  recorded. Avho ima«ined
that his stomach required to be strengthened Avith iron. ' He was seized
with inflammation of the oesophagus, of which he nearly died  He then
confessed that he had swallowed the blade of a knife.  After his death
there were found in his stomach seven oxidated lath nails, each two inches
and a half long; thirty-three  nails, two inches  long; forty-nine  smaller
iron nails and rivets; three pieces of wound-up iron wire: an iron screw,
 an inch long ;  a brass image of  a saint;  part of the blade of a knife • and
 other articles ; amounting  in number to 100, and weighing  about twenty
 ounces.  It will be necessary, incases  like those  to which I  have been
 referring, to ascertain whether  the determination not to eat is the effect
 of such perversions or hallucinations of  taste                      t<"-<^»
   The time will only admit of my alluding  generally to the importance, 
INTESTINAL AFFECTIONS.
33
as a principle of treatment, of the admhiistration of tonic remedies, active
exercise in the open air, and to good  and generous  living.   It is rarely
necessary, in the treatment of insanity, to deprive the patient of animal
food.   Individual cases occasionally come  under our  notice, in which it is
necessary, for a time, to enforce a farinaceous diet; but such is not often
our duty.  Among paupers, insanity is frequently cured by the free use of
good  animal food, and a generous supply of porter.   Even Avhen we are
satisfied  of the  necessity of local depletion, it Avill often be necessary to
give wrine,  and allow the patient a generous diet.     Part xxvii., p. 313.
>n
                 INTESTINAL AFFECTIONS.
  Treatment of Injured Intestine from a Blow upon a Hernial Sac.—
  Accidents of this kind usually occur either by a direct blow, or by the
person being forced against some hard body.  Mr. Key says:
  The extent of injury which the intestine sustains will vary according to
the violence of the blow.   The contusion may be insufficient to burst the
bowel, or to  occasion such a lesion of tissue as shall end in gangrene, its
effects being only inflammation of the coats of the intestine: or the vio-
lence may be such as at once to rupture the intestine: or, failing to rup-
ture the  bowel, the contusion may be so severe as to be followed  by
sloughing and escape of faeces.   These three  states  require distinct con-
sideration, as the treatment required for each necessarily varies.
  The mildest form of injury which a blow inflicts on a hernia is analogous
to the contusion of other soft parts.   Such contusions, it is  probable, are
not followed by any  serious consequences.
  Collapse, vomiting, and  abdominal tension, are wanting to give a char-
ter of severity to the injury.
  The two first indications that immediately force themselves on the sur-
geon's attention, are, the necessity of returning the contents  of the her-
nial sac, and obtaining free  evacuations from the bowels.  To the former
of these proceedings there can be no objection, as the vitality of the boAvel
is scarcely endangered: and if it were left in the sac, adhesion  might form
between the injured  boAvel and peritoneum, that would afterward inter-
fere with its return into the abdomen.  The administration of purgatives
ought to be Avholly abstained from, notwithstanding the confined state of
bowels  usually consequent upon  an accident of this nature.   A bruised
bowel is placed by nature in a state of rest: the exhaustion of the nervous
energy of the part diminishes  in the muscular tissue the disposition to
contract.  Such inactivity of the bowel should be encouraged,  and not
thwarted by irritating  purgatives.   The safety of  the bowels depends on
the non-occurrence of inflammation ; but if, by undue  interference, the
bruised structure is hurried into a state of inflammation,  sloughing or
ulceration will probably be the result.  Beyond an occasional enema, to
unload the larger intestines, nothing need  be done.  Opium may be re-
quired, if pain come on, indicating peritonitis ; and if joined  with calomel,
care should be  taken that the action  of the former should preponderate,
in order to prevent the probability of stimulating the bowel.  Food should
also be given in the smallest quantity, and in a  fluid form, that little or no
    VOL. II.—3 
34
INTESTINAL AFFECTIONS.
feculent residue may remain to oppress the part.  In this respect nature u
our guide : vomiting Avhich usually ensues immediately after the accident,
empties the upper part of the canal;  and the little desire that the patient
feels for food, prevents, if nature be allowed her  own way, any chance of
repletion.  Thus the part is placed in a state of repose ; and the circula-
tion soon regaining its healthy condition, the functions of the intestines are
restored
  The necessity for repose in an injured state of boAvel it Avould be Avell
to bear in mind, after the operation of strangulated hernia.   The boAvel is
gorged by the strangulation, bruised  by the taxis as it is too often prac-
tised, or  inflamed by~long incarceration in the sac.  An intestine in such a
condition cannot but be injured by an early administration of purgatives,
which irritate and inflame the  boAvel, or exhaust Avhat little remains of
vital energy.
  If the contusion  be so severe as to destroy the vitality of the bowel
Avithout rupturing it, the condition of the patient, both immediately after
the accident  and for several days subsequently, sufficiently attests  the
severity of the lesion Avhich  the part has sustained.    The  hernial sac is
usually found filled  with the injured bowel; but the absence of  distention
serves to distinguish it from a state of strangulation.   The  integuments
appear to be bruised, though sometimes but slightly.   The part is very
tender Avhen handled, but feels soft and pliant; and very moderate pressure
is sufficient to reduce the contents of  the sac.
  The shock Avhich the nervous system  receives, is folloAved by a feeble-
ness of the circulation, a corresponding pallor of the Avhole surface, and a
sense  of  syncope.  This condition is, however,  only  transient: re-action
almost immediately ensues: the patient passing from the state of collapse,
and gradually rising into a state of inflammatory excitement, as the injured
bowel becomes the seat of more  or less inflammation.
  The speedy recovery of the patient from a state of collapse, quickly dis-
sipates the suspicion of a rupture of the intestine ; and the surgeon usually
endeavors to  replace the contents of  the hernial sac as soon as reaction
takes place.    To this proceeding there  is no objection, if it be  done with
gentleness.  The danger of abdominal extravasation will not  be increased
by replacing  the injured boAvel at the  neck of the sac;  for should slough-
ing of its coats ensue, the slough may be walled in by adhesion of the sur-
rounding peritoneum,  and fecal  extravasation be prevented;  or,  should
this salutary  process of adhesion fail  to  insulate the  slough, the 'sac will
receive the fecal matter, and quickly give intelligence of°the impending
mischief, by the tumefaction that will  ensue within the scrotum
  The symptoms that arise in this state of things, in some points resemble
those of a strangulated bowel.
  It does not appear that persons are always aware of  bein<r the subjects
of hernial protrusion.   Their ignorance of the fact is  not to be taken as
evidence of a rupture not having existed previously to the blow; and it is
of no  little importance to establish the existence of a hernia, as without it,
a rupture of  a bowel is in the highest degree improbable  by a blow re-
ceived upon  the pelvis  or scrotum, or even upon the inguinal canal
  When  the  blow or injury has been  so severed to cauteTe rupture of
the bowel, or the violence of the symptoms are snr-h ™  .~/uiJtu\e °*

toneal cavty, the most judicious practice, according to Mr Key% t0 opeu 
INTESTINAL AFFECTIONS.
35
 the sac, and if faeces are present to liberate them; and if not, to wait, in
 order to see if the boAvel should  slough.   In either case, the  opening  of
 the sac will allow a free exit io any fieces  which are, or which  may  be
 present.  In one case, the patient experienced no relief for three days from
 the opening of the sac, when a copious  discharge of faeces  took place and
 completely relieved him.  In another  case, the  blow was so  severe, and
 followed by such severe symptoms, that  the bowel Avas supposed to be rup-
 tured.  On opening the sac, hoAvever,  no fieces escaped for four  days;  at
 the end of which time, the faeces appeared and escaped freely.  On the 7th
 day, the faeces escaped by the  rectum, although they continued to pass
 through the Avound for five or six Aveeks, Avhen ultimately the part healed.
 These facts will recall to the minds of most practical men  cases of such
 contusion, which have been left to  themselves and have proved fatal by
 extravasation of the faeces into the cavity of the peritoneum, when an open-
 ing into the sac would have prevented such an  occurrence; for although
 such an opening ought not to be undertaken  except  from the strongest
 suspicions that rupture or sloughing has been caused, yet, Avhen we remem-
 ber Iioav often the sac is opened in cases of supposed strangulated hernia,
 without any danger resulting, we need  not risk the life  of  a  patient by an
 unnecessary delay in such a procedure.                   Part v., p. 104.

    IVounds of the Intestines.—M. Boutard  recommends a method of ob-
 taining direct union in wounds of the  intestines; in longitudinal wounds,
 by approximating the edges of the Avound by means  of suture; in trans-
 verse Avounds,  either by the same method or by invagination.  To  effect
 this, the author excises the projecting lip or ring of mucous membrane  at
 the level to Avhich the mucous and serous coats have retracted ;  the everted
 mucous membrane, Avith its epithelium, which prevents all  union,  being
 thus removed, on bringing the  lips of the Avound together, serous  mem-
 brane is in contact Avith serous membrane, muscle with muscle, and bleed-
 ing mucous membrane with the  same structure.  If invagination is  to be
 practised, the mucous membrane is scarified and  excised to the extent of
 four or five millimetres in the portion of the intestine Avhich is to be the
 recipient;  and thus the serous surface of the invaginated intestine is placed
 in contact with a mucous surface reduced to a condition favorable to union.
                                                      Part ix.,p. 189.
   Chronic  Intestinal Eruption—Therapeutic Action  of the Salts of
 Cerium.—The  salts of few metals were at present in our  pharmacopoeia,
 and Prof. Simpson saw no reason why many more might not be added to
 their number.  He had recently drawn  the attention of  the  profession to
 the salts of nickel, which, as far  as his  observation went, presented  much
 similarity in action to those of iron and quinine,  and  seemed to be of use
 in cases of sick headache.   He now proposed to  read to the  society some
 very imperfect observations on the therapeutic action of some other metals:
 and first, as to cerium,  which, given in the form of nitrate, and in one-grain
 doses twice or thrice a day, appeared to act as a sedative tonic of consider-
 able value, strongly resembling bismuth, and the  salts of silver.  He had
 employed it, in  the first instance, in cases of general chronic  intestinal erup-
tion—a peculiar and  intractable form  of disease, for which arsenic and
nitrate of silver Avere generally prescribed; and where these remedies had
failed, cerium  had been tried Avith marked advantage.  In irritable dys-
 pepsia, Avith gastrodynia and pyrosis, and  in chronic vomiting, its exhibi- 
36
INTESTINAL OBSTRUCTION.
tionwas  attended  with satisfactory results;  and in the vomiting which
occurs during pregnancy prompt relief was afforded.  It was a good tonic,
and a useful f ubstitute for the salts of silver, bismuth and hydrocyanic acid
Dr  S had  not  employed it much in  convulsive diseases, as chorea ana
epilepsy,  in which nitrate of silver was used, but the exhibition of the salts
of cerium was certainly attended with this  advantage,  that  it could  be
persevered  in without any fear of discoloration of the skm.  As far as his
experiments with cadmium went, it bore much resemblance to the prepara-
tions of antimony, and excited diaphoresis and vomiting.   Tellurium, be-
sides its expense, was precluded from  being  used  m practice  by its dis-
agreeable effects.  Dr. S. mentioned a case where a dose had  been inad-
vertently given to a student of  divinity, and  had been followed by the
evolution of such a persistent odor, that for the remainder  of  the session
the patient had to sit apart from his fellow-students.   Part xxxi., p. 222.
               INTESTINAL OBSTRUCTION.
  Intestinal Obstruction from  Stricture of the Sigmoid Flexure of the
Colon.—The operation of M. Callisen, of Copenhagen, to producean arti-
ficial  anus in the lumbar region, over that portion of the intestine, not
covered by the peritoneum, has been  revived  by M. Amussat Avith great
success.  In all the old operations for this purpose in the iliac region, by
MM.  Littre and  Pillore, the peritoneum Avas wounded, which  seems to
have been the chief cause of death in numerous cases.  In his operation in
the lumbar region, Cahisen " proposed to make a vertical incision extend-
ing from the edge of the false  ribs parallel to the anterior border of the
quadratus lumborum muscle.  He thus hoped to reach the colon between
the layers of its short and  imperfect mesentery."  This operation, how-
ever, Avas  attended with some difficulties, till modified  by Amussat, Avho
" has shown  that the failure of  the  operation on the  dead subject was
owing to the intestine being empty, and that in such cases as require the
formation of an  artificial anus, the  colon is greatly distended;  in  which
condition the layers of the peritoneum, forming its imperfect mesentery,
are so far separated as to allow the intestine being reached without open-
ing the peritoneum."   Amussat  has, moreover,  adopted the transverse
instead of the vertical incision.   This important operation  has  not only
been performed on the adult, but also in an infant of forty-eight hours old.
                                                       Part v., p. 107.
   Treatment of  Volvulus.—Mr.  Pilcher has recorded a case of volvulus
occurrmg in a child, in which all the remedies commonly employed for the
removal of the disease had been unavailingly employed, when he was in-
duced by the recollection  of a  former case to  order  thin  gruel  to  be
injected by the rectum until the lower intestines had become completely
distended regurgitation being prevented by pressure  around  the anus
The effect was almost immediate, the obstruction giving way and the pa-
tient completely recovering.                     b    fe „* an.7 iae Pa
          r   J          °                           Part vni., p.  73.
   Internal Strangulation  of  the  I?itestines.-[Mv. Mackenzie remarks
 that, considering the great fatality of  this disease, if  leFto Ldfit i
 strange that  operative interference  is  not more  frequently resorted  to 
INTESTINAL OBSTRUCTION.                    37
An operation  cannot make matters worse than, in the  majority of cases,
they are; while it is not unlikely to be successful if a correct diagnosis can
be made.   There is one class of cases which Mr. Mackenzie thinks can be
diagnosed Avith almost certainty—cases of " dislocation  of the sigmoid
flexure of the colon:''  Mr. M. says:]
  I use the term dislocation, as  being more applicable, inasmuch as it im-
plies the operation of some active force, considering that condition neces-
sary before a sudden displacement can take place.  That  the intestine is
torn from  its  attachment by  a sudden force, I am fully  convinced, from
having discovered the mesocolon  lying in loose shreds amongst the intes-
tines, saturated with extravasated blood : a circumstance which  could not
in any other manner be accounted for.
  What renders this sigmoid flexure  so peculiarly liable  to dislocation, I
am at a loss  to determine.   In those cases Avhich have come  under my
observation, the imprudent use of raw indigestible substances, as cranber-
ries, turnips,  cabbage, etc., A\ras suspected  as the cause of the  disease.
Possibly violent distention of the tortuous gut, by flatus,  may force it, on
physical principles, to assume a straight position, and thereby a strain  be-
ing necessarily made on  its attachments, contribute to its separation.   In
Avhatever manner the  displacement is  effected, the  result is remarkably
uniform: the intestine is thrown from its natural situation toward the cen-
tre of the abdomen, and receives a twist at its termination in the rectum,
Avhich causes complete obstruction of the passage ; the small intestines get
coiled round  it in such a  manner as to  strangulate the gut by the free
margin of the mesentery.  In these cases, while all the symptoms of stran-
gulation and obstruction of the bowels are present,  there is one symptom
never absent,  Avhich, respect being had to the history of the case, leads to
a correct diagnosis, namely, that it is impossible to throw up injection per
rectum in any quantity, for as soon as the gut is filled as far as the twist
or volvulus, which  is always low doAvn, the water or fluid  injected flows
out  as fast as it is thrown up, independent of any action of the rectum
itself.   Besides, the introduction of the long tube is impracticable, being
always arrested at the obstruction.
  It is evident that no method  of treatment, save by operation, can pos-
sibly do any good in this class of cases.  The administration of purgatives
in these as well as in every other case where there is mechanical obstruc-
tion, cannot be too severely reprobated, inasmuch as they invariably ac-
celerate the fatal result, and add to the sufferings of the patient.
                                                     Part x\il, p. 162.

   Ileus, or Volvulus.—The abdominal cavity should certainly be only
opened as  a last resource.  When an  exploration is  determined on, it
should be performed in the lineaalba, except the obstruction is in the large
intestine, Avhen an artificial anus must be formed in the lumbar region.
                                                    Part xviii., p. 185.

  Ileus.—In cases of intestinal obstruction, when  the constipation is com-
plete, and there is fecal vomiting, and these symptoms are not relieved by
the use of ordinary means, for three or four days,  it is justifiable to resort
to operation.   If there are satisfactory indications of the seat of the  ob-
struction, make the incision at  or near that  point, but  if there is much
doubt, make it in the median line.  If the cause of the  obstruction cannot 
ss
INTESTINAL OBSTRUCTION.
be removed, or it is deemed imprudent to make an extended search for it,
make an artificial anus as near as may be to the seat of obstruction.
                                                    Partx\x.,p. 169.

  Treatment of Obstruction of the Bowels.—[Let us  suppose an instance
of this kind.  We are called to a patient who has had no proper evacua-
tion from the boAvels for the last seven or eight days, though he has taken
repeated doses of powerful aperient medicines, none  of which have ope-
rated effectually.   On examination you find some degree  of  distention
about the umbilicus, Avith a varying degree of tenderness on pressure.  In
severe cases you may find permanent sickness, mucus or bile  being re-
jected from the stomach.   The tenderness  on pressure  is not so great as
we might expect.   Flatus is felt to rumble in the intestines, and proceeds,
as it were, downward to a certain point, and then  stops.  With all this
the tongue is moist and often clean; the pulse is not perhaps accelerated,
generally Aveak;  the urine, provided the obstruction is not high up in the
bowels, is not necessarily affected, though generally high colored.]
  Under these circumstances, and especially in the milder cases, the first
thing that perhaps you do is to order a  large enema to be thrown up. It
is found to traverse the large intestine easily ; the patient assures you that
he feels  it go  as far  as the  ilio-caecal valve, and after  a short time it re-
turns Avithout any tinge of fecal matter.   The obstruction is not  in any
part of the colon, but somewhere in the  small intestine.
  We f^iust  not forget that the most simple case of  obstruction is liable
to run on into a fatal form, if, with the view of obtaining an action of
the bowels,  we are incautious in the  prolonged use of  irritating medi-
cines.  Concerning treatment, Dr. E. Wells continues:
  Endeavor, in the first place, to compose and soothe  the mind of the pa-
tient.   A slight faintness, produced by  blood-letting, has often acted
beneficially in  this state.  After these measures, the safest plan is to give
repeated doses of calomel and opium, the latter in half to one grain doses
every four hours.   Wait  now until the boAvels begin to act,  which they
generally will  do, and when they do, then a small  dose of  castor oil will
do  good.  Gruel may  be taken  now, as it prevents the sense  of sinking,
and probably acts mechanically in propelling the contents of the intestinal
tube.
  In  those severer cases, where  there  is frequent  sickness, with pain in
the bowels,  and a rumbhng of flatus, abstain from giving any food by the
mouth for some days.  The support should be entirely trusted to beef-tea
injections, these not exceeding a  quarter of a pint, and administered every

laudaniTm!'          *       %J  °f retention> add *> them a few drops of


'^^^^^^^^^^  r?gth for some
which forbid' the exhibition of*'Z^TyVe wL^T^W?^

aTfoVdTon^^^
vomiting, there will be littleXnce of an-estln^h. ' ^^ rej.e?ed b7
■taltio action of the intestinal tube    MiestmS the version  of the peri-
                  v                                  Part xxm.,p. 119. 
INTESTINES.
39
                          INTESTINES.
  Intussusception—Recovery from, by  Sloughing of the Intestines.—
  [At a meeting of the Royal Medical and Chirurgical Society, Mr. Jeaf-
freson read an account of a case of intus-susception of the bowel, Avhich he
had attended, and recovery by sloughing of a portion had occurred.  The
patient Avas a young man, 17 years of age.  He Avas laboring under gene-
ral febrile symptoms ; the countenance Avas anxious, the abdomen becom-
ing tympanitic :  nothing would stay on the stomach; the matters vomited
had a grass-green color.  Calomel and opium, and purgatives, were given
for three days, and clysters used, Avhen  decided symptoms of inflammation
of the peritoneum and bowels appeared.]
  Leeches, fomentations,  etc., Avere  used  in addition to the other means,
but no evacuations took place till the 31st, when there were very copious
and offensive discharges from the bowels, and the vomiting ceased.  From
this  date the patient  gradually  recovered.   Copious  evacuations  took
place, charged Avith gelatinous-looking mucus, and on one occasion a small
quantity of  blood.   On the 8th of June, there was discharged from the
boAvels what the author supposed to be either a portion of the small intes-
tine, or a cast of it  (of coagulable lymph): it was about 2\ or 3 inches in
length, and  of a tubular form; smelt  horribly putrid, and one or two
minute  points presented the appearance of  sphacelus.  After this, Avith
some slight interruption,  the patient recovered.  The substance voided
was examined under the microscope by Mr. Toynbee, who  stated that he
found cellular tissue, traces of blood-vessels and nerves, and  epithelium.
  [Dr. Williams could not agree that such case.s were remarkably uncom-
mon, though they might  rarely be met Avith by any one individual.]
  In tropical climates  it Avas by no means uncommon for  even a foot or
more of intestine to  come aAvay in seArere cases of dysentery.  It would
seem almost as  if this Avere  the  mode established by nature to effect a
cure.
  [Mr.  Fitzmaurice had practised  many years in Ceylon, where severe
sloughing dysentery AAras very common among the natives.]
  It was no uncommon occurrence for six, eight, or even eighteen  inches
of intestine to slough away, and yet recovery take place.  In the Museum
at Woolwich are many preparations illustrative of this fact.
                                                     Part xu.,p. 199.

   Wounds  of the Intestines.—[When after a wound of the abdomen, we
find symptoms of wounded intestine, without there being protrusion, we
must keep the patient perfectly quiet, administer stimuli if  needed, but
insist upon total abstinence from food for some time.]  B. Cooper says:
  When the Avounded intestine  protrudes, its contents may be perceived
issuing from the Avound, although the opening itself appears to be  closed
by the  protrusion of the internal mucous  membrane.   The  size of this
opening  and its direction, as to whether it be  longitudinal, or transverse,
must now regulate  the treatment to be adopted.  If the wound be very
small, its edges  may be  pinched  up by a pair of  forceps, and a thin silk
tied round so as to include the Avhole of the Avound; the  intestine is then
to be returned into the cavity of  the abdomen, but must be kept as close
as possible to the external Avound.   The ligature produces a sloughing of
all  the  included tissues, and adhesive  inflammation  of the peritoneum 
to
OTI EST! NE8.
being set up, an external wall or plastic matter is formed around the dead
part, which ulcerate* off into the intestines, and is carried away wth tne
faeces   Sir Astley Cooper successfully employed  this method of treatment
in one or two cases in which the intestine had been inadvertently wounded
in the operation for strangulated hernia.           ,.,.■,  *  ,^1,00 a™
   When the  opening in the bowel is large, different kinds of stitcbes are
used to keep the edges of the wound in apposition    fhe uninterrupted
suture, hoAvever, or  glover's stitch, is, I believe, the best, but the finest
procurable needle  and silk must be  employed;  and after the bowel has
been returned into its natural cavity, the same precaution as I have already
mentioned to  keep it in proximity to the external wound  should be
adopted.  When the intestine  has been completely divided  by a trans-
verse wound, various plans have been recommended for reestablishing its
continuity. For this purpose, some animal substance  of a cylindrical form,
such as the trachea of a sheep, has been introduced.   This serves as a sort
of mold and enables the surgeon to keep the edges of the severed bowel
in juxtaposition during the application of the suture, the  foreign substance
easily passing away afterward Avith  the  stools.   Some have recommended
that the upper extremity of the intestine should be passed into the lower,
and that a ligature be then applied around  the whole.  This produces
contact of the peritoneal coat of the intestine, above and beloAV the liga-
ture, and,  as adhesive inflammation is set up, an effusion of plastic  matter
soon covers the ligature, and reestablishes the continuity of the external
part of the canal, the ligature  itself,  and the constricted  portion, ulti-
mately sloughing off internally, and being conveyed  away with the excre-
tions.
   It has been  objected  to this operation, that, in bringing the  severed
ends of the intestines together, a serous is presented to  a mucous surface,
and that these two structures are ill  fitted for union ;  but it is  not in-
tended in  this operation that they  shall unite; the union is caused by the
effusion of the plastic matter from the external surface above and below
the ligature, and from serous to  serous membrane, the Avhole of the intes-
tine included in  the  ligature  being  destroyed  and   sloughing  away.
M. Jobert has proposed, as an improvement in the above operation, to
invert the inferior extremity before the superior is introduced.   In that
case, two  serous membranes are brought in  contact, and the union may
take place at once between them ;  but, under these circumstances, the in-
vaginated  portion would not  be included in  a  ligature, but  retained in
position by suture.
   After all, however, from  the result of the  experiments, it  remains
questionable whether, in complete  division of an intestine by a transverse
wound, it is  not better to establish an artificial anus and leave nature to
her own efforts for the ultimate restoration of the  patient;  and this does
not indeed appear to be so difficult a process as may be  supposed, particu-
larly if nature be judiciously assisted by the art of the surgeon
   Almost immediately after the divided intestine has beeh replaced in the
cavity of  the  abdomen, an adhesive  inflammation shuts out the onen ex-
tremities  of the intestine from the peritoneal cavity, so  that after a few
hours have elapsed the stitch employed  to secure the wounded intesS
near the external wound in the abdomen may be reraov^lSi,
the feculent matter  passes partly through tlX™*£$£™£
 considered safe, as  far as refers to the danger of extravasation ofthe 
INTESTINES.
41
faeces into the abdomen.  But as the formation of an artificial anus renders
the  patient  loathsome to  himself, and unfitted for a social state,  subse-
quent means  must be adopted to reestablish the integrity of the intestinal
canal.
  With this view, one of the first steps is to diminish as much as possible
a tendency which the upper portion of the boAvel has to prolapsus or ever-
sion  of its mucous membrane; and this object maybe attained by keeping
the  fieces in  a semi-fluid state, and by maintaining  slight pressure upon
the  extremity of the protruded part.  The loAver portion of the intestine
is liable  to contract at  its extremity, so that the ready passage of the
contents of the upper  portion  is prevented from passing  into the lower;
this  may be  in  some  measure obviated by the use of enemata,  Avhich
stimulate the natural action of the boAvel and prevent it from falling into
the abnormal condition always produced by disuse.  The strictest  atten-
tion  to cleanliness of the external Avound should constantly be observed,
otherwise the presence  of the feculent matter  Avill interfere very mate-
rially with the progress of the healing process.   As the Avound goes on
uniting it gradually contracts  into a narrow fistula: this contraction is
still  further promoted by gentle pressure ;  and after a Avhile, as the faeces
meet with some  resistance in the direction  of the wound, they acquire a
tendency to pass on  through the  natural passage—a change Avhich is first
indicated by  the escape of  flatus and  mucus per anum; upon which ene-
mata, should be freely employed to reestablish the natural function of the
rectum and anus.
  By such treatment, a recent artificial anus may very generally be  cured,
but  if neglected, the loAver part becomes  so much retracted, and at the
same time contracted, as to render the cure almost impossible.
  In gun-shot Avounds where the ball has penetrated the parietes  of the
abdomen and Avounded a viscus, nature has sometimes effected the repara-
tion of the part—the  ball passing aAvay Avith the faeces.  A musket ball
has  also  been known to  penetrate and lodge in the urinary bladder, from
which it has  afterward been removed incrusted Avith calcareous matter,
the patient ultimately recovering.                    Part x\n\.,p. 175.

  Peculiar Affection  of the  Intestinal Mucous Membrane.— Treatment
by Electro-Galvanism.—[Dr. dimming gives a detailed account of a dis-
ease, which, he says, is not described in systematic Avorks, but which is,
nevertheless, very common, and is productive of serious discomfort to the
patient.  Dr. C. says:]
  We are often  consulted by patients who, at the first glance, convey the
impression that they are imperfectly nourished: they have an emaciated
appearance.  In detailing their symptoms, they lay great stress on  a feel-
ing of emptiness, or rather  faintness, at the  epigastrium: they complain of
exhaustion there.  They generally next direct our attention to a more or
less fixed pain either in the left hypochondriac or iliac region, sometimes
both, more frequently the latter—a pain from which they are rarely ex-
empt, and  Avhich is  sometimes very severe  and  acute, though oftener an-
noying and irritating.  If they have eA'er been induced to apply a mustard
blister to the seat of pain,  they dwell on the relief, great, though  tempo-
rary, they have  experienced from it.  The  stomach, in most of the cases I
have seen, has not   been irritable; it commonly retains and  digests the
food; but  pain  is frequently felt in the course of  the colon, in a  period 
42
INTESTINES.
varying from an  hour to two  hours thereafter.   The bowels areatojj
time constipated, at another lax, in the same person.   Some are umtoinrly
costive, others more frequently loose ; but  in all {and this is  theJ^r^
teristic mark  of the disease), a peculiar membranous fibrinous niattei is
discharged.  In some cases it is stringy, in others tape-like in its 101m ,  in
others fgain, in small masses, resembling flit;. while in  the milder cases it is
more diffluent and gelatinous.   That the disease has, from want of pioper
examination of the Intestinal evacuations, frequently eluded observation, I
know too well from my own experience, and that it has consequently been
maltreated does not admit of doubt.                  .     .  .
  To take the report of  the appearances from the patient is, in too many
instances, the surest way  to deceive both you and himself.  In addition to
this, there is not  unfrequently a considerable discharge of blood from the
bowels, and that, too, Avhere no  hemorrhoids can be detected.   Almost
uniformly there is great pain during evacuation, and always a feeling of
exhaustion for some time after.  In most of the  patients there is a peculiar
expression of countenance.  It is an expression of anxiety, quite different,
hoAvever, from  that Avhich usually marks organic disease. You  do not
conclude, as is too often the  case  with the latter, that your patient  is
laboring under an incurable malady.
  Scarcely less characteristic  of the disease than any of the preceding
symptoms is the state of  the mind.   In all there is more or less nervous-
ness, greatly increased toward night, inducing sleeplessness: and Avhen,
toAvard morning, sleep  does  come  on, nightmare   is frequent—dreams
(generally of an unpleasant nature) invariable.
  When the affection has been of long duration (and too frequently this is
the case before we are consulted) the mental irritability is A'ery great.
  It is vastly more common in the female than in the male sex, though
by no means uncommon in the latter; and  in the former it is very  often
accompanied by dysmenorrhoea, and occasionally by the membranous form
of that affection.
  In the treatment, the primary, and, I believe, indispensable point is  total,
or almost total, abstinence from aperient medicine; and secondly, external
counter-irritation.
  Circumstances, Avhich I need not  at present detail, led me to surmise
that electro-galvanism Avould accomplish  both these indications  of  treat-
ment.   The results of its  use in a considerable number of cases of this dis-
ease, Avarrant me, I think, in affirming that it is competent of itself to the
cure of almost every  case, and that, aided by  the internal exhibition of tar,
it will cure both certainly and  speedily.   In  the first place, it  acts  as an
aperient—seemingly  by its  action  on the muscular  coat, as  well as the
mucous membrane of the bowels.  In every case  in which I have used it
this has been the effect;  and if it had no other consequence than this, the
advantage Avould be prodigious; for, as in a multitude of instances the
disease has been traced to the use or abuse of laxative medicines as a cause,
and as during  the treatment even the mildest aperients irritate the  mem!
brane, and so far aggravate  (temporarily) the  disease, the evacuation of
the bowels by any means that do not irritate, is obviously of great conse-
quence  It supersedes counter-irritation.   The pain in the s!ae  foi the
removal ofwhich  he counter-irritant was employed, is relieved by an  a£
plication of the galvanism for at least twenty-foui- hours; in manv  cases for
a much longer period; but as the agent is applied once a day.Vhe'e no 
INTESTINES.
48
 contra-indicating cause exists, till the disease is lemoved, the pain  may be
 said to be abolished.
   Galvanism, therefore, might of itself effect a cure ; but I have generally
 combined it ivith the administration of tar, suggested  first, I believe, by
 Dr. Simpson, and have found it of all internal means by far the most effec-
 tual.   It  relieves the feeling of  exhaustion at the epigastrium, imparts an
 agreeable Avarmth, and promotes appetite and digestion.  The plan I have
 hitherto adopted has  been, to give the tar, in the form of pill or capsule,
 thrice a day; the electro-galvanism (Kemp's, of Edinburgh, machine is the
 one I have used), is applied for a quarter of an hour daily, the intensity
 being increased from time  to  time.   Steady  perseverance  is  requisite.
 With this, the case must be obdurate indeed that Avill resist a cure.
   One remarkable fact connected with the treatment by galvanism is, that
 it determines the portions of the bowels Avhere the greatest amount of irri-
 tation exists—a knoAvledge  Avhich manual pressure fails to convey; for  it
 is a singular truth, that  Avhen the instrument is in  action, extreme tender-
 ness is complained of in more than one Avell-defined spot or tract, of Avhich
 the patients were not previously aware.  And it is extremely interesting to
 observe how this tenderness, after a time and the continued use of galvan-
 ism, diminishes till a mere point is fixed on as its seat, and how this also is
 removed.                                             Part xx\.,p. 150.

   Intestines—Stricture of.—If the stricture is Ioav in  the colon, the vomit-
 ing does not come on until some  time afterward ; if it is in the small intes-
 tines, the vomiting conies on early.  If the vomiting is not stercoraceous,
 it is not likely to be an obstruction of the small  intestines.  When  it  is in
 the larger intestines, it takes a longer time to produce stercoraceous vomit-
 ing than Avhen it is in the small.   When the  seat of  obstruction is below
 that point, Amussat's operation of an artificial  opening is the most prefer-
 able in the left colon.  When this, from the circumstances of the case, can-
 not be effected, then the opening should be made in the right colon.
                                                     Part xxv., p. 204.
   Wounds of the Intestines.—Mr. Guthrie gives the  following: When  an
 incised Avound in the intestine is not supposed to exceed a third of an inch
 in length, no interference should take place ; for the  nature and extent  of
 the injury cannot always be ascertained Avithout the committal of a greater
 mischief than  the injury  itself.  When the Avound in the external parts has
 been made by an instrument not  larger than  one-third, or from that to half
 an inch in Avidth, no attempt to  probe  or to meddle with the Avound, for
 the purpose of examining the intestine, should  be  permitted.   When the
 external Avound has  been made by a somewhat broader and longer instru-
 ment, it does not necessarily folloAV that the  intestine should  be Avounded
 to an  equal extent;  unless it protrude, or the contents of the bowel be dis-
 charged through the wound, the  surgeon Avill not be  Avarranted in enlarg-
 ing the Avound, in the first instance, to see Avhat mischief has been done.
It may be argued that a ivound four inches  long has been proved to be
oftentimes  as  little  dangerous as a Avound one  inch  in length; yet  most
people would prefer having the smaller Avound,  unless it could be believed
that the intestine  Avas injured to  a considerable extent.  FeAV surgeons
even then Avould like to enlarge  the Avound to ascertain the fact, unless
some considerable bleeding, or a discharge  of fecal matter, pointed out the
 necessity for such an operation. 
u
INTESTINES.
and firm
 Avound, indicate the commencement of effusion from the  bowel, or an  ex-
 travasation of blood, an enlargement of the opening alone can save the  life
 of the patient.  The external Avound should be enlarged, the effused mat-
 ter sponged up Avith a soft, moist sponge, and the bowel or artery secured
 by suture.  When a penetrating Avound, Avhich may have  injured the intes-
 tine, has been closed by suture and docs not do Avell, increasing symptoms
 of the inflammation of the abdominal cavity being accompanied by general
 tenderness of that part, with  a  decided  swelling underneath the wound,
 indicating effusion beneath, the  best chance for life will  be given by  re-
 opening the Avound.   It is a point in surgery Avhieh a surgeon  should con-
 template  in all its bearings.   The proceeding is  simple,  little dangerous,
 and under such circumstances  can do no harm.
   When the Avounded boAvel  protrudes, or the external  opening is  suffi-
 ciently large to enable the  surgeon to see or feel the injury by the intro-
 duction of his finger, there should be no difficulty as to the  mode of pro-
 ceeding.   A puncture or cut,  Avhich is filled up by the  mucous coat so as
 to be apparently impervious to air, d#oes not demand a ligature.
 _ An opening Avhich does not appear to be so Avell filled up as to prevent
 air and fluids from passing through  it, as such Avound cannot usually be
 less than two lines in length, should be treated by suture.  When the open-
 ing is small, a tenaculum may  be pushed through both the cut edges, and
 a small silk ligature  passed around, below the tenaculum, so as to include
 the opening in a circle, a mode of proceeding I  have adopted with success
in wounds of the  internal jugular vein, Avithout impairing its  continuity;
 or  the opening may be  closed by one,  two, or  more continuous stitches,
made Avith a very fine needle and silk thread, cut off in both methods close
to the bowel, the removal of Avhich from the immediate vicinity of the ex-
ternal Avound is little to be apprehended under favorable circumstancos.
The threads or suture will be  carried into the cavity of the bowel, as has
been already stated, if the  person survive; and the external part of the
wounded bowel will either adhere to the abdominal  peritoneum, or to one
or  other ot the neighboring parts.
  When the intestine is more largely injured, in  a  longitudinal  or trans-
verse direction, or is completely divided as far as, or beyond the mesentery,
the continuous suture is absolutely necessary.
_ When the abdomen is penetrated and considerable bleedino- takes place
it is necessary to look for  the wounded  vessel.   When  the" hemorrh^
comes from  one of the  mesenteric  arteries, or from the eoio-astri,  thl
wound is to be enlarged until  the bleedino- artPi-v £*l™  Pi S itUc'.the
teres are to be placed on its divided ei^f t^^ b^L VhTe seen"
the epigastric artery tied several times  with success
  A Portuguese cacador  on picquet, was wounded at the second sieo-e  of
Badajos, in a sally made by some French cavalrv   Wo i  TTu     g?
trifling cuts on the head and shoulders  and onlt    .,  **?  th''ee °r four
the belly, on the right side. He  bled m-ofosX  acr,OS\the ,lower part  of
had lost  a considerable quantity of Wood  whichndJh^'^t tome
 wound made by the point1 of a ih e   This woundI L   °Ufh a ^f
 wounded but  undivided artery  became v siblp   n.   !" arSed untll the
 were placed, and the external wound Va", «?' 3P°n th" two %*™
 was opened to a small extent, but the  bowel did n^t" pi 0^?^^ 
INTOXICATION.
45
patient (not being  an Englishman, and not, therefore, so liable to inflam-
mation), recovered.
  The recollection  of other nearly similar  cases, causes me  to  say, that
when hemorrhage takes place from within the abdomen, the wound should
be enlarged; and that if an artery in the mesentery, or in any other place
which can  be got at, should be found  bleeding, a very fine silk ligature
should be placed, if possible, on each side of its  divided  extremities, and
cut off close to the knot, the external Avound being afterward accurately
closed.   This is a point of practice to Avhich future attention is directed.
  When a musket-ball penetrates the cavity of the belly,  it may pass
across in any direction Avithout injuring the intestines or solid viscera.   It
usually does injure  one or the other, and it has been knoAvn  to lodge with-
out doing much mischief.   The symptoms are generally indicated by the
parts injured, although in all, the  general depression and anxiety are re-
markable ; their continuance marks  the extent,.if not the  nature, of the
mischief.                                       ,    Part  xxvlil, p. 190.
  Intestinal  Catarrh.—In those cases of intestinal catarrh  in children  in
wdiich the mucous membrane becomes ulcerated around the anus, give  an
enema containing about a drachm of borax.           Part  xxxaI.,p. 300.
-•-•-•-
                    INTOXICATION.
   Results of Drinking.—Of all diseases of the internal organs produced
by drinking, the granular liver seems  to  have attracted most attention;
perhaps justly; but there is no doubt, that of all organic diseases, the two
most to be feared in intemperate persons Avith recent surgical  injuries, are
the granular kidney, and slight but general emphysema, with  a dilated,
but not ahvays much diseased heart; and  in persons  past the middle of
life, dying rapidly in hospitals after  operations and surgical injuries, com-
bined with much Joss of blood, these two affections of the urinary and res-
piratory organs are very far from uncommon.   The three chief affections
destroying patients  after operations and  injuries — namely,  the general
hobit produced by drinking; secondly, organic disease of the lungs and
kidneys, especially emphysema in the former, and  granular disease in the
latter; and, thirdly,  tubercle—act very differently and at different periods.
During the early period, and often for weeks after operations, patients la-
boring  under tubercular disease do  Avell; and it is  often  only at  the
absolute return to health, rather than during the recovery of  the patient
from  the operation itself, that the effects of tubercle begin to shoAV them-
selves.  Organic disease produced by drunkenness, and habitual drunken-
ness,  act differently; the organic disease presses heavily at every period,
and may destroy life early or late;  but the mere  habits of the drunkard
show  themselves  chiefly at a very early period.  The  patient who nearly
sinks  from his unsound organs within the first feAV days, often lags on for
weeks and months in danger; but the man who has simple delirium tre-
mens  is taken ill directly, and often dies;  but if he recovers from his de-
lirium, he generally gets well from the  operation, and  sometimes quickly.
                                                     Part xiv.,p. 324. 
46
INTOXICATION.
  Intoxication.—It is sometimes puzzling to distinguish intoxication from
cerebral disease.                                    .  ,  ^..i,,,,-., nn a
  Mr. Corfe says: A patient is brought into the hospital  pe»hapa ™ a
policeman's stretcher, or he is carried in by friends, who state that he was
nicked up in the streets, senseless.   His pupils  are  dilated, immovable,
his breathing is deep, and low, and heavy, the expiration  being short and
abrupt, whilst the inspiration is a prolonged  deep sigh, with more or less
stertor; pulse is full and strong.  The suspicion  arises that the  man has
sanguineous effusion into one or both ventricles of the brain    But it must
be again acknowledged that, of all the  perplexing, deceitful, and varying
symptoms which diseases occasionally put on, those  of cerebral lesions or
mere cerebral disturbance are, of  all  others, the most  <hmcult to decide
upon.  We have admitted cases into the hospital in the dead of the night,
brought here by policemen, Avho have found the  patient   senseless, or he
has been seen to fall senseless on the pavement;  Ave have bled, blistered,
leeched, and purged; shaved the head, and  given turpentine enemas, but
all to no purpose; insensibility has remained ; when, to our surprise, in
twelve hours afterward Ave have gone to visit our patient, Ave have found
him perfectly sensible and tolerably well, not more surprised at the loss of
a head of hair than Ave have been  at the sudden revival  of our  supposed
case of apoplexy.  Whilst, on the other hand, I  have admitted  a case as
one of "dead drunk," perfectly inanimate, and have, for the sake of pre-
caution, sent him into the Avard to  bed, and yet-have found it to  prove an
instance of apoplexy.  I have, however, learned a valuable lesson by even
these  difficulties: for in every instance of late years  Avhen a case of com-
plete  insensibility is admitted, I  have requested the house  surgeon to
empty, and then Avash out, the stomach by means of the pump  ; and if it
has been from drunkenness, the " sot"  has shown his character  up before
Ave have finished this operation; and if it has been one of apoplexy, it has
done no harm, and it has proved that it was more than intoxication, as no
alcoholic fetor has been detected in the contents of the stomach.
  In all cases of intoxication the mental faculties  become roused before the
operation of thoroughly washing  out  the  stomach by the pump  is con-
cluded; whilst, on the other hand, it may be  said,  the reverse  is ordina-
rily the case in cerebral lesions, or in mere concussions of the brain. Be-
fore Ave allow the tube to be withdrawn from the stomach,  in cases of ine-
briety, we usually inject  three ounces  of the diluted acetate of ammonia
draught, which has an extraordinary effect—sometimes in "sobering" the
head, and calming the stomach too.
  I am aAvare that it is much easier to recommend the employment of the
stomach-pump  than to administer it to persons who are  sometimes in the
highest state  of excitement bordering on maniacal fury.  I  am anxious,
therefore, to describe the mode in Avhich we employ this remedial agent in
such cases:                                                     &
  The patient is seated in a strong wooden chair, another chair  is placed
behind him, and an attendant  is ordered to sit in it, and taking  the arms
of the patient, he pinions them by holding the wrists firmly Lainst the
back of the chair.   11ns method serves to fasten the trunk securely in the
chair ; the legs are then swung in a round towel, which is passed  round the
ankles by a noose, and, a second chair being placed so that *1.p wt ^f it
shall be toward the legs of the patient, anofhL aS^a^VpkSfi„° k*
he carries the towel over the back of the chair, and sits upon it, and thus 
IODIC PREPARATIONS.                       47
the legs are at right angles with the trunk, and consequently they are al-
most powerless.   If, hoAvever, the man offers to flex  the knees, the ankles
are instantly raised higher, and  the power of the flexors of the thigh is
thereby overcome in an instant.   By this position, it  Avill be observed, that
the patient is deprived of all  muscular power, and the only fixed point on
which his body rests is theischiatictubera. I am satisfied that the stomach-
tube may not only be introduced  with comparative ease, but that the ope-
ration of the pump  is perfectly harmless, Avhen judiciously administered,
upon a refractory patient thus immovably fixed.        Part xvii., p. 49.

  Action of Alcohol.—From an elaborate series of experiments, the folloAV-
ing conclusions are  arrived at by  Dr. Duchek:  1. Alcohol in the organism
is subservient  to fcan  increased combustion, the intermediate products of
which are found in  the blood.   2. Intoxication  is dependent upon the ex-
istence of  aldehyde in  the blood at the  time.  3. The effect of aldehyde
upon  the  blood  is that of rapid consumption  of oxygen ; and, finally, 4.
Hereby the combustion of other substances is interrupted, or rather  di-
minished.
  [In these short remarks the reader will at once perceive the most power-
ful  inducements  to  abstain from alcohol.   It  runs aAvay with that oxygen
which he is always  inspiring for the oxidation Avhich  is required in almost
every process of the animal economy. We live, as it Avere, to oxidize. Al-
most all the changes in the body are the results of oxidation, and yet the
spirit drinker continually checks this process  of nature.] Part xxx.,p. 298.

   Chronic Alcoholic Poisoning.—From the long-continued use of alco-
holic drinks, even long after their discontinuance, various nervous symptoms
sometimes arises, as hallucination and loss of sleep.  Oxide of  zinc in tAvo
grain doses, tAvice a day, an hour after each meal, is the best medicinal treat-
ment that  can be  adopted, this  dose may be gradually increased till the
patient takes six or eight grains twice a day.  Of course it is necessary for
the patient to cease drinking.  By the use of the above remedy, sleep was
induced, and  the trembling of the body and  limbs along  Avith other nerv-
ous symptoms, rapidly disappeared.                  Part xxxix.,p.  56.
                          t

                              —►-»-•—


                    IODIC PREPARATIONS.
  Hints for the Administration of Iodine.—Dr. Mojsisovitz, of Vienna,
has contributed  an  elaborate paper  to the Medicinische Jahrbucher, on the
administration of  iodine and  its various  preparations, in Avhich he has
pointed out certain precautions AAdiich are  probably  not generally knoAvn,
and the ignorance  of Avhich may account for the unsatisfactory results  so
often derived from their use.
  As the feculent matters decompose the preparations of iodine, we find
this substance in the state of ioduret of starch, in the stools  of those Avho
eat bread,  potatoes, rice, gruel, and A^egetables, wdiile taking the medicine.
It is therefore necessary to interdict the use of every sort of food contain-
ing fecula to patients to Avhom iodine is given.  It is probably OAving to a
decomposition of this kind having taken place, that  we are to explain the
inert effects of  those enormous  doses of the medicine Avhich  have been 
48
IODIC PREPARATIONS.
exhibited by some physicians, as Dr. Elliotson, Dr. Buchanan of Glasgow
and Professor Forget of Strasbourg.                       .   ,.    ,  .,
  According to the experience of  our author,  the use of saline  baths
greatly promotes  the  action of iodine  on the system.   lie  has also
?eason to believe  that the  activity of its operation is a good deal influ-
enced by the condition of the weather at the time.   When the air is clear
and dry, it seemed to have most effect, and more  especially when there
was a tendency to inflammatory complaints: whereas, on the  other  hand,
its action seemed to be almost null during the endemic prevalence of  small-
pox, puerperal fever, and diarrhoea.
  The crises, which iodine has a tendency to provoke, are salivation,  and a
cutaneous eruption like scarlatina or miliaria; the secretion of the urine is
usually the more abundant in proportion as the diet of the  patient is kept
low and restricted.
  Dr.  M. prefers the  hydriodate of potash, and the proto  and deuto-
iodurets of mercury, to either pure iodine or to any other of  its prepara-
tions.  He regards  the  tincture  of iodine as  one  of the  very  worst
formulae that can be  used ; it is more likely, he says, to cause a wasting
of the testicles or mammae, hemoptysis, palpitations of the heart, etc., than
any of its salts.
  The dose of the hydriodate Avhich  he recommends for adults is  about
fifteen grains dissolved in distilled Avater, in the course of the  day.
  If there be any  open ulcers, they should be kept wetted Avith a solution
of the hydriodate  ; but if the local affection be a tumor, then he recom-
mends that it should be Avell rubbed Avith the ointment  composed of two
parts of the proto-ioduret of mercury and twenty-four of lard.
  The disease in Avhich Dr. M. has used iodine  Avith  advantage are, cezena,
ulceration of the tongue, palate, etc., various forms  of obstinate cutaneous
disease, and of secondary syphilis, Avhite SAvelling,  and other maladies of
the joints, periostitis, tumefaction  of the lymphatic glands,  scrofulous
induration  of the subcutaneous cellular tissue,  and  many of the  other
kinds of strumous disease.                               Part iv., p. 58.

  Iodide of Potassium—Therapeutical Action of.—Dr. Lisfranc obtains
great success from the administration of this IPubstance, in Avhite SAvellincs,
necrosis, ulcers of the  legs, engorgement  of the  breasts and testicles,
chronic syphilis, and some diseases of the skin.  When a patient is  about
to be submitted to this mode of treatment, certain precautions  are  neces-
sary, since some persons may take 3j., Avithout experiencino-  any inconve-
nience, Avhereas others  cannot take gr. iv., and  even grs.  ii   Avithout
offering  untoward accidents.  Formerly Dr. L. added from 9ss to B]  of
iodine to the  iodide, but, having  remarked that it gave rise to intestinal
irritations, he  omitted it, and now employs the following formula- R Aq
destill. tihae Europ. §v., sirup, aurant. |j., iodid.  potas. %j   M Ft   mist
   ',      *•*  -tit 7°  ' ,         "A iwuiue is raised to Siss., and an
equal  quantity is added to each succeeding  one, until  the patient  takes
5iiss.,  311J., Sss., and  even 5v, which last Dr.  L very  seldo n  surn^se«
The advantages resulting  from the  administration of th s sub tancfa e
amelioration ot the general health, especially in lymphatic patientsaffected
with necrosis, and abundant  suppuration, or  marasmus, caused  by Wd 
IODIC PREPARATIONS.
49
white swelling.  The inconveniences are: an astringent, metallic taste in
the mouth, with some patients very disagreeable, every morning on wak-
ing ; this may be remedied by the use of the tooth-brush, or gargles, with
water alone, or water to which, for every half tumbler, a tablespoonful of
the spirit, cochlear, is added ; a cutaneous eruption, similar  to  urticaria,
and when the remedy is continued, resembling  eczema, or prurigo ; when
the face is the seat, the subcutaneous cellular tissue is  SAvollen, and forms
small tumors, like tubercles.  These accidents  ought  not to prevent the
administration of the remedy, Avhen the disease is very serious;  but Avhen
it is slight, the  medication must  be ceased  for a time, and  then recom-
menced.   As to the  iodic salivation, observed by. Mr. Wallace, Dr. Lis-
franc, in  upAvard of one  hundred patients, never witnessed it once.   The
disease in which Dr. L. has advantageously  had recourse to it, are: ter-
tiary syphilis, and that in spite of irregularities in regimen  and  excess of
drink ; this was especially manifested in one of the lesions produced by
the affection, Avhich  is seated in the rectum,  and  resembles cancer; so
much so, that he always commences by administering the iodide, and it is
only Avhen that substance, aided by compression, etc., has  failed, that he
decides upon operating.  In necrosis of the bones  of the extremities, and
for Avhich amputation seemed  to be the only means of obtaining a cure;
the parts thus affected, Avere the  femur, the  tibia, the phalanges, after
whitlow.  White swellings;  ulcers of the legs ; for instance, in those of
atonic nature, or in wounds which, on individuals of a lymphatic tempera-
ment,  from want of attention and  cleanliness, or  from friction, have
become covered Avith vegetations, bleeding with the greatest facility, and,
in  every respect, analogous  to  a cancerous  ulcer.   The cicatrix  thus
obtained, is, from its very formation, Avhite, firm, resistant, and allows the
patient to move about at  a very early period.  Cancer  of the uterus,
and of the breast;  in the pain caused by these  affections, opium is admi-
nistered  in some cases ; at first it soothes, but very soon  becomes ineffica-
cious ; nor does it ever prevent the disease  progressing; their  cure  may
then  be  attained  with  the  iodide of  potassium.  In engorgements of
various organs, chronic orchitis, tumors of the  breast,  etc.
  It sometimes happens that, Avhen this substance has been given  a few
days, the accidents above described appear ; in such cases we must cease
to  administer it for  eight or ten  days, and then  recommence it, to be
ceased again should the accidents reappear;  and it is very  rare that, after
having prescribed it thus, it is not tolerated  on the third  or fourth trial.
Again, in diseases Avhich require it to be taken for a very long time, cer-
tain peculiarities may be observed ; for instance, when the  iodide is admi-
nistered  to  a  patient  affected Avith white  swelling, at first  a  notable
amelioration  manifests itself, but  very soon  after the  disease becomes
stationary, and anorexia and insomnia declare themselves.  Such a state is
what Dr. L. calls iodic saturation ; here, the  continuation of the  remedy is
not only  useless, but even hurtful;  it must therefore be discontinued for  a
time, the patient be  ordered  to amuse  himself, to take a nourishing diet,
some tonics, etc., and to go into the  country,  if possible.   Finally, when
the system has  thrown off the iodide, it may be prescribed aneAV, and Avith
the same success as at first.                             Part x\.,p. 103.

  Iodide of Potassium.—The iodide of potassium Avas shoAvn by the late
Dr. Robert Williams to be of great certainty in rupia and  hard  periosteal
    VOL. II.—4 
50
IODIC PREPARATIONS.
node ; that its power is much less in roseola, purpura, and ecthyma, but
still it is better than  mercury; while, in lichen, lepra, psoriasis, and intis,
mercury is more  beneficial than  the iodide.  It mfVn™*?n^Ji™'
menced in  the node, then sarsaparilla  is the remedy, the iodide being use-
less.  In soft node and prurigo, he showed the true power of sarsaparilla ;
and in syphilitic angina and rupia, the invariable good effects of combining
local mercurial appfications with the internal administration of the iodide
of potassium.    ™                                 Fart xxlv"' P- 268"
  Iodine rendered Soluble  by Sirup  of Orange-peel and Tannin.--M.
Debauque  has found means of keeping iodine in a state of solution, when
added to mixtures in  the form of tincture.  The author uses,  for that pur-
pose, sirup of orange-peel, which answers the purpose perfectly.  It was
suspected that tannin was mainly instrumental in this result; and this wa3
rendered evident by putting a few grains of tannin into a quantity of water
to which tincture of iodine had been  added,  and  in which the iodine had
of  course  been precipitated.  The addition of the  tannin  caused  the
iodine to be immediately  re-dissolved.  Thus will  the sirup of orange-
peel be advantageously added to mixtures containing tincture of iodine,
and tannin  to injections composed of water and the same tincture.
                                                     Part xxv., p. 306.
  Topical  Application of.—The topical application of this remedy is very
general. The following is  the formula :   R Iodini, 3j.; sp. vini rect., 5jj.;
ft. solutio.   It is better to keep this some time before using.  It should be
applied in glandular affections beyond and around the enlarged  parts, so
that the absorbed fluid may be carried through the gland  by the  lym-
phatic vessels.  It is used topically, 1st, in pleuritic and neuralgic stitches/
2d, to  the  throat in  cases  of aphonia or hoarseness; 3d, to the mucous
lining of the throat itself in  cases of congestion and of enlargement of the
tonsils y 4th, around  the external parts of the eye, in cases of strumous
inflammation / 5th, in all forms of periostitis, whether syphilitic or stru-
mous ; 6th, in glandular affections as above mentioned ; 7th, as injections
into cysts and cavities of abscesses, provoking adhesive, but  not  suppura-
tive inflammation, as in hydrocele.                    Part xxix., p. 326.

  Iodide of Potassium with Ammonia.—It  is said that this medicine  is
more valuable. Avhen  combined  Avith ammonia,  gently  stimulating  the
stomach, diffusing the blood, and with it the medicine through the system,
and, by chemical decomposition, liberating the free iodine, and thus send-
ing it on its salutary message.
  The proportions usually prescribed are, two to three grains of the iodide
with four to five of the ammonia.                     Part  xxx  » 300.
  Iodine Adhesive Paint.—The following is the formula for an iodine
paint, made adhesive  by the addition of mastic, which is used at the Moor-
fields Ophthalmic Hospital:
  R Spirit, vin. rect., 3ij.; sp.  aeth.  nitr, 3iv.;  mastic. 5ss.; iodini, ad

  This  is very useful  where iodine  is required about the eyes, as it does
not run on  the skin.                                 p^ J^ ^ ^

  Effects of the Tincture of Iodine  applied locally on the  Mucous and
Serous Membranes, vn relation to Pain.-Dr. Boinet remarksThat the
contact of tincture of  iodine with the mucous membranes iTnoatalf pa n 
IPECACUANHA.                          51
 ful; and that  it is  possible to paint, almost without the consciousness of
 the patient, the pharyngeal and buccal mucous membranes, the tonsils, the
 neck of the uterus, the vagina, etc., Avithout  causing  any pain ;  on con-
 dition,.however, of not allowing the tincture to touch the orifices of the
 mucous cavities—namely, the points Avhere the mucous membrane termi-
 nates and the  skin commences; for the  pain  is very severe, and is pro-
 longed for a considerable time, whether the tincture is applied to the lips,
 the anal orifice, or the female external parts of generation. In these cases
 the patients experience a pain as intense as Avhen the tincture of iodine is
 applied to the skin  denuded of its epithelium, or  to a recent  wound.
 There is the same pain when the ocular or palpebral conjunctiva is touched
 for the treatment of certain inflammations of the eye, the removal of gra-
 nulations,  etc.   If  several successive  paintings  take place,  the  same
 change ensues  on the mucous membrane as on the skin—namely, that des-
 quamation having taken place, the pain becomes then very severe after the
 subsequent application.  As to  the  serous  membranes, the tincture of
 iodine always  produces in  them very severe and cutting pains, and in an
 instantaneous manner.  But this pain is much less severe upon the articular
 membranes than on  the peritoneum.   The  acute  pain  produced by  the
 contact of the  tincture of iodine with the peritoneum is, in fact, a certain
 sign Avhich indicates that  an ascites has been mistaken  for  an  ovarian
 dropsy; inasmuch as, in the latter affection,  the iodine injection is  never
 painful.  This  pain  is also  a proof, Avhen it arises with less intensity in
 injecting an ovarian cyst, that  a certain quantity has penetrated into  the
 peritoneum.                                         Part xxx\.,p. 281.

   Iodide of Lime.—This preparation, made Avith one part of iodine and
 seven  of lime, is recommended by Dr. Pidduck as superior to the iodide
 of potassium—in the comparative smallness of its dose; in its ready com-
 bination Avith the blood and tissues, manifested by its  alterative  effects;
 in not passing so quickly through the  kidneys; in  not  producing gastro-
 enteric and vesical irritation : and in being nearly tasteless.  Dr. Pidduck
 uses a solution  of one drachm (containing  eight and a half grains of iodine)
 in a pint of boiling Avater, Avhich, when cold  and filtered, is colorless and
 transparent.  The iodine  is found to exist in the  solution in the form of
 iodide of calcium and iodate of lime.                Part xxxvii., p. 251.


                                 »•»---


                     IPECACUANHA.
  Practical Remarks upon Ipecacuanha.—The  value  and efficacy of
ipecacuanha, as an emetic or expectorant in many affections of the respira-
tory organs, more particularly of children, are too generally conceded and
acted upon to require an extended notice.
  In dysentery, ipecacuanha has been, and continues to be,  much  used.
By Mosely, Avho held it in high repute, ipecacuanha was given in doses of
half a drachm to two scruples; and by the late Professor B.  S. Barton, it
was regarded as almost a specific, particularly in cases of a typhoid charac-
ter.  In chronic diarrhoea, small doses of the powder, repeated  several
times a day, either  alone,  or  preferably in conjunction with  opium or
Dover's powder, will bo found of great value, and  frequently, Avith strict 
52
IPECACUANHA.
attention to a proper regimen, will succeed in curing man? ^^^X
ing cases.   In these last  cases; when dependent  upon, or connected witn
derangement of the biliary secretion, additional power will be giien to tne
above doses, by uniting with them two or three grains of blue mass, to De
repeated every night as long as requisite.                       „„„„„u„
  In hemorrhage from the lungs  or uterus, small doses of ipecacuanha,
combined with sugar of lead and opium, are used Avith decided benefit  In
hemorrhage from the stomach,  large  doses of ipecacuanha have  been
stronoly recommended, particularly by Dr. Condie.
  In the early stages of the bowel affections of children, no less  than in
adults, an emetic of ipecacuanha will often succeed in arresting the progress
of the disease, and rarely fail to prove beneficial.      #
  By combining from one-fourth to half a  grain  of ipecacuanha Avith a
minute portion of opium, and tAVO or three grains of blue mass,  the altera-
tive properties of this last are materially enhanced.   This method  Avill be
found of great  benefit in most mild cases of -biliary and bowel derange-
ment.
  Formula for  the Sirup.—Finding the process for the  sirup,  recom-
mended in  the  United States Dispensatory, attended  with unnecessary
trouble, and uncertain as to uniformity, I adopted, after  many trials, the
following formula:  R Ipecacuan. rad. contus., §iv.; aquaeOij.;  sp. vin.
rect., §x.; sacch. alb.  lbs., iiij.  Macerate the bruised ipecacuanha in one
pint of boiling water for twelve  hours, then add  the  remainder of the
water and  alcohol, and continue the  maceration for  five or  six  days.
Place  the whole in a small displacement apparatus, returning the fluid
that passes  until it becomes perfectly clear, and then continue to pour a
small quantity of water occasionally upon the surface, until two pints and
ten ounces by measure shall have passed.  Now add  the sugar, and with
a gentle heat, evaporate until the syrup shall be of a proper consistence,
readily ascertained by occasionally taking out a small portion and alloAving
it to cool.   When of a proper consistence, pass it through a small quantity
of fine tow  placed in  the tube of a funnel,  to  render the sirup clear and
transparent. Three pints and ten ounces of sirup is the quantity obtained.
It is,  in strength, nearly double  of that prepared by the usual formula;
and this I consider an additional recommendation.     Part xxiii., p. 299.

   Saccharized Alcoholic  Extract of Ipecacuanha.—Mr. A. G. Dunn
recommends the employment of a saccharated extract  of ipecacuanha in
preference  to the usual preparation of the drug, such as the Avine and
sirup, which he  considers liable to vary in strength; and the poAvder is, he
thinks, objectionable, from its insolubility.   The following is the  formula
for preparing the extract:
   Rad. ipecac, §iv.;  bruise to a coarse powder, and macerate for thirty
days in f. Jxvj. of diluted  alcohol, shaking  it occasionally, then filter and
express.  Evaporate  the tincture thus  formed to  §ij. with  Avhich mix
powdered white sugar, gviij., and triturate them  in a  mortar until they
become dry.
m  The extract thus prepared has the peculiar odor and taste of ipecacuan ;
it is of a  browpish-yellow color, and soluble  in  water, ether,  alcohol,
mucilage of acacia, and, m fact, m all the solutions with  which this remedy
is usually  combined   The dose  required  to  be  exhibited is the same
(twice as  much) as  the gehume  powdered root.   From its agreeable 
IRON.
53
taste and perfect  solubility in fluids, it is much preferred to the other
preparations of the drug, by those Avho  have employed it; more especially
in prescribing for children, for whom its sweet taste renders it an excellent
form for combining Avith other remedies.               Part xxx., p.  300.
                              IRON.
  Bisxdphate of Iron and Alumina.—When  ten parts  of well washed
alumina, three of soft iron filings, and five of carbonate of soda or potass,
are compressed  by fixed air for a considerable time in distilled water, a
clear carbonated solution is obtained.  But Avhen the pressure is removed
and the consolidation of the carbonic acid ceases, the solution no longer
remains  clear or permanent.   When the fluid, however, is  treated Avith
sulphuric acid in excess, a bi-sulphate results in the  crystals of which the
iron is permanently safe from rusting or peroxidating in  the air, or even
when dissolved, as is the  case Avith other salts, or preparations  of that
metal.  When used as an internal tonic or astringent, the iron of this salt
does not irritate ; Avhen applied as a lotion, it does not rust  or stain the
linen.  Sir James Murray continues:
  Great  care must be taken not to confound this new saline  remedy Avith
a salt called by writers  " iron alum."
  This neAV salt is also entirely different from a  "sulphate  of alumina and
irony"1 mentioned in some chemical Avorks.
  The neAV salt is Arery  soluble in any cordial or aromatic water.  I give
it in doses  of five or ten grains every two or three hours, till its effects
succeed.  In order to stay the bowels, in wasting looseness during cholera,
it might be  repeated much oftener.  The iron is not a stimulant in this
salt, but rather calms whilst  it sustains.  The aluminous quality abates
tormina  and soothes the mucous membranes.    EAren alum itself  dimi-
nishes pain, and does not increase or induce paralysis of the intestines, as
salts of lead are sure to do when long continued.       Part xix., p. 312.
  Preparations of Iron: Ammonio-Acetas Ferri.—Dissolve one drachm
of iron Avire in half an  ounce  of hydrochloric  acid, mixed with an  equal
quantity of Avater (by  measure);  then add  half a gallon of Avater, and
precipitate Avith an  ounce of liquor  potassae;  set  aside  for twenty-four
hours; draiv off the  supernatant  liquor Avith  a syphon ; fill again Avith
Avater, and repeat the process a third time.  Lastly, collect the precipitate
on a linen filter; dissolve the oxide thus prepared in two  ounces of strong
acetic acid, and  make up the measure to ten ounces with  distilled water;
set  aside for twenty-four hours, and filter.  To every twenty ounces of the
filtered liquor add half  a  drachm of strong liquor ammoniae.  Dose ten
minims to half a drachm.
  Sirupus  Ferri Acetatis.—Dissolve twro pounds of sugar in ten ounces
of water, in a water bath; to the sirup, Avhilst hot, add eleven ounces of
the acetate of  iron prepared as  above  (without the ammonia); when
cold, filter through paper.  Dose, twenty minims to one drachm.
                                                    Part  xxiii., p. 301.

  Phosphate of.—Two specimens,  one solid the other fluid, have been in-
troduced, of  phosphate  of iron dissolve 1 in the  metabasic acid in a boiling 
54
IRRIGATION.
state, and allowed to cool.  If exposed to the air for a day it hardens, but
can be made at once into pills, by means of liquorice powder or noui.  it
is stated to be superior to the other preparations of iron.   Liosc, one to
two grains, three times a day.                        Part XXU1" P- 30J"
  Administration of Iron in food.—M. Martens read an essay before the
Belgian Academy of Medicine,  on Ferruginous  Medicines.  Among his
conclusions, we find the following :                   . .
  " Wheaten bread may be rendered  much more nutritive "tor chlorotic
patients, " by adding a small  quantity of sulphate of iron.   In this way,
alone, it can be capable of forming a substitute for meat."
  In the discussion, it Avas suggested that the same method of medication
would be beneficial to patients recovering from acute  diseases, especially
Avhen the system was not yet able to bear animal diet.  This idea is good ;
and Avould be easy of application.                    Part xxiii.,  p. 304.
  Pyrophosphate of Iron.—There is no tonic Avhich acts so promptly and
favorably as the pyrophosphate of iron and soda, prepared in a liquid form ;
it is easy to administer, rapidly absorbed, and does not produce fatigue to
the digestive organs.                               Part xxxvi., p. 254.
  Sirup of Protocarbonate of  Iron.—The facility Avith Avhich protocar-
bonate of iron dissolves in organic acids, and its  perfect harmlessness in
irritable subjects, render it one of the  most valuable agents in therapeu-
tics ; accordingly, all the new preparations into Avhich sugar has been  in-
troduced, for the purpose of giving stability to this saline compound, have
been adopted in practice.
  M. Dannecy, a distinguished pharmacien in  Bordeaux, having ascer-
tained that  the precipitate of protocarbonate of iron obtained  by mix-
ing sweetened and boiled solutions of carbonate of soda  and of protosul-
phate of iron possesses the singular property of dissolving  in simple sirup
without becoming colored, conceived the idea of thus preparing a  new fer-
ruginous sirup.
  This preparation being permanent, will be employed in  cases in which
the form of sirup is preferable to that  of pills; for example, in the treat-
ment of children.                                  part xxxvii., p. 250.
                      IRRIGATION.
  Improved Method of Continuous Irrigation.—-The instrument consists
of a zinc reservoir, with a vulcanized India-rubber tube openino- from it at
its side, close to the bottom.  The entrance of water into the tube is regu-
lated by a stop-cock ; at the other end of the tube is affixed a broad ztnc
head, resembling a compressed or flattened rose of a watering-pot, a linear
series of perforations being cut through its lower or convex edge   Equi-
distant from each other and about half an inch apart, threads of worsted
were passed through these holes from within, and made  to project about
three-quarters of an inch below the metal.  This end was suspended over
the part to be irrigated ; the reservoir charged with water placed upon the
usual little shelf situated at the head of the bed, and  the  stop-cock be in«
turned, allowed the water to escape into the tube    Th* «v+J£   V    • i
ity of the irrigation were, by the L of tho^p-cook^ peS J^Zl 
ISSUES.
55
A small sheet of oil-skin Avas placed under the arm and separated from the
bed, the  oil-skin being  so  arranged as to conduct the Avater which had
passed over  the limb into a basin or upon the floor of the ward.  It is
obvious that water of any temperature, or medicated in a prescribed man-
ner, may be made, by this  simple and cheap apparatus, to distribute itself
over any part, however small or extensive it may be.
  By enlarging or diminishing, by elongating or shortening, the head, or
varying its form, the drops may be carried simultaneously over  a larger
or smaller, or any irregularly-formed surface.         Part xxvii., p. 257.

                              ---•-»-•—

                           ISSUES.
  Mode of Inserting.—Dr. Geoghegan  recommends  the  application of
kali to the surface of the true skin, denuded of its cuticle by the applica-
tion of a blister.  The  blister should be of precisely the same size as the
issue to be inserted, and having been applied for the usual time, the cuticle
should be  gently but  completely removed, and  the superfluous moisture
absorbed by a piece of lint (the surface  of the  skin  not being rendered
altogether dry).   The stick of potass  should  be then passed once lightly
over the entire surface, no friction avhatever being necessary.  The opera-
tion is noAV complete, save the removal of superfluous potass by the press-
ure of a piece of lint applied after the lapse of about half a minute—a pro-
cedure Avhich is, however,  unnecessary, where due care has been observed
in its application.
  The caustic at once extends its influence into the substance throughout
its entire depth, and the pain, which is of an active burning kind  for some
moments, rapidly  subsides, and, in a great measure, disappears in from 15
to  30 minutes, in the generality of cases.   By the mode of procedure just
described,  the more  prolonged pain and  apprehension attendant on rub-
bing in the caustic, is avoided ; and from  the simplicity and facility of the
operation,  the latter may be  administered in the* guise of a stimulant  ap-
plication to the blistered surfaee without  inflicting on  the sufferer the for-
malities of an issue, or the horrors of expectation.  The destruction of the
skin to an  unlooked-for and  undesirable  extent, which  is  so frequent by
the ordinary methods, is entirely avoided by the proposed modification.
                                                      Part xii., jp. 251.
  Issues—May be made by applying to the part, slightly excoriated or
denuded of cuticle,  a smooth  zinc plate  of proper size, having a silver
wire  soldered to  its back; to  the other end  of the wire is soldered a
smooth silver plate of the  same  diameter as  the zinc, and this is closely
applied to  an abraded surface, lower down in the body than the zinc plate.
In a few days an eschar will form beneath the zinc plate.
                                                    Part xviii., p. 340.
  Issues—May be thus  conveniently made by means  of galvanism.  Get
a piece of  perforated zinc fastened or riveted to a sixpence, shilling, or
half-crown.   Place this on  the spot where  the issue is to  be made, with
the zinc surface next to  the skin, and cover it Avith a piece of spongio-
piline moistened Avith salt and water. Moisten  the  spongio-piline with
salt and  water  every twelve hours.   An eschar will  be thus formed in 
56
JAUNDICE.
about twelve days, or, if the cuticle is removed before applying the little
battery, the  slough will  be formed in from four to  six days, but more
irritation is created than  by the former method.         Part xx., p. 272.
  Issue-making.—Cut a hole the  size of the issue required  in a piece of
leather plaster, and  apply  it to the part, then introduce into this hole
powdered potassa cum calce, just sufficient  to  cover the skin, drop upon
this two or three  drops of spirits of Avine, and cover the" whole  over Avith
a large piece of plaster. In twenty-four hours the plasters may be removed.
                                                   Part xxxv., p. 308.
                         JAUNDICE.
   Inspissated Ox-gall in Jaundice.—Dr.  Johnson states  that  he has, in
 some very bad cases of jaundice, administered inspissated ox-gall in doses
 of five grains, gradually increased to ten grains, three times a day, with
 the best effect.                                          part n^ p31m

   Treatment of Jaundice.—(Dr. Budd recommends the folloAving treat-
 ment in cases of jaundice arising from suppressed secretion:]
   *rom. 5ss. to 5j. of sulphate of magnesia, in conjunction Avith gr. xv. of
 carb. of magnesia, and 3ss. of aromatic spirits of ammonia three times a
 day—the sulphate of magnesia  to keep up free action of the bowels; the
 carbonate of magnesia to neutralize any excess of acid in the stomach or
 bowels ; and the aromatic spirits of ammonia to support the nervous sys-
 tem, and to keep up the action of the skin.            part xxvi., p. 95.

   Use of Turpentine in Jaundice, etc.—Turpentine has long been used in
 purpura hemorrhagica, and cases where the blood  seems to become more

 slf wntv n " T ^T i tS ^f °y *? yCll0W feVer haS MtQl']y bee» wel*
 shown by Dr. Laird  who considers the  pathology of yellow fever as pri-

 rnlVrsiedt1,Wlth 3 Trbid aIterati°n °f th* bl<>od> a»d that the ter-
 nosseLes S neinliS n   pr°?ertieS as a  sedati^> styptic, and antiseptic,
 possesses also peculiar power of action on the  skin and kidneys   lean
 bear ample testimony to its success in another form o^iaundn^e Avhich Ave
 meet with much more frequently in fovp,- »»a  „  • •  J*1UUU1CC'  w7n we
 tinct cansp • T nllnrU +« Vo,  a-   V        ' and  ansing from a totally dis-
 year 1845  Dr  Corri^nT-Tf0"1- ?CeSSive Secret^n of bile-  In the
 ("con^^^^                                        ease  of  this kind
 which occurred in the* Hardwfoke^W
 after the brain began to be 2e    ft'      V^1 recov^d> ev<m
 cases of this kind within  the lastL» „    X had,x" m7 ^rds  several
 under the use  of  turpentine  The „^l n,lonths'a11 of which recovered
 two  or three hours.   %b™wuntiv^J^^Qred is a drachm eveir
 promote perspiration and avo?d Sg^y   D? "rtro™»PWt of ether, to
  There is a form of jaundice occasiofaflymet wfth Tl^ ''a   vu-
of great practical  importance to be acquainted St?   T' ™d W-hlch M
tinued fever, without any appearance nfl ,  ?•     .    A  Patient in con"
the previous day, suddenly becomes «„;*!    n   °\ hePatic symptoms on
fifteenth day of fever, an/all thT t ssTe b^  ™ ^°Ut th° fourteenth or
besides giving the usual tint  to  'he skS         impregnated with bile ;
off by the bowels most copiously, and the u,oneT"l™ dT' ^ bUe paSSG3 
JAUNDICE.                            57
case I observed that the posterior part of the dorsum of the  tongue, the
soft palate, and fauces, had assumed the yelloAv hue, and that not merely
the saliva, but the expectoration, Avas deeply tinged Avith it.
  These cases are purely critical, and differ from other forms of crisis only
in the organ in Avhich the  critical  action takes place.  Instead of occur-
ring in any of the usual modes, such  as perspiration  or diarrhoea, etc., it
occurs by a profuse secretion of bile, which  endeavors to pass rapidly
away through all the outlets of the body.  Such  cases require but little
treatment ;  the rapidity with which all the icteric symptoms pass  off is
most surprising.  There are two facts, however, to  be noticed regarding
it; one is, that the premonitory symptoms of this form of crisis are more
severe than I have eA'er seen in any other ; the other important feature in
this mode of crisis, is the excessive debility which follows it.
  I have also A'ery frequently seen jaundice  arise in the course of fever, as
a symptom of pneumonia.                              Part xxx.,p. 68.
  Properties of  Carbazotic  Acid.—It is formed  by the action  of  nitric
acid on indigo, aloes, silk, and other  organic substances.  It forms yellow
shining scales, soluble in Avater,  to  Avhich it gives an intense  yelloAv color
and bitter taste.   The process recommended by Liebig for prepariug it
consists in boiling ten parts  of diluted nitric acid in one of indigo, and
adding to the liquid, when cold, a quantity of potassa.  The potassa com-
bines Avith the carbazotic acid, and  forms carbazotate of potass; Avhich, in
its turn, is decomposed by the addition of another acid, by which the car-
bazotic is set at liberty, and is deposited in brilliant yellow crystals.   It is
soluble in alcohol and ether.  Dr. T.  Moffat says:
   I have prescribed carbazotic acid and the carbazotates of potass, ammo
nia, iron, and zinc, in eight cases, and in four of these the skin and con-
junctiva became yellow during the administration of the remedies.   They
Avere completely jaundiced; and I believe that the yellowness Avas owing
to the coloring matter of the remedies having tinged the serum  of the
blood.  The coloration may have  been owing to some change produced
in the biliary system by the  remedies;  but I  am inclined to the former
opinion. The tinge of the  skin and conjunctiva so  perfectly resembles
 jaundice, that the keenest observer would be deceived.
                                                     Part xxxii., p. 41.

   Jaundice.—The first principle to be borne steadily in mind in all cases,
whatever their cause, is  to promote in every  Avay the functions of those
organs compensatory by which elimination of bile is effected, using Avarm
and vapor baths, saline purgatives, and the Ararious kinds of diuretics.   In
employing blisters, cantharides is inapplicable, from  its action  on  the
kidneys.
   In jaundice from acute congestion of the  liver, leeches,  cupping fomen
tations, etc., over the region of the liver, and saline purgatives to unload
the engorged portal system, are  the  curative measures most likely to be
folioAved by relief.   When the congestion is primary, due to  spirit-drink-
ing, and such as  may go on to  inflammation of the  adhesive character,
mercury pushed to slight specific action is indicated; but in cases of clos-
ure of the  ducts, mercury can do no  good,  here we can only carry out the
principle of elimination by other channels.                Part xl., p. 67. 
58
JOINTS.
                             JOINTS.
   The Excision of Diseased Joints.—The removal of diseased articulating
surfaces may certainly be ranked amongst  the greatest triumphs of modern
surgery.  Instead of leaving  the disease  to wear out the constitution of
the patient, or amputating  the limb, and thereby crippling him for life,
the joint is boldly laid open, the diseased  portions excised, and the wound
allowed to heal by granulation; taking care to place the limb in  the most
suitable position for  its after use, after anchylosis has taken place.
   Mr. Cooper says:  Noav, as  to the rationale of the operation, I cannot
help believing that those Avho have recommended the excision  of joints,
have dwelt too strenuously  upon its advantages, as to the  quantity of dis-
eased structures which, by mechanical means, they remove. In my opinion,
the great benefit Avhich  is  derived is from  exposing and  perfectly layin<*
open all the affected tissues, so that nature  is not herself  obliged to pro-
duce sinuses and ulcerations through the soft parts.  It is not the quantity
of bone you cut away, but,  by exposing a large  surface, you  allow the dis-
eased tissues to readily come  away, instead of burrowing through the soft
parts.  No more should be removed than  is evidently already destroyed
by disease, and we find that this is generally confined to  the articulating
 surfaces alone of the bones implicated.   If  you  remove beyond this, you
 do no good, but, on the contrary,  detach muscles which would  otherwise
 have been of the greatest  service to the new joint, and thereby  render it
 far less capable of natural and useful motion.  *            Part ii., p. 122.

   Removal of Foreign Bodies in Joints by means of Subcutaneous Inci-
 sions.—The proceeding recommended  by the author, Dr. Goyraud, of Aix,
 consists in pushing  the loose  body (if in  the knee joint) into the synovial
 pouch above and to the outer sida  of the patella, beneath  the vastus ex-
 ternus muscle, and  while an assistant holds it fixed there, passing a narrow
 knife through  the skin at some distance above the joint,  and through all
 the intermediate tissue down to the foreign body.  Without enlarging the
 opening in the skin, the synovial membrane and adjacent tissues over the
loose  substance  are now to be freely divided, till, by the  pressure on the
latter, it slips out of the joint through the  Avound and lodges itself in the
subcutaneous cellular tissue, or in some of the  other  tissues between the
skin and the joint.  After this the patient must remain at rest for several
days (the smail external aperture being  merely covered by sticking-plaster),
till all chance  of inflammation occurring has passed away.  The foreign
body dislodged from the interior of the joint will form a cyst  for itself,
and remain in its new position Avithout producing any annoyance; but if
it should be deemed necessary, it may  easily be removed by a single inci-
sion through the skin over it,  Avhich will no longer be likely  to excite any
inflammation of the joint itself.                           Part iii. p. 95;

   Treatment of Cartilaginous Bodies  in Joints.—Mr. Liston, in his lec-
tures on the " Diseases of the Joints,"  says he  has, in several cases, pur-
sued the plan recommended  by Dr. Goyraud, of Aix, Avith  excellent suc-
cess.                                                  Part ix., p. 185.
   Use of Issues in Diseases of the Joints.—Br. Brownless condemns the
indiscriminate employment of  issues in  chronic diseases of the joints, be-
lieving that the continual and profuse  discharge sometimes kept up by 
JOINTS.                             59
them is very injurious, by Aveakening the powers of life in diseases where
so much depends upon the state of the general health.
  If issues are used, make one of moderate size,  and when  it is nearly
healed, make another at a different part of the joint;  and  do this again
and again.  If an issue is  kept open (which is not advisable), it must not
be with peas, but by occasionally retouching with caustic.
                                                      Part xa*., p. 169.
  Joints—Scrofulous Disease of.—Secure rest of the, joint by plasters,
leather or gutta  percha splints, and bandages;  but confine the patient to
the house no more than is absolutely necessary, or the  health will be  in-
jured,  and the local  disease thereby aggravated. Apply tincture  or  oint-
ment of iodine, night and morning, so as just slightly to irritate the skin;
and  alternate its  use Avith other stimulating liniments, blisters, or, in slight
cases,  the cold douche.  When abscesses form, allow them to burst spon-
taneously.                                            Part xxi., p.  25.
   Chronic Disease  of.—In chronic diseases of  the joints, connected Avith
gout and rheumatic  gout, much may be done to prevent its progress at its
very commencement.  Place the patient on a careful system  of diet, par-
taking very moderately of animal food, avoiding fruit, acids, etc., and tak-
ing  little or no fermented or  spirituous liquors.   Perspiration  should be
induced by exercise or by the hot-air bath, once in  a  Aveek or fortnight.
Acetic extract of colchicum, in alterative  doses, combined Avith mercurial
pill, and occasional purgatives, should be given from time to time.  Moder-
ate doses of potash and  magnesia (always avoiding soda) may be given
three  or  four hours after  the principal meals, to neutralize any super-
abundant acid in the stomach.  If the  patient is depressed by the colchi-
cum, give Dr. Gregory's powder.   Little is to be done locally.  If pain is
severe in the part, leeches may be applied, and, if  need be, a bandage for
the  purpose of  limiting motion.   When  the  disease is fully established,
these  remedies may be still used to mitigate the symptoms, but Ave  must
then give the iodide of potash  in two or three grain doses twice daily, and
continue it for Aveeks, if it agrees Avith the patient.  No general  rule can
be laid down.  In one case, great benefit Avas found from the use of cod-
liver oil locally, and from its administration internally.  Part  xxii., p. 192.

   Iodine Injections in Hydrarthrosis.—M. Velpeau says, in his  opinion,
there  is not more danger in  injecting a joint than in injecting the tunica
vaginalis, and that he has done it Avith complete success, the smallest pos-
sible trocar being employed.   Neither  does the question of injecting  the
abdomen in ascites with iodine seem to him one of mere hypothesis.  Many
French surgeons have related numerous cases followed by complete  suc-
cess, Avhere the practice has been employed, while others consider the con-
clusions drawn to be somewhat hasty.                   Part xxii., p. 198.
   Inflammation of the Synovial Membranes of Joints.—[As  to the consti-
tutional origin of these affections, Sir Benj. Brodie  remarks:]
   Inflammation of a synovial membrane may arise  as a local affection, the
consequence of a sprain, a contusion, or other mechanical injury.  In other
cases,  various joints being affected, either simultaneously or in succession,
it is manifestly the effect of a disordered state of the general system.
   I must confess that, in proportion as I have  acquired a more extended
experience in my profession, I have found more  and more reason to believe 
GO
JOINTS.
 that local diseases, in the strict sense of the term, are com}?^tl]eiV^'
 Local causes may operate so as to render one organ more liable to urease
 than another; but everything tends to prove that, in the great majonty
 of cases, there is a morbid condition, either of the circulating  fluid or ot
 the nervous system,  antecedent to the manifestation of disease in any par-
 ticular structure.                             ,             r       ■,.
  [Sir Benjamin insists  in the treatment "on the necessity of regarding
 them as constitutional and not local affections."  When the joint is greatly
 and distressingly distended Avith serum, it is recommended to  make a few
 minute  punctures, and apply an exhausted cupping glass ; and as soon as
 pus is known to have been secreted,- to make a free incision  into the joint.
 He then says:]                                  .  .    . .
  " If it be a question whether the collection of fluid in a joint  be purulent
 or otherwise, it is prudent, in the first instance, to make a puncture with a
 grooved needle.  If it prove to be purulent, a  free opening should  then at
 once be made Avith a lancet, in a depending situation.  It  is  important that
 this operation should not be long delayed, lest the matter should make its
 way out of the joint in other directions, and form irregular and circuitous
 sinuses among the neighboring tendons and  muscles.  It is equally import-
 ant that the opening  should  be sufficiently large  to allow the matter to
 flow spontaneously, Avithout it being necessary to have recourse to pressure
 on the joint.   If afterward there be reason to  believe that there is still  a
 lodgment of matter in any part of the joint or among the neighboring soft
 parts, the original opening should be dilated, or the  surgeon should avail
 himself of the first opportunity Avhich occurs of making another opening
 in a convenient situation ; and it  will often happen that several such open-
 ings will be required before the cure is completed."   Part xxiii., p. 271.

  Joints—Diseased.—That as the  separation  of diseased cartilages from
 the extremity of the bone is commonly by a process  of " shedding;" that
 as the portions so exfoliated tend to keep up a constant  irritation within
 the joint; that  as the natural outlets for these portions, the  sinuses, are
 inadequate for that purpose;  that as for their removal they have to be dis-
 solved in the discharges  of the joint, Avhich is necessarily a  very slow pro-
 cess ; but as, whenever they are removed, an immediate process of repara-
 tion commences, Mr. Gay recommends that free and  deep incisions should
 be made along the side of the joint, so as to lay open  its cavity freely, and
 to allow of no discharges being retained by any possibility Avithin it.  The
 incisions should be made  in the long axis of the limb.  They  should  extend
 into the abscesses of  the soft parts so as to lay them open,  and the incisions
 should pass through sinuses, unless out of  the Avay  of the incision.  If
 either of the bones be carious or necrosed, the incision  should be  made
 deep into  them, to alloAV the free  escape of diseased portions   Important
 vessels should be avoided.  The Avounds  should be kept open by pledgets
of lint, and free suppuration encouraged.              par( XxV. ». 179.

  Scrofulous and Rheumatic Inflammation of Joints —Mr  Stanley re-
marks upon the difference in the frequency Avith which certain joints are
attacked by  disease, and how exempt others  seem to be from  the like
affections   An example  of the former fact  may be  taken in the hip and
knee joints and of the latter in the lower jaw, the sterno-clavicular articu-
lation, or the heads of the ribs Avith the vertebra*.  Some explain this by
tiieir greater  or less  exposure to external influences;  but this cannot be 
JOINTS.       '                     61
 the case^else why should the hip be  more frequently attacked  than the
 ankle joint?   Others  say  that joints  are  more susceptible from the
 activity of their functions;  but few joints  are more  exercised  than the
 lower jaAv, and yet few are more free from disease.
   I now come to  the consideration of strumous inflammation of joints,
 and before proceeding to investigate its phenomena, the following ques-
 tions  demand attention:  1st. What are the  circumstances Avhich would
 lead us to regard the disease as strumous, Avhen brought to the bedside of
 a patient ?   2d.  In Avhat condition should Ave expect  to find  the struc-
 tures, viz.: the bones, cartilages, and synovial membranes of a joint, pro-
 vided the disease  be strumous ?  With  reference to the first question, I
 am unacquainted Avith any local  symptom, any precise condition in the af-
 fected joint itself,  Avhich wrould  enable us at once to  decide  on its stru-
 mous  nature.   We  must look  elsewhere.   The  age and aspect of the
 patient, the past or present existence of scrofulous disease in other parts,
 Bitch as  enlargement  and suppuration  of the  cervical absorbent glands,
 strumous ophthalmia, tubercle in the lungs and  other organs—any of these,
 especially if actually coexistent,  would  justify us  in regarding the disease
 as scrofulous.  Often, indeed, these cases are  obscure, and sometimes we
 are led to a Avrong conclusion.  The aspect of the patient is delusive, and
 should not be too much relied upon.  Many instances occur in  Avhich the
 patient's appearance  seems  indicative  of the existence of scrofula, whose
 subsequent progress and favorable recovery proA e that  such evidence is
 fallacious.
   We have now to answer the  second question.   What is the state of a
 joint invaded by strumous disease ?  The morbid specimen I hoav exhibit
 sIioavs the condition of the  articular extremity of a bone in an extreme
 attack of this  nature.   The end of the bone is softened  from  absorption
 of its  earthy matter, and its  cancelli are filled with tuberculous  deposit.
 It is, hoAvever, according to my experience, rare  to meet Avith so  com-
 plete an example of strumous disease as  this specimen furnishes.   In the
 majority of cases, I believe that  no tubercular matter is found deposited,
 and Avhen found, it is only in the last stages of the affection.   Such a con-
 dition  of bone, when it does exist, is, in my  opinion,  irreparable;  and,
 when the surgeon is summoned to a case  exemplifying the disease in this
 its latest stage, he can do nothing to restore  the bone to its natural state,
 nothing  to  accomplish  a cure.  There is, however, an earlier stage in
 these affections, which you will often have to treat in private, although it
 is seldom seen in hospital practice—a stage amenable to treatment, a stage
 in Avhich, generally speaking,  the morbid impairment of the bone may be
 arrested, and its integrity restored.  It is  characterized by increased heat,
 and  enlargement of the bone, immediately above the joint.  There is,
 indeed, increased A'ascularity,  and low inflammation of the bone, which is
 quickly followed by expansion of the cancellous texture, and absorption of
 earthy matter.  Ultimately in bone thus  degenerated, tubercle is some-
 times deposited.  Such, then,  is the state of the bone in a joint affected
 with struma.  The  other structures—the cartilages, synovial membrane,
 etc., are in a state  of low inflammation, inflammation  Avhich  has com-
 menced either in the bone or the synovial membrane itself, and  wThich, if
 suffered  to  advance, is  followed by its usual  consequences—exudation,
thickening of tissues, and sometimes suppuration.   Noav, the appropriate
treatment for an attack of this sort is, perfect  rest for the limb,  and re 
62
JOINTS.
movaI of all weight and pressure from the «^™^J^» e^istVin any
as far as possible  its complete  ta™qmlhty.  B» *™™™^       J
activity, the judicious  application  ot leecnes  a in »«      „m„i„Vod  i«
should  be borne in mind that  leeches must not be lavishly ""Ployed  a,
strumous patients cannot stand  deplete  ll.e ^Tet oratlu^f the

general Shif'tha- 'h^faS ^tsSnance if it has not   To this
gentji^i Jic^it ,                rimptipible a resort to the sea-side should
end country air, or, where it is practicapic, <* ««^
be recommended; a light, nutritious diet enjoined, and the state of the
stomach and bowels be carefully attended to.         -,••*•«_
  Not  unfrequently disease in the  soft tissues around a joint  inflamma-
tion, and abscess,  are mistaken for  disease inside the joint; and, in some
instances, eminent surgeons have amputated limbs  under the impression
that an irremediable articular  affection existed, while in reality, the exte-
rior tissues alone were involved, the joint itself being sound.
  Joints are liable to another form of inflammation, differing from that
we  have just reviewed—" rheumatic inflammation."  The diagnosis  of
articular  rheumatism  is not usually difficult.   When rheumatic  fever is
present, it is, of course, obvious; but, Avhen  it  is not, the  implication  of
other joints, the  cause and  symptoms of the attack, and  the  history  of
prior rheumatism, will generally  guide us to a right decision ; the implica-
tion of other joints, because it is extremely rare to find rheumatism affect-
ing one joint only; it attacks  two or three simultaneously, or  flies about
from one to another :  the cause and  symptoms of the attack—because we
shall almost invariably find that  the patient has been  exposed to cold or
dampness,  and  because muscular  pains  are generally precursory to the
articular  inflammation.   Rheumatic disease thus  induced, is  commonly
marked by pain in one particular spot; the patient  does not complain of
general pain in the joint, but points to one especial locality, and describes
it as the seat of all his sufferings.
  Articular rheumatism is, moreover, intractable, leaving  one joint and
assailing another, or departing and  recurring  in  the same joint.  Joints
are attacked by rheumatic inflammation in two Avays;  either their fibrous
structures,  their  ligaments, suffer,  or their synovial membranes.  Now,
the  consequences of  rheumatic inflammation  of the  ligaments may  be
serious, such, indeed,  as  may  terminate  in dislocation  of the bones of a
 joint.  For, under its influence, the ligaments become soft and elongated,
so as to permit the bone to slip out of the cavity in which it is naturally
fixed.  In this Avay the  head of the femur may  be  displaced  upward on
the dorsum ilii without rupture or  ulceration of either  the capsula or the
ligamentum teres.
   Rheumatic synovitis commonly  ends in effusion.  Ulceration of the
 articular  cartilages may, however, supervene; and I  have witnessed a
 case in which this condition was set up within nine weeks from the com-
 mencement of the attack, so that it was  found necessary to amputate  the
 limb.  More usually, however, rheumatic synovitis  gives  rise to anchy-
 losis, such anchylosis  as may result from the adhesion of opposite synovial
 surfaces by effusion of fibrin, and which is  called  spurious, in contradis-
 tinction  to true or osseous anchylosis.
  _ Gonorihceal rheumatism is  a form of  the disease  occurring in coniunc-
 tion with  gonorrhoea  brought on by  exposure to the  vicissitudes of
 weather, and to  the  development  of which, a certain unhealthy constitu- 
JOINTS.
63
tional state appears necessary.  Unlike ordinary rheumatism, it confines
itself to one or two joints, and, unshifting, clings to them Avith remarka-
ble tenacity.   It is, in truth, an affection that has long baffled the powers
of medical surgery.  In many instances the  patients appear to recover,
but the complaint  returns on the slightest exposure, and no permanent
cure is effected.   There  is novv under my care a* Pole  suffering  from
gonorrhoeal rheumatism  of  the wrist-joint.  In  him  the disease has
yielded for the present to three grain doses of the iodide of potassium,
given three times daily; and I am informed that the gonorrhoeal discharge,
which had become scanty, has reappeared since the mitigation of the arti-
cular disease.   The best possible termination in these cases, a termination
which has ensued in the instance I have mentioned, is serous effusion into
the joint; for when the fluid is absorbed, it is not unlikely a useful joint
may remain.   Some time back, a young  man, aged twenty-one, Avas my
patient in the  hospital, in consequence of a most  acute attack of rheuma-
tism in the shoulder-joint, following  gonorrhoea.  Though  he was in a
reduced  state, 1  ordered  him to be  bled  from the arm; mercury was
administered; in fact, very active treatment was adopted.  Serous effu-
sion in the joint resulted, and within five weeks I had the gratification of
seeing him leave the hospital Avith  the functions of the joint  in  a  great
measure  restored.
   We occasionally meet Avith examples of rheumatic synovitis  occurring
after parturition, Avhich may originate anchylosis. The affection differs in
no shape from ordinary rheumatic  synovitis; but it requires gentle  treat-
ment,  as the  patients attacked by  it  are  generally much  debilitated,
and frequently suffering from some  uterine complication.
                                                    Part xxvi., p. 118.

   Joints,  Diseased.—M. Tessier, of  Lyons, has showm that prolonged
rest alone, even Avhere little or no disease previously existed—a  rest for
five or six months—is sufficient to  cause absorption or  ulceration of the
cartilages of joints.   This prolonged rest also aggravates existing  disease.
   In the early stage  of inflammation of joints,  apply plenty  of  leeches,
except in scrofulous subjects.   To relieve pain, use the folloAving:  moisten
a bit of lint with twenty or forty drops of chlorinated hydrochloric ether,
and apply it to the joint.  After bleeding bring the patient rapidly under
the influence  of calomel,  or  give tartar  emetic.  The limb should have
absolute rest in the most  favorable position, for five or six weeks, but not
longer, for fear of stiffness, etc.  The joint may be splintered with lea-
ther in the folloAving Avay: Get some thick leather, soften it in  Avarm
water, and mold it, when pliable, to the  joint, and when hard, remove it
and line  it Avith wash leather.  This forms an admirable splint.  One may
be made for  each side of the joint.   Evacuate  any pus that  may be
formed, in good time. Promote the  absorption  of such materials as the
inflammation  may have  deposited, by counter-irritation,  by means  of
blisters, croton oil, discutient plasters, composed of equal parts of galba-
num and  mercurial plaster, pressure, friction, the cold douche.
   Ulceration of Articular Cartilages of.—Acute inflammation is marked
by rapid  effusion  Avithin  the joint, and uniform  SAvelling;  in  disease  of
cartilage, the  swelling is slower, and outside the joint, not coming on till
some time after the first sensations or uneasiness.  In chronic degenera-
tion of synovial membrane, the swelling,  although indolent, is more rapid 
JOINTS.
64

than when the cartilage is diseased  Th;; sweUhig: is £^^«*
superficial.   Scrofulous disease ot  the heads of the  bone  is        tif
he  confounded with  disease  of  cartilage;  f.^SVdyS
chiefly belongs to the middle and after periods of  "^{WP^
Insc/ofulous°disease,the pain generally comes ^/{^.^^^ay con
mm   In ulceration of cartilage, the pain comes on eajliei, and may con
pus.  muiceiauon 01 caiuidto ,     ^        «  perfect repose, acconv
tinue a long time without pus foiming at  an. rv        L bv leathei
nlished bv sMntinq the joint, either by Mr. Scott's method, or by leatnei
S^Sa^SSrs&iito molded to the joint.  Give -ercury early  when
not contra-indicated, colchicum, with alkaline aperients.   By and by apply
counter-irritation.                                „  ,    -,.      «•  t>
  Scrofulous Disease of.-In the  early  stage of the  disease, Sir B.
Brodie says, "All kinds of counter-irritation,  such as blisters, issues, setons,
and tartarized antimonial ointment, are not only not useful, but actually
mischievous."   The only exception is in  cases of hip-joint disease  of  a
painful character.  These  counter-irritants certainly excite absorption of
fluid which  may exist in the joint, but do not act  on  the diseased  struc-
ture.  Perfect repose of the parts in the horizontal position, with leather
or gutta percha, or other kinds of splints lightly applied, is, no doubt, the
best local treatment;  at the same time,  allowing the patient as much out-
door amusement as possible.                            Part xxx., p. 93.
   Veratrine Ointment as a  Local Application in Scrofulous Affections
of the Joints.—To promote  absorption in these cases, use the  following
ointment: veratrine,  grains five to ten, dissolved  in  spirits  of wine, and
add to one ounce of axunge.  This is not to be used in acute affections,
but in chronic.  Rub about the size of a small bean  upon the joint for a
quarter of an  hour daily.   If violent  itching be produced, use a little
glycerine and water.                                  Part xxx., p. 123.

   Articular Disease illustrating  the Advantages of the Actual  Cautery'
—[The following case commenced  after cold and  fatigue, about  four
months before admission into the Edinburgh Royal Infirmary.  The pain
in the shoulder was at first intense.]
   On admission she complained of  constant gnawing pain in the left shoul-
der, and extending down the limb as far  as  the elbow, and sometimes  to
the fingers; Avhen in the sitting posture she held the affected  limb Avith
the other hand, to ease the pain: the arm was also affected Avith a feeling
of numbness and weakness; and  although the shoulder Avas not very ten-
der on pressure, and very gentle passive motion of the arm could be per-
formed through a considerable angle without pain, yet any  attempts  on
her OAvn part to move it  produced great aggravation  of her sufferings.
As a result, no doubt, of habitual disease, the  muscles about the shoulder
were much atrophied, and this caused a remarkable apparent prominence
 of the bony points, viz., the spine of  the scapula, the acromion, the  ante-
 rior border of the outer part of the clavicle, and the head of the humerus.
 The shoulder had an appearance  that suggested at first sight the idea of
 dislocation.
   The patient being  under the influence of chloroform,  Mr. Syme  cauter-
 ized thoroughly the skin over the  anterior and posterior  aspects of the
joint, rubbing a red  hot cautery iron freely backward  and forward four
 or five times over each part.  It  had  the  effect of raising and rubbing  off
 the cuticle, but did not char the skin.    An hour afterward the  patient 
JOINTS.                             65
was suffering but little pain.  Said she slept well that night, the first time
for four months, and feels now no pain save that of the burns.
  A poultice Avas applied yesterday; the pain of the burn  is now gone,
and she feels no pain at all.  Says that she has not only lost all  pain, but
also that the feeling of numbness is gone from the limb, and that she seems
to have more power in it.  The burned parts present a Avhite sloughy ap-
pearance.
  The poultice A\ras continued till the sloughs  separated, when simple cer-
ate was substituted for it Avith a view of retarding, rather than promoting
cicatrization.
   In time, this case fully recovered.   Other cases are given shoAving in an
equally striking manner the beneficial effects of the actual cautery in certain
forms of articular disease.  It Avill be observed that it is by no means so
painful a remedy as is generally supposed, and also  that its  good  effects
are more than  can be attributed  to the mere discharge of pus from the
sore which it produces, seeing that a great improvement commonly occurs
within a few hours of its application, and long before suppuration is estab-
lished.                                              Part xxx., p. 120.
   Incisions into Joints.—According to Mr. Gay, these may be made with
advantage:  1st. In cases of chronic inflammation, with effusion  and pain,
if these have resisted ordinary remedies and health  is declining ; 2nd. In
 cases of acute or subacute synovitis, Avhen the symptoms  are  unusually
 severe, and the external coverings show a  tendency to ulceration, or when
 there is reason to believe that there is pus within the joint; 3rd.  When
 the joint is occuped by bony or cartilaginous debris, Avhich cannot find
 exit;  and 4th. In cases of carious disease  of the bones.
   Mr. Hancock thinks that these can  only be  beneficial Avhen, from  the
 long duration of the disease, the actual structure of the joints have become
 so changed as to diminish the danger of opening into their cavity.  When
 the disease is recent and  progressing, opening the  joint is  attended with
 an aggravation of the symptoms.                     Part xxxv., p. 71.

   Affections of the Joints following Operations on the Genito- Urinary
 Organs.—Mr. Coulson, Surgeon to St. Mary's Hospital, in his lecture, re-
 marked as follows:
   It is known that certain affections  of the genito-urinary organs are occa-
 sionally folloAved by severe disease of the joints.
   The injuries and diseases of the genito-urinary organs with Avhich they
 may be connected are various.  They may follow lithotomy and operations
 on the  urethra.  They may follow lithotrity ; the  introduction of instru-
 ments  into the  bladder; irritation  of the urethra from the  passage of
 foreign bodies, and gonorrhoeal abcess, with ulceration of the urethra.  In
 fact, any injury or disease Avhich gives rise to  primary suppuration in or
 about the genito-urinary organs of the male, may be followed by secondary
 articular disease.   Besides these, there are joint affections, Avhich appear
 to be  excited by mere irritation of the  same parts without suppuration.
   The articular affections are sometimes purulent, sometimes non-purulent;
 and this distinction is Avell marked, the two varieties being seldom mixed
 in the same case.   The attack of the joint sets in very soon after the ap-
 pearance of constitutional symptoms.   Thus it frequently  happens that
 the joints begin to SAvell on the first or second day after the rigors  and
 fever.  The secondary deposits are often  confined  to the joints and mus-
     VOL. II.—5 
QQ                            JOINTS.
 cles, and do not extend to the principal viscera.   Notwithstanding the ap-
 parent limitation  of the  general  disease, death  ensues  rapidly after  the
 first appearance of  the  constitutional symptoms—on  the fourth, sixth,
 tenth, and twelfth days.
   On the other hand, many of these cases, though extremely severe, ter-
 minate by recovery of the patient; yet the joints have been extensively
 injured, as is shown by the anchylosis which ensues.
   The purulent affection of the joints generally sets in under the following
 circumstances;  a slight injury has been inflicted on  the genito-urinary
 organs, or the patient may have irritated the urethra by attempting to pass
 a catheter  himself.   Severe rigors, folloAved by  fever of a nervous kind,
 ensue;  and in one or two days the joints are attacked by pain and swell-
 ing.  The tumefaction may increase to a considerable size in a few hours
 the joint becoming red  and hot.   The  knee, shoulder, ankles, and elbow
 are the joints most  commonly affected. Some of these  cases terminate
 fatally in a fortnight; others again are chronic; even in these the joint dis-
 ease may commence as early as the second day.
   The morbid changes in  these cases are various.   They are usually inflam-
 matory.   The synovial  membrane is injected, and sometimes  lined with
 false membrane, and the joint contains pus; but ulceration of the cartilages
 is not common.  In other  cases the lesions are confined to the periarticular
 tissues,  which are  infiltrated Avith pus;  or the purulent inflammation  may
 occupy the interior as well as the exterior of the joint, although the cap-
 sular ligament has nowhere given AAMy.  In a few  cases the joint  has been
 the seat of simple inflammation, and does not contain any pus; and matter
 may be discoved in joints  which did not seem during life to be  attacked.
 It is very rare to find pus in a joint Avhich appeared healthy up to the time
 of death ; but this has occurred in  one case.
  In chronic cases  the periarticular swelling often contains pus, and  the
 cartilages are softened or eroded.   Indeed, Ave may infer that the cartilages
 and even ligaments have  been extensively diseased from  the  anchylosis
 which ensues.
  In the milder form of the disease, the joints become painful and SAVollen;
 but these symptoms are not severe, and the  skin is not  red.  In a few
 days the  affection may subside,  and pass  to another joint; hence this
 form is often mistaken ^ for rheumatism.  The effused  fluid is sometimes
 purulent; in the majority  of cases, Ave may infer that the effusion is serous
 from the manner m Avhich it disappears.  I should observe that many of

 lleZlTtt^Chf ^ Cbr°mC CaS6S ^ —mpanied by intermuscular

 BZ!f Tvf the  a!???ar affftions Just Ascribed is  not well under-
 stood.   M  Velpeau  attributes them to poisoning by urine   M Civiale
 confesses that he is unable to explain hoAv they frproduced   For  my
 own part I am inclined to  attribute the  severe cases accompanied by cS

 of l^o\:S^ ^  f°U0Wed by PUrulent deP°^> t" thrince
  I have found small abcesses along the urethra, produced by the frenuent
-.lassage of instruments for stricture   T bnv« Ja~  r   ji • I    lrequent
 the prostatic veins.  In other cases sm3T ™!       i  inflammation  of
found in the prostate or wall of thhlSll T   T  abc-e8Se.8  have been
in the cellular tissue of the crotum  All tW !UPP"at-Ve inflamination
                             lum-  A11 these are sufficient causes.
                                                Part xxxvii., p. 12a 
JOINTS.                             67
  Hysterical Joint Affections—Mr. F. C. Skey says, that in three-fourths
of diseases of the  knee joint occurring ir. young women  from fifteen to
twenty-five, you Avill find more  or less palpably the traces of hysteria; for
even the presence  of real disease of the joint is no guaranty or safeguard
against the existence of some symptoms really attributable to hysteria.
                                                  Part xxxix., p. 133.

                          ANKLE JOINT.
  Amputation  at  the.—One reason, Mr. Fergusson says, why  surgeons
refuse  to  perform amputation at the ankle joint, is, that the integuments
are often swollen and ulcerated.  But this is no objection to the  proceed-
ing, the disease being produced entirely by,  and kept up by,  the irritation
of the carious bone, a principle of the greatest importance to  be remem-
bered.  Sloughing of the lower flap has been often observed, ajid in order
to obviate this, Mr. Syme has  recommended a shorter flap to be made ;
and Mr. Fergusson states that  he has even  made a shorter one than that
recommended by  that  gentleman.   It is desirable to make the flap no
longer than is absolutely necessary.                  Part xxiv., p. 185.
   Caries  of the Ankle Joint.—Amputation of the leg, below the knee,
used to be the common  operation for caries  of the ankle joint and bones
of the tarsus ; but Avhen the disease does not extend above the  articulat-
ing'extremities of the tibia and fibula, the foot may be removed, and the
thick integuments about the heel preserved  to form a cushion for support-
ing the  Aveight of the body.   Besides this, there is  much less fatality
about this operation than in that of amputation of the  leg.
                                                  Part xxvii., p. 352.
   Amputation at  the Ankle Joint.—Take care to make as much use as you
can of the sole of the foot for the flap.   It will have to bear all the pressure
afterward, and  is skin ready formed for such purpose.  Preserve not only
the skin but the Avhole of the fibrous and fatty granular structure of the sole.
Keep the knife free from the posterior tibial artery, which is  best done by
cutting quite behind the flexor tendons, close to, or eAren shaving the
periosteum.  Instead of  using  adhesive strips and  bandages afterward,
make use  of sufficient sutures, and then apply straps of linen about a foot
long and an inch wide,  soaked  in warm Avater, to the stump between the
sutures.   Keep the  parts  warm generally,  with warm water on  lint
covered with oil-silk, and keep  up gentle pressure on the flap.
                                                   Part xxix., p. 184.
  Astragalus—Non-Excision  of.—This  is a modification of Syme's ope-
ration ; but  Mr. Simon believes the stump to  be better than  Syme's,
because of its greater breath, its mobility in  the joint, and the  saved inch
and a half of leg.  The operation is performed similar to that of amputa-
tion at the ankle joint, the knife running between the  astragalus and  os
calcis.  The flap is taken in the same manner as in amputation  at the
ankle joint.                                          Part  xxix., p. 186.
  Ankle Joint—Exarticulation of.—Peregoff, of St. Petersburg, modifies
Mr. Syme's  operation at this joint.   He preserves the posterior portion
of the os calcis, which is thus left to fill up the heel flap.  The operation
is conducted in  the same Avay as Mr. Syme's, except that, after the exarti-
culation of the astragalus, the os calcis is divided  by the saw behind the 
gg                             JOINTS.

posterior extremity of the astragalus, and the heel is thus ^f^d>^f
of bein- peeled out.  The saw is then applied to  separate  the  rtuUeoh,
and a thi/slice of the articular surface of the tibia.  The cut surface of the
tibia is then brought into apposition with  the cut ™^™f.^. °\f™>
and the skin flaps accurately united by sutures.        J- art  xxix., p. an.
  Lines of Incision Suitable for Operations at  the Ankle Joint.-ln
operations at the ankle joint, arrange your incisions so that you  can gain
access to the tarsal bones, and if the disease  be more extensive than  anti-
cipated, that you can even remove the entire foot at the joint, it you AVish,
Make "a transverse incision across the sole of the foot, commencing about
three-quarters of an inch in front of one malleolus, and ending at a similar
point in front of the other malleolus: a second incision is then made in the
median line, beginning over the tendo-Achillis on a level with the  ankle
joint, and joining the former at right angles in the sole of the foot.   The
two  lateral flaps thus marked out being  next dissected upward, close to
the bones, the calcaneum and astragalus are freely exposed.  By division
of their ligamentous  and  tendinous  connections, one or both  of  these
bones may°be easily removed ;" and other parts may be easily reached by
extending the median incision a little  forward. If, from the great  extent
of disease, it is found necessary to remove the entire foot, it  may be  done
by uniting  the two  extremities of the transverse  incision  by a curved
incision across the dorsum of the foot.                 Part xxx., p. 117.
  Tarsus—Excision of the.—When the  calcaneum and astragalus are not
diseased, Chopart's operation is  the  best;  if these  tAvo bones  are  very
much diseased, then Syme's ; if the calcaneum be sound, then Peregoff's ;
or the calcaneum, astragalus, scaphoid, and cuboid, may any or all of them
be removed, if the disease  is confined to the  tarsus, and the foot  saved,
by Mr. Teale's operation.   In Peregoff's  operation, the calcaneum has to
be cut through Avith a saw.   The chain-saw has been generally used, but
Mr. Simon thinks the " Dublin saw " much preferable, and does aAvay with
the objections usually urged against the  chain-saAv.   In Peregoff's opera-
tion, as performed by Mr. Simon, first make the usual transverse incision
across the  sole of the foot, from the external malleolus to  the opposite
point on the inner malleolus; next cut rapidly across the instep meeting
the ends of the former incision; then disarticulate the astragalus, and cut
through the end of the calcaneum.                   Part xxxii.  p. 111.
  Ankle Joint—Excision of the Os  Calcis.—[William S.,  aged  thirty-
four years, states that three years ago he had a fall  and injured his ankle;
in a few months an abcess formed on  the dorsum of the foot, which, after
some time, healed, but  broke out and healed again repeatedly.  He has
not been able to move excepting Avith crutches since the accident and has
repeatedly been advised by different medical men  to have the foot re-
moved.  On examination, the soft tissues about the heel Avere found very
much swollen   There were the  openings of two sinuses, one under the
the outer ankle  and the other near the tendo-Achillis, which both  led  to
dead bone m the os calcis.  The ankle joint was  free from any serious
lesion   Removal of the calcaneum was recommended, and was submitted
to on August 22d, 18o4   On September 17th he was discharged  cured ;
m twelve weeks he could walk with only the aid of an ordinary walking
stick; and in eighteen months after the operation, he could walk ten miles
a day without any mconvemence.]  Dr. R. W. Coe observes • 
JOINTS.
69
  The first incision  must  be begun where the calcaneum, astralagus,
scaphoid,  and cuboid bones meet,  and carried  in  the direction of the
calcaneo-cuboid  articulation  outward  across the  dorsum  of the  foot, a
finger's breadth behind the  projection of the  fifth  metatarsal bone, and
directly inward across the sole of the foot,  as far as a line drawn from the
fourth toe.  A second incision must be commenced Avhere the first termi-
nated, nearly at  right angles to it, and carried backward so as to termi-
nate on the inner side of the tendo-Achillis, an inch above its  insertion.
This flap must be turned back, keeping the knife close to the bone, except-
ing where crossed by the peroneal tendons.  The tendo-Achillis must now
be divided, and  the knife carried through the articulation of the calca-
neum Avith the  astragalus, then  the calcaneo-cuboid joint must be  laid
open, and the bone will be found  pretty movable, but it must  not be torn
away, neither must other parts be  used as a fulcrum to pry it out; the
connections must be cut.  The greatest difficulty is in separating its deep
connections, which cannot be seen, and scarcely felt, the bone being in the
way.  You must take care to keep the knife  close to the bone, so as to
avoid wounding the posterior tibial artery  and  nerve.
                                                   Part xxxiv., p. 128.
   Amputation  at the Ankle Joint—Peregoff^s Operation.—The essential
point in this operation for removal of the  foot is to  leave the posterior
part of the os calcis so as to fill up the heel flap ; by this means the limb
is lengthened by an  inch and a half or two inches more than by other
operations, and  the posterior flap has not the bag  shape of Syme's, and so
 does not form a receptacle for a collection  of pus.  The os calcis  is sawn
 through immediately behind the  disarticulated astragalus, the remnant of
 the os calcis uniting by its divided  surface Avith the inferior extremities of
 the tibia and fibula.  The tendo-Achillis is not divided.
                                                   Part xxxvii., p. 116.
   Excision  of the  Os Calcis by a New Method.—In the removal of this
 bone, the  incisions, one transverse and one longitudinal, are usually made
 across the sole  of the foot, but here there is a great  disadvantage, namely,
 that cicatrices are left along the  line of most pressure.  A better plan is
 to carry a-horse-shoe incision from a little in front of the calcaneo-cuboid
 articulation round and  behind the  heel to a corresponding  point on the
 opposite side of the foot; dissect up the semi-circular flap thus formed by
 carrying the bistoury close to the  os  calcis, the under-surface of which is
 exposed.   Then make a perpendicular incision  about two inches in length,
 over  the  middle of the tendo-Achillis, falling into  the horizontal one.
 Detach the tendon and dissect the flaps up close to the bone, carry the
 blade over the upper and posterior part of the os calcis, open the articula-
 tion Avith  the  astragalus, divide  the ligaments,  and  turn the  bone out.
 Thus there is no cicatrix over the parts most exposed to pressure.
                                                   Part xxxvii., js?. 119.
   Resection of the  Ankle Joint.—Syme's and Peregoff's operations or
 modifications of them, are frequently performed  in diseases  of the ankle-
 joint, when, by resection of the joint the otherwise healthy foot might
 be saved.   These  former operations  should never  be performed unless
 there is so large an amount of disease as to preclude all hope of preserv-
 ing a good and useful foot.   Mr. Hancock, at the Charing Cross Hospital,
 has now performed this operation four times, three times successfully, and 
70
JOINTS.
once unsuccessfully, owing  to  pulmonary affection.  The  success of the
operation depends upon leaA'ing the anterior and  posterior tibial arteries
intact, and not opening the  sheaths of the  tendons ; the  only parts cut
through  are, the external and internal  lateral  ligaments, and the bones.
Neither the extensor nor flexor tendons, the  anterior nor posterior tibial
arteries  are injured, consequently, there  are no vessels to tie; when suc-
cessful, the  patients are able  tOAvalk  and  run  about Avith  scarcely any
perceptible limp.                                       Part xl., p. 81.

                         ELBOW  JOINT.
  Excision of.—M. Robert  presented a Avoman, aged 26 years, on whom
he had practised the operation of excision of the elbow joint.  The disease
rendering the operation necessary Avas caries of the humero-cubital articu-
lation, following a fall on the elboAV.  There  Avere several  fistulous open-
ings about the olecranon.  In the fold of the arm were two  deep sinuses
penetrating into the joint.   The soft parts  around  Avere  moderately
engorged.   The operation  Avas effected by  dividing and  reflecting the
integuments over the olecranon.   The humerus Avas sawn through imme-
diately aboAre the condyles, the ulna below the  coronary process, and the
radius just  beloAv its articular extremity.  The  limb Avas placed in the
apparatus of M. Guizot. But little reaction  ensued, and the fever and
sleeplessness Avhich had previously harassed the patient ceased immedi-
ately.  The patient recovered sufficient use of  her arm to resume her
occupation as sempstress.                              Part vi., p. 148.
   Operation for the Removal of Loose Cartilages in the Elbow Joint.—
[Mr., Solly's patient Avas left, after a severe attack of rheumatism, Avith
pam and swelling  of the elbow joint.   This was  treated by rest, counter-
irritation, iodine, and mercurials; and on the  subsidence  of the general
swelling, there Avas found a  small circumscribed swelling, Avhich appeared
to be a sac containing  several hard and movable  bodies, situated above
and behind  the inner condyle.  It was determined to remove these bodies
by operation.  Mr. Solly says :]
   I made an incision about one inch in length over the swelling above the
inner condyle, dividing the skin, fascia, and synovial membrane, till  I ex-
posed the loose cartilages, for such they proved to  be.  They Avere easily
pressed out of the opening.  I introduced my little finger into the sac, and
felt the articulating surfaces or the humerus and radius, and I thought I
felt an irregular surface on the ridge betAveen the radius and  ulna, like an
attached portion of a false cartilage, but there  were no more loose bodies in
the joint. Those removed Avere eight in number.   I brought the edges of
the wound into close apposition,  put one suture in through the  skin, and
the isinglass plaster over it.  I placed a  pasteboard splint on  the back of
the joint, fixing it to the upper and fore-arm, so  as to prevent  the slightest
motion in the joint.  The wound was quite healed in forty-eight hours, but
I kept the joint at rest for a week:  after this he Avas able to move it  with-
out the slightest pain—he did not suffer in any  ivay after the operation,
except for the confinement  occasioned  by the splint.  I have  seen him
repeatedly since he left the hospital, and he has remained  quite Avell and
resumed  his occupation on the river.                   Part x\x.,p. 130.
  Disease of the Elbow Joint.—Amputation  of the Avhole limb, excision
of the articulating surfaces, and the bringing about of anchylosis are the 
JOINTS.
71
three modes which have been hitherto resorted to, not  to cure diseased
 joints, but to prevent the constitution from sinking under the drain of a
disease but too often found incurable, and to render the  portion saved in
some degree useful to the individual.
   It is almost needless to say, that in a vast many instances all ordinary
means of curing these diseases fail.  Rest, splints, bandages, tonics, change
of air and diet, mercurials, iodine, all fail to stay the progress of the disease,
until it no longer becomes a question as to Avhether we shall have recourse
to the knife or not, but how soon, and in what Avay it is most advisable.
   Mr. Gay has for some time past  been in  the  habit of treating eases of
diseased joints by a plan Avhich has so far been found to be at one and the
same time simple, rapid,  and effectual.  It is nothing more or less than to
make one or more incisions right down to the diseased joint, with a view
of letting out  the debris of the diseased articulation, the  remnants  of the
cartilages, etc., Avhich seem  to him one  of  the principal  obstacles to the
procuring of anchylosis; a healthy inflammation is by these means  set up
in the cavity,  Avhich speedily results in firm and complete  anchylosis.  The
constant success which has attended this plan seems calculated  to  bring
about a complete revolution in the treatment of these complaints.
   J. T.,  a laborer, entered the Royal Free Hospital, under Mr. Gay, with
disease of the elbow joint.  Of  its origin and cause he knew nothing, and
only remembers that it began about seven years ago, and since then it has
 run its course unchecked by any means.  On admission, the state  of the
limb was as follows: The arm was straightened and the elbow joint  almost
 immoArable, even the slightest attempt to procure motion being followed by
 excessive pain.  The joint itself  was very much enlarged, but the remain-
 ing part of the limb was wasted  to a considerable extent.   There Avere six
 sinuses leading to the joint, two on either side, one in front, and another
 on the inner side  of the olecranon.  Around  their orifices the skin was
 livid and unhealthy-looking, and they all conducted direct to the joint, so
that the probe passed immediately into it.   A quantity of thin, ichorous
fluid  was consequently poured  out from them.  The man's  health was
much impaired.
   Although the state of the joint seemed to hold out scarcely the remotest
hope of success, Mr. Gay made an incision on either side,  carrying it alonf
the course of the lateral sinuses,  and fairly down to the joint.  These inci-
sions were each four  inches long, and left behind  great gaping wounds,
laying open  to view the interior  of the joint.  The ends of the bones were
found completely bereft of cartilage, and so soft that portions were as readily-
torn away by  means of a steel director as if they had been so much cork.
But little bleeding followed the operation, Avhich was concluded by filling
up the cavities Avith lint, and confining the joint Avith a bandage.  The first
thing that ensued Avas a most profuse discharge, Avhich continued unabated
until about nine days after, Avhen it gradually began  to  lessen,  OAving to
the evident healing of the wounds, which now appeared strongly disposed
to close.   The patient Avas  seized with simple fever, but   eventually reco-
vered, with complete anchylosis.                     Part xxiv., p. 171.

   Excision of the Elbow Joint.—Always remember that in caries of the
joint, little more than the articular surface is engaged in the disease.  It is
the ignorance  or neglect  of this point Avhich  has  made many cases  unsuc-
cessful.   The incisions originally practised by Moreau are the best,  viz., a 
72                             JOINTS.
transverse one across the back of the articulation, immediate.y aboie the
olecranon, from the ulnar nerve to the external condyle, and two longitu-
dinal  through the extremities of the transverse, so that  the  incision alto-
gether has the form of the letter H.  When the flaps have been raised, tree
nccesa is gained to the articulation; and when the operation  is  completed
the edges of the transverse incision, if brought  accurately together, gene-
rally  adhere by first intention.   Having dissected up the flaps, do not at-
tempt to remove  all the  articulation at once, as otherwise there will be a
risk of cotting the ulnar nerve; but having  exposed the  olecranon, cut it
off in the first instance, so as to get free access to the joint; then divide the
external lateral ligament, and having pushed the ulnar nerve over the inner
condyle, free the end of the humerus and saw it off on aline with the tuber-
osities ; and lastly, remove, in succession the ends of the radius and ulna
on a line Avith the base of the coronoid process.  More than the extent thus
defined Avould be unnecessary and injurious, Avhile less would hardly re-
move the disease, and even if it did, would incur the risk of anchylosis.
                                                    Part xxxi.,^. 106.
   Excision of the Elbow Joint.—When this joint has been anchylosed in
a wrong position, so as to be useless, a certain degree of motion may be
securecf by the following operation : cut out a large portion of the end of
the ulna, radius, and humerus, making, in fact, a resection of the anchylosed
joint.                                              Part xxxl, p. 108.

   Wounds of.—To excise the elbow joint, because a compound fracture of
the olecranon had been sustained, would, of course not be warrantable, as
it may heal and unite without the occurrence of inflammation ; but if arti-
cular inflammation do take place, the question does admit of serious con-
sideration Avhether it Avould not be best to excise the ends of the bones
with the hopes of saving the patient's constitution, and of gaining a mobile
joint.                                             Part  xxxiv., J9.122.
   Elbow Joint—Severe Injuries of.—Primary amputation ought never to
be thought of in compound fracture of the elbow, excepting the artery be
 torn  through, or the soft parts both before and behind hopelessly damaged.
 The  ill consequences to be feared are in inverse proportion to the amount
 of external laceration inflicted.  In  cases sufficiently severe to Avarrant it,
 it is  far better surgery to freely enlarge the Avound behind the joint,  and
 excise the projecting ends of the bones, than  to be content with a simple
 reduction.
   Much less of  suppuration and of constitutional disturbance appears to
 follow cases so treated, and the chance of good motion being obtained after
 an excision is infinitely greater than it is when the ends of the injured bones
 remain.  It may be Avorth  a question Avhether, even  in certain  cases not
 usually deemed sufficiently severe to warrant it, for the reasons above men-
 tioned, it  might not be Avell to enlarge the Avound  and excise the joint.
 Crushed elboAVS  with but small external Avound, undoubtedly, as a rule, do
 badly.  The excision of joints during the acute or commencing  stages of
 inflammation, Avould seem hitherto to have been regarded with suspicion,
 though probably with no very definite reason.   In cases of  slight injuries,
 in which at the time it  had been thought best to do nothing, but which
 have subsequently gone wrong, it  might, perhaps, be good practice to do
 secondary excision, say  Avithin the first week or two.   The  immediate re
 lief afforded by free incisions under such circumstances is well knoAvn, and 
JOINTS.
73
it would probably be increased by the removal of the  bones and their ul-
cerating cartilages.
  In treating these cases poultices and warm fomentations should be utterly
escheAved.
  When it has been decided to preserve the arm, it is the surgeon's duty
(excepting, perhaps, in a case of sloughing), to persevere, in spite of dis-
couraging circumstances, afterward.                Part xxxiv.,p. lul.
  Elbow-Joint—Resection of.—The last improvement in this operation is
that of Langenbeck, Avho makes only one lung incision on the inner edge
of the ulna.  The ends of the bones maybe readily turned into the wound
and sawn away Avith a key-hole  saAV, cutting from before backAvard.  In
certain cases, where there is great SAvelling and the ligaments are sound,
this plan Avill be more difficult, and a cross incision will be necessary.
                                                     Part xxxv., p. 69.
  Excision of the Elbow Joint.—There are two objects to be attained by
this operation, viz.: First, to remove all the diseased bone, and second, to
do this in such a way that a  useful and movable joint may result.   It is
ahvays far better to remove the whole of the articular  surfaces of the joint
than  to remove  the diseased portion only, for the disease often  extends
afterward to the other bones; and there is often more suffering and fever
than Avhen the Avhole is removed.                     Part xxxvi., p. 148.

   Excision of the Elbow—Heath's Splint.—The great object in this ope-
ration is to obtain a movable joint; to this end always  remove not a mere
slice from the edge of the bones, but a full inch or so ; there is then  less ten-
dency to anchylosis.  Employ a splint invented  by Mr. Heath, late house-
surgeon to King's College Hospital, consisting of four  iron plates, well
padded, concave on their front  surface, to  fit  the limb, comTex  behind;
these are intended to be placed opposite to one another, one pair above and
the other beloAv the  joint, projecting portions  perforated with a female
screw spring from the convex back of each plate.  Two iron rods Avith
hinges in their centres, and a small screw at either end, cut in opposite di-
rections" to fit in  the female screws of the iron plates,  connect the plates
above the joint Avith those below.  The plates are now attached firmly by
means of straps and buckles, and, if necessary, additional strips of plaster.
By turning round the rods the extremities of the bones are separated to
the required distance, wdiile by means of the hinges in the centres of the
rods motion can be made with the greatest facility.  Part xxxvii.,p.  108.


                            HIP JOINT.

  Treatment of Disease  of.—Dr.  Evans- believes that mercury  may be
regarded as a specific remedy in hip disease.
  That Ave may apply it Avith equal certainty and benefit in scrofulous and
non-scrofulous subjects.
  That it is better to bring the system at once and fully under its action
than to give a long and lingering alterative course of mercury.
  That in the majority of cases, mercury alone, Avhen pushed to salivation,
will effect a cure.   That the application of leeches are occasionally,  though
not always required, and Avhen any little pain remains at the groin, a small
blister will then be of benefit. 
74                             JOINTS.
  That rest, the horizontal posture, and attention to regimen, etc., must
be strictly enjoined.
  That hip-joint disease, if not in all, certainly in nearly all cases, is caused
not by primary ulceration of the cartilages, but by scrofulous inflamma-
tion of the synovial membrane—this morbid state being the first link in the
chain of pathological actions.
  Lastly.  That the  diseased limb is  really elongated during the second
stage of coxalgia, and that this appears to be in a great measure effected
not by curvature of the spine, etc.,  but by the pushing out of the head of
the  femur;  this is caused by the inflammation within the joint, aided by
the organic relaxation of the surrounding muscles.       Part v\.,p. 152.

  Hip-joint Disease.—[Affections of the hip joint are too seldom seen at
the  commencement, Avhen properly applied  remedies might restore the
joint.  In the second stage, Ave have no longer a simple case  of  erythema
of the synovial membrane, but an active form of inflammation extending
to the more dense  parts of the capsule  and cartilage, attended with severe
pain in rotation and abduction of the limb.]
  Often in the earliest part of the  second stage, the limb will not  admit
of perfect extension,  and by  careful examination of the joint it may be
discovered that  the thigh is permanently flexed on the pelvis.  It  is this
state of the limb to which Mr. Key directs attention, as fraught with the
worst consequences to the patient.  This state of flexion of the  femur on
the pelvis usually takes place slowly and imperceptibly, but  sometimes it
is rapidly induced by  a sudden attack of inflammation in a joint  that has
previously exhibited  signs of disease  in  its mildest form.   This is the
worst form of  the disease, so far  as the deformity of the  joint is  con-
cerned ; for the intense  pain Avhich  the patient  experiences on the slight-
est movement of the  limb induces her to seek for ease in positions  that
add  greatly to  the distortion of  the  limb  by the obliquity  given  to the
pelvis.  The  patient  is  seen  lying usually on her sound side, Avith the
affected limb drawn  up  to nearly a right angle with the pelvis. As the
patient lies on her  side the affected  limb appears to be three or four  inches
shorter than the other.   When she is  placed on  her back, Avhich position
she assumes Avith difficulty, and the bearings of the tAvo  patellae, and the
spinous processes of the ilia noticed, the former are seen to differ as much
as from two to three inches, Avhile only a difference of an inch is percepti-
ble in the level of the iliac spinous processes.  This Avould seem to  show
that the limb was actually shortened ;  such, however? is not the  case, and
by examination of the pelvis it will  be  seen that  the twist  of  the pelvis on
the lumbar  vertebras, by carrying the affected joint backward, is the
cause of the great shortening of the limb.
  During the stage of inflammation it  is impossible to use any  means of
counteracting this  distorted position of the  pelvis, and by the  time that
the patient is able to bear extension so as to restore the pelvis to  its na-
tural bearing, and to diminish the angle which the femur  makes with the
pelvis, the parts have  become so  fixed in their  new position as  to render
it difficult to alter their position, and  impossible in the majority of cases
to restore them to  their natural bearings.  The consequence  is, that Avhen
the patient is convalescent Avith a somewhat  stiffened joint, the foot can-
not be brought down to the ground, and a shoe Avith a sole'of two  inches
is required to enable her to walk Avith  the foot flat on the ground.   iljvr 
JOINTS.
75
is this state of things to be prevented ?   The only remedy for the evil is
in every case of disease of the hip joint to maintain the straight position,
as soon as the nature of the affection is ascertained.  It is a position appli-
cable in all stages of the disease.
  In the early stage characterized only by a slight limping in the gait, or
by an occasional slight pain in the  knee  or thigh, it  possesses the advan-
tage of maintaining the joint in a state of complete repose.   The articula-
tion  being at rest, the muscles do not  act, but remain in a passive state.
On the contrary, Avhen the limb  is kept bent with a pillow placed under
the knee,  a position usually resorted to in the early stage, the pelvis and
thigh in a child are continually in motion;  little  or no pain  is felt by the
little patient, and  injunctions to  preserve rest are made in vain. In the
bent position, therefore, rest, one of the most important elements in treat-
ing  a  diseased joint, is  not maintained, and the disease, therefore, fails
often to be arrested.  By a long splint applied along the outer side of the
limb, and made to extend from  the toe to the axilla, entire rest is given
to the joint,  and absolute inaction of the muscles preserved.
  The arrest of the disease is greatly expedited  by the entire  tranquillity
obtained by  the straight position in conjunction Avith the mercurial treat-
ment.  The  principal advantage of preserving the limb in a  straight posi-
tion is  seen  in the second stage of the disease, when under  the united
effects of inflammation and ulceration of the cartilage of the joint, the ten-
dency of the flexor muscles to contract, induces such a degree of deform-
ity in the lumbar vertebra?, pelvis,  and hip-joint, as Avhen once alloAved to
take place, can never afterward be Avholly remedied.
   The  course  Avhich abscess takes Avhen  suppuration  takes place in the
 joint  seems to be  in'  some  degree modified  by  the straight position.
When the limb is allowed to bend  upon the  pelvis, matter is usually
formed at the back part of the joint under the  glutasi muscles, or at the
side of the joint on the anterior margin of the glutseus medius.  But Avhen
the  straight  position is observed, the suppurative action is inclined to the
fore part of  the joint, and the collection of fluid is formed on the outer
edge of the iliacus muscle, by the side of the tensor vaginas femoris.   This
course of the matter may be accidental; but in tAvo cases now in the hos-
pital, suppuration  has taken this course, one having burst and discharged
itself; and in the  other  case  the abscess  is making its way  tOAvard the
surface in the same direction.
   But there  is an advantage gained in the advanced stage of the disease
too  important to be passed over; namely, the pre\rention of dislocation of
the  head of the bone on the  dorsum ilii—an  occurrence, though by no
means frequent, yet found sometimes to take place, and greatly adding to
the  deformity and  shortening of the limb.   It can only occur in the
flexed position of  the limb, which thrusts the head of the bone backward
against the capsular ligament and  posterior part of the acetabulum ;  and
these structures, together Avith the head of the bone, being partly de-
stroyed by the ulcerative process, the femur  gradually escapes from the
cotyloid  cavity, and becomes lodged upon the dorsum of the ilium.
  The state  of anchylosis in Avhich this disease usually leaves  the joint
requires a concluding observation in reply to any objection that might be
raised to  the utility of a limb anchylosed in a straight line with the body.
The only inconvenience arising from  it  occurs in the sitting position,  in
which the patieut being unable to flex the limb sufficiently to sit on a chair 
76                             JOINTS.
in the usual manner, is  compelled to drop the affected limb in a nearly
perpendicular posture, and to sit with the pelvis resting on the side of the
chair.  This is the only evil attending the straight position, and is more
than counterbalanced by the uniform  length of the  two limbs, and the
absence of almost all lameness in the act of progression.   Care, however,
should be taken to prevent the patient bearing too early upon the unsound
 imb during convalescence, Avhen the straight position has been  observed
in the treatment of the case; for a sense of Aveakness, as in the first stage
of the disease, induces him to raise the pelvis on that side in order to pre-
vent much Aveight being  throAvn upon the weak limb.  The effect of this
elevation of the ilium is  to curve the  lumbar vertebrae in a lateral direc-
tion ;  and this distortion becomes permanent.           Part xii., p. 241.

  Formation of an  Artificial  Joint.—This method, for which Ave are
indebted  to the ingenuity of Dr.  John Rhea Barton, has  been applied
as yet but to the anchylosis of a single articulation—that of the hip joint.
It has, however, been suggested by this surgeon, that it might likewise be
found applicable to similar affections of the lower jaw, knee, elbow, lin-
gers, and toes, when the  muscles of these  respective articulations remain
uninjured.  The method  consists in the uncovering of the bone at or near
the diseased point, dividing it across with the saw, and subsequently mov-
ing the lower portion from time to time upon the uppei*, to prevent a  solid
reunion of the  divided parts.   By this mode of proceeding, there is the
same disposition on the parts for the formation of a false joint, as Ave often
find producing that result in fractures Avhere the  bones are not kept  suffi-
ciently at rest.   Under such circumstances, the two opposing  surfaces of
bone may be expected to unite  by flexible ligamentous matter, or become
smooth and polished by  the friction ; the lower fragment, in the latter
case, rounding  itself into the form of a head; and the  other hollowing
itself more or less into the shape of a cup, in Avhich the former plays; the
periosteum  and  surrounding  cellular  tissue  becoming  condensed and
thickened, so as  to  perforin the  office of a  fibrous capsule,  and  the
muscles  modified to a certain extent, to accommodate themselves to the
neAV articulation.                                      Part xii., p. 243.
  Inflammation of the Hip Joint.—[The test proposed by Dr. O'Ferrall,
as a means of diagnosing between hip-joint  disease and other affections
 resembling it, Ave made use of, and it was found  that when adduction and
abduction of the affected limb Avas made, the entire pelvis moved, forming
an angular lever, whose fulcrum was the acetabulum of the  opposite side.
On disease in this locality, Dr. O'Ferrall remarks:]
  When a hip joint case  is brought under our notice, it is of great practi-
cal importance  to determine its  probable  duration, before  the  period at
Avhich Ave are consulted;  for the  success of the  mercurial  treatment will
depend much on this question.  In T.'s case, the nates of the affected side
drooped, as in cases of some standing; but when he Avas laid on his face
 and the muscles of both  nates were equally at rest, there Avas  no remark-
 able loss of bulk in the  muscles themselves.  The measurement of the
 thigh of the affected  side, showed  also a circumference equal to that of
 the sound one.   There could be no doubt, then,  that the case  was compa-
 ratively recent, for the characteristic Avasting Avhich belongs to disuse  had
 not yet been established.  It might be thought that the history of the' case
 would be sufficient to determine this point. Nothing could be more fallacious. 
JOINTS.                              77
  [In  another case, a young  gentleman, whilst hunting, in crossing  a
hedge, his left foot Avas caught in a bramble, and forcibly  everted; he ex-
perienced great pain in the hip, groin, and knee, and there was percepti-
ble shortening of the limb  of one inch.J
  The diagnosis arrived at Avas—recent sprain of the hip joint, previously
in the  state of morbus coxae.  This diagnosis, most startling and unpalata-
ble to himself and friends, Avas grounded, 1st, on  the  constitution  of an
angular level by the pelvis and thigh bone, Avhen  the  latter was moved;
2ndly, on the  obliquity of the pelvis, ivhich Avas certainly not  of sudden
occurrence; and 3dly, the fast of a remarkable Avasting of the muscles of
the entire limb.
  In the one,  the absence  of wasting, marked  the case as one of recent
occurrence, and promising a recovery from antiphlogistic  treatment.  In
the other the  presence of Avasting, Avith obliquity of the pelvis enabled him
to distinguish an actual case of morbus coxae, when presented to him as an
instance of recent accident only.  The  value of the mercurial  treatment
introduced  by Dr. O'Beirne, is  lessened  by employing it  in  unsuitable
cases.   The diagnosis of  stages, in  joint diseases, is, therefore, of  the
utmost importance in practice.                         Part xiii., p. 194.

   Hip Disease.—[After alluding to the severe  measures formerly adopted
in the treatment of hip disease, Mr. Syme says:]
   The great object now held in vieAV is to prevent motion of the joint, and
this is effected by means of mechanical support, in addition to the horizon-
tal posture.  The splint employed should not be limited to the neighbor-
hood of the hip, but be made to extend over the whole length of the limb
and a portion of the trunk; or, in more precise terms, from the sole of the
foot to the false  ribs, since it is only by preventing motion of  the  knee,
and ankle also, that the hip joint can be maintained in a state of perfect
rest.   Together with this local treatment, due attention is of course requi-
site in regard to the diet and state of the digestive organs.   Cod-liver oil,
which so remarkably corrects the condition of system that predisposes to
derangement  of the scrofulous kind, should, at  the same time, be freely
administered.
  Under  this simple and  gentle mode  of treatment, steadily pursued,  a
large proportion of cases terminate favorably, Avithout any alteration of the
limb  in  regard to form, mobility, or strength.  On some comparatively
rare occasions, the pain  continues  Avithout abatement, or  increases in
severity, and then counter-irritation becomes requisite.   For this purpose
the actual cautery affords by far the most efficient means, and if  employed
during the influence of chloroform, is divested  of the only objection that
can be alleged against its  use.   The sore established should not exceed
three  inches in length and one in  breadth.
  In the  event of suppuration  taking place, the  abscess should not be
opened until it has nearly approached the surface, when  an aperture of
adequate size,  and so situated as to afford a free drain from the discharge-
becomes proper.  Water-dressing is preferable to ointments and the long
splint; or if the limb has been allowed to  get  into  a position which pre-
vents the employment of this, a piece of leather, fashioned to the shape of
the hip and thigh, should be still carefully applied, to prevent the irritation
attending movement of the joint, great attention being at the same time
paid to the maintenance of the patient's general health and strength.  The 
78
JOINTS.
result depends chiefly upon the state of the bones composing the joint. If
they are carious, he must die; if they are not, he may recover.  The risk
of caries being induced, is proportioned inversely to the age of the patient;
so that the prognosis becomes  less and less  favorable from childhood to
maturity.
  Some operations have  been lately performed in London, Avith the view
of remedying caries of the hip joint, by cutting out the head of  the thigh
bone; but this  proceeding  must have  originated and  been conducted in
forgetfulness of the well-established pathological fact, that Avhen  caries at-
tacks the surface of a joint, it is never limited to one of  the  bones which
compose the articulation.  If the articulating surface of the head of the
thigh bone be carious, it  follows, as  a  matter of absolute  certainty,  that
the acetabulum must be  in  a similar condition.  But  as the acetabulum
does not admit  of removal in the living body, Avith any prospect of safety
or advantage, no benefit can be derived from taking away a  part of the
articulation, and, therefore, excision of the  head of the  thigh bone for
caries of the joint should be regarded as no  less erroneous in theory than
objectionable in practice.
  In an old  volume of  " The Lancet," it is stated that Mr. Syme  cut out
the head of the humerus for disease of  the shoulder joint, leaving the gle-
noid cavity to  " shift for itself"—the  fact really being  that the  patient
labored under necrosis of the upper end of the bone, so that the head was
expanded  into  a thin  shell  containing an exfoliation, Avhich Avas removed
Avith the effect  of preventing amputation at the shoulder joint, previously
deemed requisite, and enabling the subject  of  the case, then  a  boy, to
grow up into a strong healthy-man.  This statement, like others, having
no foundation except in  the depraved imagination  of their authors, Avas
treated Avith the silence that it deserved, and Avould not be  noticed  now
unless there seemed a risk of its being stumbled on by  some one in search
of authorities for bad practice.   It is true that Mr. Syme did once cut out
the head of the humerus  for caries, but in that case the disease, instead of
affecting the surface of the bone, Avhich was perfectly sound, had hollowed
out the interior substance  into a cavity, so that the circumstance of the
patient recovering the use of her  arm, and enjoying good health for ten
years after the  operation, in no wise invalidates the rule,  that  caries of an
articulating surface  is never limited to one  of the  bones which compose
the joint.
  In the London operations the hip joints must have been either carious
or not; and the proceeding, therefore, either  useless  or unnecessary. That
it is possible for patients laboring under disease of the hip joint to  recover,
after excision of the head of the thigh bone, could hardly be doubted by
any Avho has remarked the  shrunk and distorted limbs Avhich result  from
morbus coxarius, terminating in anchylosis, or examined the  preparations
illustrative of this condition  obtained after death. The scars of old sinuses,
and the histories of persons who have regained good health after suffering
from hip  disease in their youth, frequently afford evidence that the  joint
must have suppurated; that the articular structure must have been seriously
deranged ; that the respective surfaces of the bones must have  been more
or less extensively denuded  of their cartilaginous covering; and that there
must have been great  displacement before consolidation Avas accomplished
by anchylosis.  It is very probable that in some of these persons the  head
of  the 4high bone might have been cut out during the suppurative sta^e 
JOINTS.
79
without preventing recoArery, especially if the most  careful attention had
been subsequently bestowred upon the maintenance of the patient's strength.
But in Avhat respect they wTould have derived benefit from the operation it
is not so easy to see.                                  Part x\x.,p. 119.
  Scrofulous Disease of the Hip Joint.—An opening  having been made
freely Avith an abscess lancet, the limb may be wrrapped up in a  flannel,
wrung out of hot Avater, and this may be continued  until the first  flow of
matter has ceased, a poultice or water-dressing being applied afterward.
The opening should be free, so that the abscess should heal from the bot-
tom ;  and also that no  pressure need  be used to cause it to escape.  All
rough manipulation is to be carefully avoided.  The  treatment of a sinus
Avhich is left  after the  opening of an abscess  may be comprised in a few
wrords. If the orifice be disposed to heal prematurely, it may be prevented
by the occasional application of the caustic potash, care being taken that
the caustic does not enter the sinus itself; otherwise, some simple ointment
or water-dressing is all that is  required.  The old practice  of probing a
sinus  yields us no accurate information, nor is it useful; and the  same re-
mark applies, but Avith greater force, to the use of stimulating injections.
  The determination  of the  question  of amputation in instances of this
species of articular disease, Sir Benjamin Brodie makes to depend upon the
point, Avhether or not there be  indications  of  other  tubercular disease in
any of the internal organs.  It too frequently happens, that when  one dis-
eased joint is  removed by amputation, another becomes the seat of the
same  malady, or tubercular deposits in the lungs,  the bronchial glands, or
in the mesentery, finally destroy the patient.  When  there is any reason to
apprehend such results, amputation, of course,  is Avorse than useless.
                                                     Part xxii., p. 189.
  Hip Joint  Disease  treated by Cod-liver Oil.—SeAreral cases of  this dis-
ease have been successfully treated at St. Thomas's Hospital by the use of
cod-liver oil.   It changes the abnormal molecular condition of' the blood,
bo Avell known to exist in these cases,  and so often connected Avith  scrofula
and other constitutional disorders.                     Part xxii., p. 195.
  Hi}) Joint—Hysterical Affections  of.—[Mr. Coulson was consulted in
the case of a young lady, nineteen years of age, highly nervous  and ex-
citable in  temperament, Avith an  affection of the  hip joint.   Leeches had
been  applied, the recumbent position enforced, and counter-irritation in
every available form employed—but all of no avail.  The pain Avas  diffused
and complained of as insupportable.  The joint under examination seemed
natural, and her general health had not suffered in proportion to the dura-
tion of the disease; indeed, there  seemed as much pain excited if the in-
teguments alone were examined.  No persuasion  could prevail upon her
to make use of the limb.  Steel and quinine were prescribed,  but  Avith no
success. At length, by the death of her father, the means of living became
much reduced, and the different members of  the family were obliged to
exert themselves to meet the  calamity.]
  This young lady, upon being made acquainted with the particulars—for
misfortune it was none to her—one day suddenly rose from her couch and
walked. She exerted herself much, both mentally and bodily, for the good
of those around her, seemed to forget her long illness,  and has ever since
remained well.
  It has been calculated, that at least four fifths of the females among the 
80
JOINTS.
higher classes of society supposed to be suffering from diseases of joints,
are, in truth, affected with hysteria, and Avith nothing else.
  In hysterical affections of the hip joint, the patient from the first com-
plains of pain in the part, and  not in  the knee, as is frequently the  case
wdien organic changes are commencing in the joint itself.   The  pain which
the patient describes as most severe is not  limited to one spot, but extends
over the buttock to the lumbar region, and down the thigh.   It is this
general diffusion of pain Avhich  constitutes one of our most  useful distinc-
tions between this affection and disease of the hip joint.  From  the com-
mencement, the patient complains of such  aggravation of pain by pressure
and motion, that she confines herself to one position of the limb ; and yet
upon occasions, Avhen the mind  is otherwise occupied, or during sleep, she
will move it without complaint.  The sensibility of the limb to the touch
is frequently so great that the slightest pressure on any part of the hip or
thigh will cause the patient  to scream; she shrinks involuntarily from the
mere approach of the hand; but, nevertheless, upon a careful examination,
these morbid conditions will be found to exist more in the skin  than in the
deep-seated parts. As Sir Benjamin Brodie, who first directed attention to
these important affections, observes : " If  you pinch the  skin,  lifting it at
the same time  off the subjacent parts, the patient complains more than
when you forcibly squeeze the head of the  thigh bone into the socket of the
acetabulum."  The more the patient's attention is directed to the part, the
more the pain is increased;  but if her attention be directed  otherwise, she
will hardly complain, and  the  pain does  not  interfere Avith her  rest.   In
disease involving the structures of the joint, there is nothing of AAdich the
patient complains so much  as  the  inability to sleep at  night—a sudden
start, or pain, or cramp, banishes  sleep, and the patient  dreads  again  to
close her eyes.   In hysterical affections, on the contrary, the sleep is calm
and refreshing; and this, perhaps, is a great reason why the general health
so slightly suffers, even in long-protracted cases.
   Treatment.—The vegetable tonics seem to be more  efficacious than the
metallic.  But when the appetite  is tolerably good, the tongue clean, the
bowels regular, then the metallic tonics may be employed Avith good effect.
In most neuralgic  affections the preparations of iron are  valuable, none
more so than the carbonate. To relieve pain, no remedy is preferable  to
valerian.  Dr. Copland says the remedy he has found most useful is the
spirit of turpentine, prescribed  in various modes, internally and externally,
and administered in enemata; the preparations of iodine  alone, or with
narcotics and camphor.   By being compelled to move the  limb and enter
into society, patients have been known to  recover, after the complaint had
resisted every other kind of treatment.               Part xxiv., p. 167.

   Treatment of Hip Joint Disease.—-The mode of treatment pursued  by
Professor Carnochan in morbus coxarius has  been very successful.  He
relies principally on constitutional treatment, abandons the use  and motion
of the  affected  side, and allows the abscess to open spontaneously.  The
number of cases now in progress of convalescence, the general  improve-
ment in the physical appearance of the patients,  and the absence of the
distressing hectic, indicate the  soundness  of the principle upon which  he
proceeds.  . .   .  . The number of victims of Pott's disease, of all ages,
is by no means the least  interesting feature  of practice to  be  seen here.
With these  also the principal attention is given to constitutional treatment 
JOINTS.
81
rest and counter-irritation of a mild character being the adjuvant means
employed.                                          Part xxix., p. 168.

   Sinuses of the Hip depending upon Exfoliations from  the Pelvis.—
Mr. Syme remarks as follows :
   It is necessary that you should recollect the distinction between necrosis
and caries.  In  the former  disease a portion of bone dies, and separates
from the living substance, so that no obstacle to recoA^ery exists after the
exfoliation or detached piece escapes from the position Avhere it is situated;
but in the latter the bone retains its vitality, and obstinately remains in  a
diseased condition, AAdthout any natural limit of duration,  except the life of
the patient or conversion of the caries into necrosis. It must further be
recollected that the dense osseous substance which composes the shafts of
bones is chiefly liable to necrosis, and that the spongy or cancellated tex-
ture is almost exclusiA'ely the seat of caries.  Now, sinuses about the pelvis
are unhappily met Avith very frequently as the attendants or consequences
of disease in the hip joint,  vertebrae, or sacrum, where the disease, being
of an incurable kind, and the part concerned not admitting of removal, any
sort of treatment can produce  no better effect than  a  Arery imperfect
degree  of palliation, and it has hence been usual to regard such cases as of
a very hopeless character.   But nearly thirty years ago there happened to
fall under my notice a case Avhich showed that such a  judgment should
not be passed as  a matter of course, or without more caution and discrimi-
nation than had been supposed requisite.  The  patient Avas a young man,
aged 28, Avho for the preceding seven  years  had  suffered from sinuses
about the hip and upper part of the thigh, Avhich being  regarded as  pro-
ceeding from fistula in ano,  had been treated by the late Mr. George Bell
and other surgeons, Avithout obtaining the relief desired.  He had  then
applied to quacks Avith no better success, and finally abandoning all hope
of recovery, had allowed the disease to  pursue its course.   It Avas a con-
siderable time after this resolution that my assistance Avas asked.   I found
him extremely emaciated, and so Aveak that he could hardly leave his  bed,
with a large abscess of the  thigh, and several  sinuses about  the hip, dis-
charging matter  profusely.  Having opened the abscess, I examined the
sinuses, and found that  one, which opened in  the fold between the but-
tock  and thigh,  led  to the tuberosity  of the ischium, in  Avhich there
was a cavity containing an  exfoliation of bone.  I therefore  dilated  this
sinus  by  incision, introduced  my finger, and  having found  an  opening
between the origins of the extensor muscles, enlarged it by the bistoury,
so as to obtain access  to the  interior, Avhence I removed a small bit of
dead  bone.  The patient then quickly  recovered, and  e\rer afterward
enjoyed good  health.
   I am inclined  to think  that  violent  muscular  contraction may have
been the exciting cause of inflammation and death of the bone.  The  sub-
ject is curious, and worthy of investigation, but of little importance when
compared Avith the practical benefit which  may result from a knowledge
of the fact that sinuses of the pelvis sometimes depend upon loose  exfolia-
tions,  which Avill  not  find their  way out unassisted, but  which may be
readily removed artificially, with the effect of a speedy and  permanent
recovery.                                           Part xxx\.,p.  117
  Hysterical Affection of the Hip Joint.—The pain is more severe  than
in chronic inflammation.  Pressure produces greater pain when slight  than
    vol. h.—6 
82
JOINTS.
when firm, and is more general than wdien there is inflammation.   It ia
most relieved by a belladonna plaster round the joint, and general tonics,
such as quinine, iron combined with hyoscyamus, or valerian and camphor.
                                                   Part xxx\\.,p. 121.
  Hip Joint—Excision of—Great advantage will be obtained by the use
of Mr. Butcher's saw: the blade is pressed behind the bone, and then being
turned in  a horizontal direction by a screw, the head and trochanters are
readily removed.                                     Part xxxv., p. 70.
  Excision of the Hip Joint.—After the performance of this operation, a
swing should be used, sufficiently strong to suspend the entire body.  The
wound should be left uncovered, except by the dressings, in  order to
secure a depending escape  for the discharge. By this means there is no
necessity to disturb the patient to alloAv of the evacuation of the bowels,
and the accumulation of the discharge from the wound is prevented.
                                                   Part xxx\\.,p. 137.

                           KNEE  JOINT.
   White  Swelling of the Joints.—[Lisfranc distinguishes Avhite  swellings
into those in  which a sub-inflammation  exists, and those in which no trace
of this is present.  He thinks that:]
  It is  not  always an easy matter to distinguish the engorgement of the
soft  parts from an enlarged condition of the  bone itself, but  that in time
the induration often becomes  movable upon the bony parts, these  last
remaining nearly or quite  healthy;  in this case the disease spreads from
without inward.
  In cases of white swelling, it is very  important  to be assured of the con-
dition of the thoracic and  abdominal  viscera;  for, Avhere diseases of any
of these exist, they have sometimes been found to make progress in pro-
portion as the affection of the joint becomes amended—even requiring that
irritation  should be reproduced in the latter.  When the visceral affection
is incurable, but stationary, we do not treat the white-swelling actively,
unless it becomes dangerous.
  Unfortunately the  thoracic and abdominal affections are often latent, and
resist our means  of investigation—so that death may speedily follow the
cure of the disease of the joint, in consequence of some  unsuspected organic
affection.
  Abscesses, formed around the white-swelling,  should  be opened as
promptly as  possible, while,  Avhen formed within the substance of the
engorgement, exit must be given to the pus as late as possible—providing
the inflammation  be not acute, and there be  no danger of the pus pene-
trating the joint.  It is very easy to  be deceived  as to the  existence of
pus—while the sojourn of this fluid in contact with the indurations proves
to be one  of their most powerful solvents.  The most experienced surgeons
often have great difficulty in deciding whether a collection of fluid  or pus
be situated within, or external to the  joint.  The alternative of amputation
decides the  surgeon in determining  to open  the  collection, and, if symp-
toms follow which denote that the cavity of the joint  is exposed also he
proceeds at once to amputate.
  M. Lisfranc considers that, in general,  much  too  little importance is
attached  to regimen,  in chronic  surgical disease.   The  ordinary  and
sometimes an excessive diet is permitted, and the great aid in dissipating 
JOINTS.
33
engorgements, derived frcm alloAving patients, in some degree, to what he
calls " live upon their  oavu substance"  (i. e. a starvation regimen), is lost
sight of.  He has repeatedly knoAvn these tumors, Avhich have resisted
every other means, to  become dispersed after  diminishing the  diet  one-
third or  a half.   Exceptions will  occur  to  this, wdien the patient is
excessively feeble or scrofulous, and when the digestive organs suffer from
the change.
  If the patient  be strong, and any acute inflammation exist about the
joint, one or more bleedings from the arm, and  afterward leeches, Avill be
required.   But the  periods of employing  these must not succeed  each
other too rapidly—for chronic diseases, by their duration, frequently induce
great debility.
  Local emollient and anodyne baths, continued for two hours at a time,
are useful.  Although, by appropriate  means,  the inflammatory element
may disappear in a month, it may persist in other  cases for three, six, or
nine months, and, to such cases, Avhich may also have resisted mercury and
barytes, we must oppose time, and the continued application of small relays
of leeches.  Eventually the  moxa may be employed.  It  is rare, indeed,
to find  one  of  these  swellings dissipated by  antiphlogistics alone.  A
slight diminution of volume  only results from the subsidence of inflam-
matory action.   After  the employment of antiphlogistics, an interval  must
be allowed  prior to commencing the use of stimulants—but the  presence
of occasional pain, or pain which has resisted depletion, must not deter us.
Leeches may be applied for other than  the ordinary reasons.  From three
to six,  or  eight, placed around the base of the tumefaction, will cause a
degree  of heat  aud excitement in the swelling, when torpid, and favor
absorption.
   [The leeches  may be  repeated in this Avay  several times, taking  care
that the bites do not bleed for more than  a  quarter of an hour, for fear
of  the  debilitating  effects.   Cupping  may  be substituted,  and acts as
an antiphlogistic or stimulant, according to the  quantity of blood drawn.]
   Compression is useful by preventing the too  free access of blood to the
tumor,  and causing a slight degree of excitement at its surface.   It is  most
advantageously applied so that it may extend an inch beyond the circum-
ference of the  tumor.  If employed in improper cases, it may occasion
inflammation or gangrene,  and, in  all, requires regulation in its various
degrees, according to the stages and peculiarities of each.  Thus  the mere
application of diachylon, the use of bandages and  agaric, and the appli-
cation of leaden plates to the part, excite  different  degrees  of  compres-
sion.  The compression may be  readjusted every tAventy-tfbur hours, and
its employment does not exciude the use of iodine ointments, and the va-
rious internal remedies.  Even after the tumor  has disappeared, especially
Avhen of a scirrhus consistence, compression must be continued for several
Aveeks longer.
  It is to  be   rejected—1.  When  considerable inflammation  exists.
2. When the tumor, though small, is  very hard, unequal, knotted, ad-
herent   to  the  skin, and especially if this latter be red  or  discolored.
When,  however,  the scirrhous mass has been  removed, we may employ
pressure.   3. When the tumor is in some parts indurated, and  in others
puhaceous.
  The author believes Dr. O'Beirne's conclusions concerning the  utility of
salivation in these cases, are too general, and too premature. 
84
JOINTS.
  Mercurial inunction,  earned to salivation, is equally useful as the calo-
mel.  When no inflammation  of the part exists, the mercurial ointment,
applied by topical friction, is an excellent solvent, but, when inflammation
does exist, it must be applied in thick layers, to remain in contact with the
part, as recommended by M. Sevres, when it acts as an antiphlogistic, and
not, as in the case of friction, as a stimulant to  absorption.
  Lisfranc recommends applying the ioduret of lead, if properly watched
that no injurious excitement be  produced ; and he finds that in scrofulous
subjects, the internal use of iodine, and especially the iodide of potassium,
is very useful.  The iodide of  lead is certainly a valuable agent  in  many
cases,  and especially when the  cervical  or  axillary,  and perhaps also
when the mesenteric glands are enlarged; but it  ought to be  given in-
ternally as well  as applied externally.   The usual dose internally is from
four to ten grains.
  Blistering must not be employed Avhen even sub-inflammation is present,
being, as it is, essentially stimulant.
  When the blister occasions an injurious degree of inflammation, we must
meet this Avith leeches, etc.  We must judge of the ultimate effects they
are likely to produce by the degree of irritation that results.
  The application of the moxa follows the same rules as the use of blister-
ing.  When a repetition is likely to be required, the moxa must be of only
a small size, someAvhat less than  a shilling.
  The seton is the most exciting of all exutories, and must  not be em-
ployed  until the inflammatory  action has subsided.   It  should not be
passed through the substance of the engorgement, but on one side of it.
It is only to be employed when all other excitants have failed.
  There are cases of white swelling, which, after  proceeding well  on to-
ward a cure, remain, at length, quite stationary, treat them how we will.
In these we must abandon all  active measures, contenting ourselves Avith
hygienic precautions, and sometimes in a few weeks Ave may find the SAvell-
ing much dissipated, and, even if still persistent, the various therapeutical
agents will usually be resumed Avith much greater advantage after such an
interval.
  M. Lisfranc states that, under his hands, the muriate of barytes, given
in large doses, has  been found  very successful,  the patient  being also
during its use  confined  to a vegetable diet and Avater drink, upon  Avhich,
however, he often  gains  both flesh and strength.   He begins  Avith six
grains, and reaches, in some cases, as high as forty-eight grains per diem,
while, at Marseilles,  and in Italy, tAVO  drachms have  been given  in  the
same period.
  When the white swelling dates from a rheumatic origin, it has been re-
commended to place an irritant, such  as a blister, upon the  joint  itself.
This practice is attended with  the danger of fixing the locality of  the in-
flammatory action; and M. Lisfranc prefers, in the case of the knee joint,
e. g., placing the blister at the upper and outer part of the thicrh ;  and in
following this practice he  has  met with  great  success.  In some of these
cases the pain, Avhich is so distressing,  has disappeared under salivation as
if by enchantment.
  After a cure, the joint  is not at  once enabled to resume its functions
The patient has remained at rest during a long space of  time, and pain
attends his first  movements.                                        r
  Relapses were formerly very frequent, but M. Lisfranc has found them 
JOINTS.
85
to be rare, since he has given his patients a  padded  knee-cap  to wear.
This limits the movements of the joint, and  supports  it during their per-
formance, prevents any stagnation of the fluids, and aids the resorption of
any  effusion that  may occur.  Atrophy of the joint  sometimes follows,
which may be persistent, or may disappear, as the general health improves.
                                                     Part vii.,^?.  158.

   Various Diseases of the Knee Joint—Inflammation of Synovial Mem-
brane.—When the disease has been of long duration, says Sir B. Brodie, a
change takes place in tine condition of the synovial membrane, quite dif-
ferent from what is ever observed in the serous membranes.  It  becomes
thickened, of a  soft pulpy consistence; the  inner  surface is  no longer
smooth and uniform, but processes of soft vascular substance project from
it, in the manner  of fringes, into the  cavity of the joint.  In the  com-
mencement of this disease the morbid changes are, of course, confined  to
the synovial membrane ; in a more advanced stage these changes extend
to the other textures.  That  portion of the membrane which  covers the
cartilages, though it resists the disease in the first  instance,  becomes
affected  afterward.  The cartilages themselves adhere less closely to the
bone than under  ordinary circumstances, and by and by they begin  to
ulcerate; generally on the patella in the first instance, on the femur and
tibia afterward.
   The fluid found  in the cavity of the joint, Avhen the  synovial membrane
is inflamed, is serous.  In  cases of a slight  degree of inflammation, it is
slightly turbid ;  in severer cases it is very turbid, with flakes of coagulated
lymph floating in it.  Under certain circumstances the synovial membrane
Avill secrete,  not  mere  serum, but actual pus.  In like manner, serous
membranes occasionally secrete pus, though under ordinary circumstances
they merely secrete serum.   The cavity of the knee joint is then converted
into one large abscess; the abscess being  bounded  in  some parts by in-
flamed synovial membrane, and in others by the bones of the joint.  I say
by the bones of the joint; for the cartilages Avhenever they come in  con-
tact with the purulent secretion, become absorbed.  Now let us suppose
that there has been inflammation of  the synovial membrane, and that it
has subsided.  In Avhat condition is the joint afterward?  Sometimes the
membrane is left  thickened, of a gristly texture,  and that may happen
even Avhere the cartilages and bones  have altogether escaped the invasion
of the disease.   In other cases, the cartilages being absorbed, the cavity
of the joint is  completely filled up by the thickened synovial membrane,
and  the coagulated lymph effused from its surface.  The parts all adhere
the one to the other, and anchylosis by soft substance, in the first instance,
and  by bony substance  ultimately, is the consequence.  However, com-
plete anchylosis does not occur except the cartilages have been  completely
absorbed.  Where the  cartilages have been  only  partially absorbed, a
healing process  is established.  A kind of membrane is formed upon the
surface of the bone in the place of the  cartilage, and the joint retains its
complete mobility.
   With regard to  treatment in all cases of inflammation, and, I may  add,
of other  diseases of a joint, the first and  most important thing is to keep
the joint in a state of quietude.
   The best contrivance for keeping the joint quiet is splints, made of thick
and  stiff leather,  macerated  in warm water, and allowed to  dry on the 
86
JOINTS.
part.  They should be pretty broad splints, one being applied to each side
of the joint, nicely adjusted to it, and kept on by a bandage. These splints,
Avhen dry, become as hard as a  board, but they are easy to be Avorn, be-
cause they exactly fit.   When the cure  is nearly completed, the patient
should Avear an  elastic bandage, so as to allow of a little motion, Avithin
certain limits,  and the  heel of his shoe should be raised a little, to keep the
knee slightly bent.
  In cases of acute inflammation, general antiphlogistic measures may be
required as Avell as the local abstraction of blood.
  After giving a brisk purgative, then give twelve minims of \dn. colchici
in a saline draught three times a day ; in tAvo or  three  days stop  its  exhi-
bition', and after an interval of a day or tAvo give it again ; it is most useful
when there is a gouty diathesis, wdth lithates in the urine; an occasional
purgative is necessary during the administration of the colchicum, and also
small doses of blue pill to keep  up the secretion of bile Avhich colchicum
diminishes.   Give mercury  so as to affect the system;  this may  be done
not only in the gouty  diathesis,  but also where there is rheumatic inflam-
mation, and combine it Avith opium, as in iritis.
  In chronic inflammation the same measures as in the acute, only not quite
so acti\Te : leeches ; blisters ; apply them in succession,  or keep  one open
with savine cerate ;  give colchicum as an alterative, tAvo grains of the ex-
tract Avith as  much blue pill, every night, and an  aperient every third or
fourth morning : or give the acetous extract, Avith calomel and comp. ext.
of coloc. every second or third night.   Give, also,  iodide of potassium in
small doses,  combined Avith alkaline  remedies.  In slight cases,  use  lini
ments to the joints, lin. vol. camph., and sp. terebinth.; or olei olivse §iss.;
acid, sulph., 3j-,  and sp. terebinth. §ss.; or paint the.knee with a solution of
iodine.
  I said that mercury was useful in another and more  advanced  stage of
the disease, when the  altered  character of the pain, attended with starting
of the limb  at  night, indicates that ulceration  is going  on in the carti-
lages.   Here  the only remedy  is mercury, and  the effect of it is remark-
able.   Make the  gums sore,  and the  patient Avho ivas  suffering  tortures,
ivill,  in  a few days, be quite relieved.  If it be administered at a suffi-
ciently early period, it will save the limb, but will not  prevent anchylosis.
Mercury should be given here in the same manner as  in cases of iritis, or
chronic inflammation of the testicle.  Calomel and opium may be  adminis-
tered two or three times  a day till the gums are sore, mere alterative doses
being insufficient.
  Treatment of Abscess of the Knee Joint.—[In these  cases  the  suppura-
tion often involves the Avhole joint, which is one  large abscess.  The treat-
ment is comparatively simple.]
  Make an opening as soon  as you can, and let out the  matter.  But what
kind of opening ?  Not a small  or valvular one.
  All large abscesses,  and those of joints especially, should  be opened by
a very free incision, so that the pus  may  flow out Avithout squeezing, or
any kind of rough manipulation.
  There should  not be the pressure even of a finger on the abscess, Avith  a
view to force  out its contents.   Make a free opening, let the matter  Aoav
of its OAvn accord, at the same time keeping the joint in a state of absolute
and complete  repose by means of leathern splints, or by supporting it Avith
pilloAVS and cusions, and it will scarely ever happen that  any mischief fol- 
JOINTS.                              87
 lows.  If the first opening be made in a depending part, it may be all that
 is Avanted.   It may be, however, that one or two openings Avilfbe required
 in  other situations afterward.  In these cases  the disease has its origin in
 the soft parts.  The bones are in the first instance in  a healthv state, and
 the progress of the  disease is so rapid, that, although deprived of their car-
 tilages, there is not time for the bones to become materially diseased after-
 ward.
   The articular cartilages will have become absorbed, and recovery by
 anchylosis is the result:  the joint during recovery must be supported Avith
 leathern splints: or if the leg be bent on the  thigh, use the screw instru-
 ment, with splints at the posterior part of the leg and  thigh.  In using the
 screw, hoAvever, you should observe that it is better to leave the leg a very
 little bent on the thigh rather than quite straight.  The  former position
 of the leg is more convenient for Avalking than the  latter,  especially if the
 patient has the heel of his foot or shoe a little raised.
    Gouty Inflammation  of the Synovial Membrane of the Knee-Joint.—
 This disease is met Avith  in those Avho lead an indolent  life, and indulge too
 freely in wine and animal food; some  of the smaller joints  are generally
 affected first, and it has  this  peculiarity that there is seldom much effusion
' within the joint; the synovial membrane becomes thickened, and then ab-
 sorbed, and the cartilages are not unfrequently remoA'ed by a continuation
 of the disease of their structure.
    In the course of time, that is, after the lapse of some years,  the cartila-
 ges, and  even the bones, become  absorbed; the  fingers being actually
 shortened and twisted in a variety of Avays.  Not unfrequently, in cases of
 long standing, the bones of the knee, examined in dissection, present a sin-
 gular appearance, as if they had actually been Avorn away  by friction.
    In some instances there is  a deposit of lithate of soda, or chalk-stone, in
 the joint itself, and  in  its neighborhood.  This, like  the last,  is a very
 troublesome form of the disease, and  is \rery little under the dominion of
 remedies.
    Give a grain of acet. ext. of colchicum,  a grain of blue  pill, and three
 grains  of ext. of hop, every night, Avith a gentle aperient every third or
 fourth morning; after giving these pills for a fortnight, stop them for tAvo
 months, and then give them  a fortnight again,  and so on:  give also a grain
 and a half or tAA'o grains of iodide of potassium, Avith ten or tAvelve grains
 of bicarbonate of potash tAvice a day, for six  or eight Aveeks at a time. This
 system must be continued, with  occasional  intermissions,  for one or two
 years, or even longer.  This chronic gouty affection is not in itself danger-
 ous, but it shoAvs a  bad constitution, and the person thus  affected is liable
 to other diseases.
    Scrofulous Disease of the Knee Joint.—Never abstract blood, nor make
 use of counter-irritation.  Here,  as in all diseases of joints, a state of per-
 fect repose is necessary; use  the leathern splints. As soon as the digestive
 organs  are brought into  a proper state, give tonics, particularly chalybeate
 tonics.  To children give the vinum ferri of the old Pharmacopoeia, for
 three Aveeks, and then omit it for ten days, and so on for  several years, so
 as to improve the weak constitution.  If fever be produced, decrease the
 dose, or omit it altogether for a Avhile; or give the tinct. ferri mur.; or the
 sirup of iodide of iron ; or the latter and the vin. ferri alternately.  When
 you have a patient  Avith  whom no form of iron Avill agree, then  give qui-
 nine, bark, or alkaline solution of sarsaparilla;  the latter  is very useful to 
88                              JOINTS.

delicate children.   Change  of air is highly beneficial, the sei-sidc ;  when
th 3 joint has become stiff, do not use force to straighten  it; it should  be
done gradually by means of a screw apparatus ; if an abscess forms in the
joint, continue the use of the splints, but have them lined with oil-silk. If
the disease have been neglected, or it  has been  found impossible to save
the joint, amputate as soon as possible.  If, by examination with a probe
it is found that there be a piece  of dead bone within the joint, so that it
cannot exfoliate, the sooner the  limb is amputated the better.  Bony an-
chylosis takes years for  its completion, so that if the limb  be  bent  there
will be plenty of time to get it into its proper place.
  Primary Ulceration of the  Cartilages of the Knee. — [This disease
apparently may originate either  in the cartilage  itself, or in the orifice  of
the adjacent bone ; but in what  Sir Benjamin considers primary ulceration,
it invariably  begins in the surface next to the articular cavity.  He says:]
  On examining the joint in an  early stage of the disease, the cartilage is
found to be absorbed at one point, and the surface of the bone exposed and
carious.  Probably there is no  effusion of any kind in the joint, neither
serum nor pus; but  the exposed surface of bone is more vascular than
under ordinary circumstances.  As the disease advances,  the ulceration of
the cartilage  becomes more extensive,  and Avhen it has attained a certain'
point, pus is formed in the joint.  As  in  some cases  there  is suppuration
without ulceration, so in these there is ulceration without suppuration. As
I have observed in a former lecture, the tAvo processes  are  generally com-
bined, but there is no necessary connection between them.  The cartilages
at last become destroyed throughout the knee—on the femur, the patella,
and the tibia.  Sometimes Avhen abscess forms, it is limited  by adhesion to
one part of the joint, and then perhaps suppuration takes place in another
part of it.  In other cases the abscess  is not  so limited ; the whole joint is
distended Avith matter, so  as to form  one large abscess ;  and in this stage
of the disease, the bones in the neighborhood of the joint become inflamed
and dark-colored; the matter lodging  in the cancelli  becomes putrid, pro-
bably a portion of the bone loses its vitality and exfoliates  into the articu-
lar cavity, while the abscess finds its way out in various directions, making
numerous sinuses under the fascia, and among the tendons, before it pre-
sents itself externally.
   While these changes take place in the affected joint, they are indicated
by the following symptoms.   Generally there are rheumatic pains in other
joints in the first instance; by and by the  pains are,  as it were, concen-
trated in the knee.  The pain is very severe, and yet the joint is scarcely
at all swollen, or rather I  should say there  is no swelling in the first in-
 stance.  After a time there is a slight general  enlargement of the joint,
the  consequence  of a deposit of lymph,  or serum, outside of the synovial
membrane.  The swelling assumes the shape of the  articulating ends of
bones, and appears greater than it really is; because the  muscles  of  the
thigh are Avasted above, as those of the leg are beloAV.  The pain is aggra-
vated by motion, and there is a painful starting of the limb at night.  °The
pain is especially aggravated by pressure on the patella, and Avhenever, in
this or any other case of disease of the knee, this symptom exists, you may
suspect that  the cartilages of the joint are beginning to ulcerate.   The dis-
ease may go on not only for Aveeks but for many months, the  patient's health
suffering all the time, fi-om disturbed rest at night and constant pain in  the
 day, and yet Avithout suppuration taking place.  By  and by matter forms, 
JOINTS.
89
and then there is an aggravation of all the symptoms.  The matter, as in
all other cases of abscesses connected with the  knee joint, burrows  in va-
rious directions among the muscles and tendons, making numerous and
circuitous sinuses.
  Keep the joint perfectly at rest, and use setons, issues, blisters, and coun-
ter-irritants.   The  great remedy is mercury ;  two grains of calomel and
one-third of a grain of opium, three times a day, until the gums are
affected.  Where mercury cannot  be borne, give sarsaparilla and iodide
of potassium ; sarsaparilla should also be given after the course of mercury.
Ung.  hydrarg. may be rubbed into the thighs Avhere  it cannot be borne
internally.  A caustic issue inserted on each side the patella will very often
stop the pain and the starting of the  limb  at  night, Avhen  other means
have failed.
  Morbid Alteration of Structure of the Synovial Membrane.—There is
a curious condition  of  the synovial membrane  in Avhich it seems to have
undergone a peculiar morbid  alteration of structure.  It is thickened in
various degrees, sometimes  to  the extent of an inch  and a half, having
assumed a  sort  of pulpy structure  intersected by  Avhite  membranous
bands.  In some instances there is a preternatural vascularity, and vessels
injected Avith blood are seen ramifying in it to  a considerable extent.  In
other cases no increased vascularity is perceptible.   There is little doubt
that in some cases this is the result  of long-continued chronic inflamma-
tion ;  but in others  I am glad to believe that it takes place independently
of the inflammatory action.
  [The disease may progress for some time, even years, Avithout any other
symptoms.]
  As it has advanced to the  layer of the  synovial membrane, Avhich is
reflected over the cartilage, the latter has begun to ulcerate, the ulceration
being marked as on other occasions, by aggravation of pain  and startings
of the limb at night.  At this stage of the disease small abscesses form in
the substance of the diseased synovial membrane.  These gradually make
their Avay to the surface, one coming in one place, and another in another,
discharging a very small quantity of matter.
  When the cartilages are thus ulcerated,  the matter is formed in the
joint,  and perhaps in  the  substance of the  synovial membrane  also, the
patient's health  begins to  be  affected, as in other cases of articular ab-
scesses, and at this period nothing  can be done for him but to amputate the
limb.  Can  any remedial means be employed with success in the early stage
of the disease ?
  Apply pressure by means of several alternate layers of diachylon plaster
and bandage ; and afteiward by leathern splints, and a firm  bandage ; at-
tend also to the general health.
  Sir B. Brodie considers the affection to be of rare occurrence :  he  then
speaks of
  Loose Cartilages in the Knee.— Remove them by operation;  get the
cartilage fixed over the outer or inner condyle, and while it  is retained in
that situation, divide slowly, the skin, cellular membrane,  fascia, ligaments,
and synovial membrane : hold the knife Avith a loose hand, or the cartilage
will be pressed into the joint;  lay  hold of it Avith a tenaculum, but should
it recede Avithin the joint, ne\rer grope for it, but bring the edges of the
wound together, and perform the operation at some other time.   A valvu-
lar operation has been proposed.                       Part xiii.,^. 185. 
90
JOINTS.
   Case of Scrofulous Disease  of the Knee,  treated  by Sulphur and
Electro-Galvanism.—This was  a case of scrofulous enlargement ot the
knee joint, occurring  in a  young  woman, the SAvelling  being ot three
months' duration.  The general treatment consisted in the administration
of small quantities of the purest sulphur, combined with carbonate of iron,
nutritious  diet, and such open-air exercise as the case would admit of.
And the local applications Avere first hot poultices to relieve the pain, next
compression by means of strips of iodine plaster and a bandage, and then
the hot water douche.  When she  had been about  sixteen Aveeks under
treatment, Mr. Bulley began to use electro-galvanism.  He says:]
  After the electro-galvanism had been applied every other day for a fort-
night or three Aveeks, I could observe a very perceptible alteration  in the
shape of the affected joint, the more than natural quantity of synovial fluid
which remained in its cavity up to  the  time she left  the  hospital having
become absorbed;  and I could plainly perceive  that the  rounded appear-
ance occasioned by the more solid deposit in the  ligamentous tissues was
gradually becoming less  and less apparent, until at the  end of about five
Aveeks from her leaving the hospital, it had almost completely disappeared,
and she could  Avalk about  upon the  limb without any particular pain or
stiffness in the joint, Avhich, by admeasurement, did not exceed to any
appreciable extent the size of the other knee; it Avas, in fact, evident that
the morbid deposit which I  could  have no  doubt Avas of the  same solid
character as usually accompanies the  more advanced forms of scrofulous
exudation, had been absorbed and taken aAvay by the processes employed.
                                                    Part xviii., p. 152.
  Joints Diseased—Issues.—The best kind of counter-irritation is that
exerted by the issue made Avith  caustic potash.  In synovial disease  of the
knee the issue  is particularly useful.                   Part xxx., p. 122.
  Removal of Loose  Cartilages from Joints.—In his description of the
subcutaneous or valvular mode  of removing loose cartilages, Professor
Miller remarks:]
  " In the first place, the patient is  to be prepared.for the operation. For
a clay or two, the limb is to be disused, so that  previous  excitement may
have thoroughly  subsided.   Loav  diet is  enjoined, the  prima viae  are
gently yet efficiently cleared, and general secretion is seen to be in a satis-
factory state,  so that there may be  no predisposition to inflammation.
Then the foreign body, having been made superficial, is gently pushed to
the extreme verge of the synovial  pouch; either on the inside or on the
outside of the patella, as may be  most convenient.  The internal position
is  usually the  most preferable; and there  it is retained fixedly, by the
fingers of an attentive and steady assistant.  A tenotomy needle, or thin
and  narrow bistoury, of fine edge,  is passed in an oblique direction; and
an incision a little larger than the outline of the cartilage, is made through
the tense synovial membrane.  The instrument  is then withdrawn slowly
and cautiously  the finger gently yet firmly following and consolidating its
track.   A few drops of blood escape, but not a particle of synovia ; and no
air has obtained admission, even  to the areolar tissue.  The integumental
wound is immediately and carefully occluded, by plaster or collodion
  » Lhe foreign body is then gently pressed through the aperture in the
synovial capsule, Avhich aperture, as has just been stated, is  made suffi-
ciently free to admit of this being accomplished Avithout force or difficulty 
JOINTS.
91
When exterior to the capsule it is coaxed through the areolar tissue—suf-
ficiently lax readily to admit of this—by gentle pressure of the fingers;
not in the track of the  puncture, but in a different  direction, probably at
nearly a right angle to it.  When  about an inch and a half, or two inches,
from the synovial Avound, it is  there  permitted to  remain.  Not perma-
nently, however, as has been proposed.  Otherwise, acting still more as a
foreign body in its recent  and raw site, inflammatory action is excited,
suppuration is all but  inevitable, and extension to the synovial membrane
becomes extremely probable; the very result to the avoidance  of which
all our pains had been directed.  For  two days, or three at the utmost, it
is suffered to  remain in its  neAV locality, undisturbed; the most careful
prophylactic treatment being meanwhile employed, both generally and
locally, so  as to  avert  undue  excitement.  By that time the  synovial
wound Avill have closed by adhesion ;  and both tracks—that of  puncture
as Avell as that of extrusion—will have been  consolidated.   Then, the sub-
stance having been fixed as before, a direct incision is made upon it; not
more than is sufficient for its ready removal.  After it has been lifted out,
the superficial and slight Avound is brought  together by strap : and, in all
probability, it unites by adhesion."                   Part xxiii., p. 273.

  Knee Joint—Excision of.—The following description of the operation
of excision of the knee joint as performed  by  Mr. Jones, of Jersey, in a
case under his care, will shoAv the formidable nature of the operation.
  The case  Avas one of extensive ulceration of the cartilages.  It is grati-
fying  to  knoAV  that the result was completely  successful.  It  Avas per-
formed as follows: A longitudinal incision was made on each side of the
knee joint, midway between the vasti and flexors of the leg, full five inches
in extent; rather more than half the length  Avas  over  the femur, and
rather less than half over the tibia.  These  two cuts were  down to the
bones; they were connected by  a transverse one just over the prominence
of the tubercle of the tibia, care being taken to avoid cutting the ligamen-
tum patellae by this incision; the flap thus defined Avas reflected  upward,
the  patella, its ligament,  and the joint  thereby exposed. The  synovial
capsule Avas cut through as far as it could be seen; the patella and its liga-
ment were noAV drawn over the internal condyle, Avhile the joint  Avas kept
extended.   It was next  forcibly flexed, the  crucial ligaments, almost
breaking  in the act, only required a slight  touch of the knife  to divide
them completely; the  articular surfaces of both bones Avere thus  com-
pletely  brought  to vieAV, and nearly two inches of the femur and half an
inch of the tibia Avere sawn off, the soft parts being  draAvn aside  by assist-
ants.  The external condyle  of the femur was  found hollowed  out by a
large abscess, and it was necessary to saw off a portion of the carious
bone, and to gouge the  remainder, until healthy cancellous tissue Avas
reached. The entire synovial membrane Avas in a state of pulpy degenera-
tion, and Avas carefully  dissected off.   The hemorrhage had  been rather
great, but had noAV almost ceased, and  no vessel required deligation. The
blood was sponged out of the Avound, the patella (after the diseased por-
tion had been gouged  out) and its ligament Avere replaced as nearly as
possible, in their natural state, the bones brought in apposition, the flap
brought doAvn and held by sutures, the limb bandaged on a slight under-
splint and laid in a box, the  Avound covered Avith moist lint, ami the boy
put to bed yet asleep.   The  operation occupied full twenty minutes, and 
92
JOINTS.
 Avas performed while the  patient  was under the  influence of chloro-
 form.
   Preserving the patella, and not dividing its ligament, makes the opera-
 tion more tedious and difficult; but this is a very secondary consideration,
 Avhere it results in obtaining a more favorable issue.   That it proved so in
 this instance is abundantly established  by the fact that, in less than seven
 weeks after the operation, this patient is able to raise his foot without any
 assistance; Avhile a young man Avho occupies the next bed, and in whoso
 case everything has gone on favorably,  Avas only able to do so in  as many
 months.                                            Part xxvin.,/>. 155.
   Knock-knees.—An  operation is described by  Dr. Mayer, of Wurzburg,
 Avhereby this deformity Avas remedied.  The front and inner side of the
 head of the tibia having been deprived of  integument and periosteum, a
 wedge Avas cut from this portion nearly of  the thickness of the bone.  By
 straightening the limb the bony surfaces were brought in contact, and the
 limb acquired  its natural shape.   In a month the parts Avere completely
 healed and the Aveight could be borne upon the leg.   Soon afterward the
 other leg Avas operated upon Avith the like success.    Part xxviiii., p. 164.
   Excision of Joints.—There is  one  important view  always to be ob-
 served with respect to this  operation on the knee and the elbow.  In the
 knee joint  endeavor  to promote firm anchylosis.   In  the elbow joint
 endeavor to insure mobility.                         Part xxix., p. 183.
   Incision  into the Knee  Joint.—[The folloAving case by  Dr. Jordison,
 shows the extent to Avhich injury of this large joint  may be carried, with
 ultimate safety, and even Avithout anchylosis.]—G. G., aged 20 years, an
 agricultural laborer, of strumous  habit, Avhilst in the act of moAving, came
 in contact with the  scythe of his felloAV-laborer producing an incised
 Avound of about five  inches in length,  extending transversely across  the
 anterior part of the thigh  immediately above   the  superior edge of the
 patella.  The hemorrhage,  which had  been considerable, had in a great
 measure subsided.   On introducing my finger into the Avound to ascertain
 its course, I could readily pass it into the cavity of the joint, the aperture
 into Avhich was to the extent of about  an inch. I lost no time in closing
 the  Avound,  Avhich  I  did by a number of sutures,  covering the entire
 Avound Avith numerous strips of adhesive plaster, and incasing the Avhole
 m oil-skin, so as to exclude the air as much as possible.  I then placed the
 leg and thigh upon a  long,  straight splint,  and   had  him  conveyed home.
 In the course of tAvo  hours  reaction commenced, and for about six hours
 he suffered excruciating pain, which I successfully combated with large
 doses of opium, combined  Avith small  doses of calomel.   I allowed  the
 dressings to remain undisturbed for several days, and for a fortnight there
 was not the least constitutional disturbance, but at the expiration of that
 time (he  being still under  the most rigid antiphlogistic discipline), the
 pulse suddenly  rose to 135, the tongue became loaded, and the counte-
 nance anxious ; the knee Avas very much enlarged, exquisitely tender, and
 discharged large quantities of synovia.  I ordered two dozen leeches to be
applied, hot fomentations,  and to  take calomel and opium  every  four
hours.  In the course  of a few days the constitutional disturbance Gradu-
ally subsided, but the size of the  knee  remained unaltered ; the integu-
ments now sloughed to a considerable  extent, and the  discharge of syn-
ovia still continued very profuse. 
JOINTS.
93
   It  was upward of two months, before the wound  commenced for the
first time to  ivear a more healthy aspect, and the tenderness to subside.
In fifteen weeks from  the infliction  of the injury it Avas cicatrized.   The
motion of the joint Avas at first  very limited,  but  as  time Avore  on it
obtained greater mobility, and I have now the satisfaction of seeing him
industriously  employed in his wonted avocation, with his once afflicted
knee  as strong, as flexible, and of  as  much .service to him as it wras prior
to the accident.                                     Part xxix., p. 183.
   Knee  Joint—Amputation  at  the.—First make a  small  anterior flap,
drawing the knife  across the front of the joint, and  then inserting the
point of the blade behind the femur, thrust  it through to  the other side,
close to the condyles; then carrying it doAvmvard cut the posterior flap
from the calf  of the leg.  The saw is then applied a little  above the con-
dyles, and the flaps brought  together as in an ordinary amputation.   Mr.
Potter, of Newcastle,  saws through the bone before making the posterior
flap.   Take the full length of the calf for the posterior flap, as the soft
parts at the back of the thigh contract very much in the  course of time.
                                                    Part xxx., p 110.
   Knee Joint.—In operations for diseases of the knee joint, save the pa-
tella, if possible, Avith its ligament.                   Part  xxxi., p. 105.

   Excision of the Knee Joint.—Take care to clear away from the face of
the flap the Avhole of the synovial membrane.  Be careful of the direction
of the saAv as  you saw through the femur and tibia—take care that you
cut  through  these bones parallel to  each  other, else their surfaces will
not meet properly. The line of section in  the femur should be close to  the
edge of the articulating cartilage  of the inner condyle, Avhich will remove
all the articular surface likely to be implicated in disease, and still leaA'e a
breadth of bony surface about equal to the cut surface of the tibia.  The
patella must be left.  It is indispensable.              Part xxxi., p. 108.

   Excision of the Knee Joint.—Having  turned back the flap containing
the patella, apply the saw carefully, and "divide the required amount from
the femur and tibia, AAdthout disturbing the  soft parts by the needless in-
troduction of a  spatula; remove both ends together,  first raising the
separated extremity of the  femur, and dissecting from above downward.
By thus keeping the articular extremities in connection, their dissection
from  the popliteal vessels is rendered safe and  easier, time  is saved, and
the operator can have the upper soft parts depressed by an assistant  Avhen
the continuity of the vessels is unimportant, AAdiilst he is enabled himself
to raise the back part of the joint from the more perilous vicinity of the
vessels inferiorly.                                  Part xxxii., p. 109.
   Knee Joint—Diseases of.—In obstinate cases, which defy the usual forms
of treatment,  local depletion by means of leeches or cupping is injurious.
You Avill find  the most benefit from the inunction of mercurial ointment,
with one-third its quantity of fluid extract of opium, followed by perfect
rest in the recumbent position, and firm application of a flannel roller.
                                                   Part xxxiii.,^?. 137.
   Contractions of the Knee.—When from nervous irritation, as a symptom
of general hysteria, there will  be no evidence of disease within the joint;
in these cases  put the patient  under  the influence of chloroform, and  the 
94
JOINTS.
limb wdll almost of its own accord fall into  a straight position, in Avhich it
must be retained by means of a long splint.  When  depending  on spas-
modic contraction  of the ham-strings from irritation of the nerves at some
distance, as by the pressure of fieces, etc., give powerful cathartics to clear
out the bowels.  When from subacute inflammation Avithin the joint, it
will generally yield Avithout the necessity of extending force, by the appli-
cation of leeches, blisters, and other remedies to reduce the inflammatory
action, as small doses of mercury and morphia,  etc.  When from consoli-
dation of ligamentous structures  in  and around the joint, you will gene-
rally succeed by gradual and forcible extension.   Never  mind the snaps
and cracks Avhich may be heard; there is no fear, if you only take care
that there is no inflammatory action going on in the joint  at the time.
                                              Part xxxiii., p. 137-160.
  Anchylosed Knee Joint.—During the acute inflammatory stage, keep up
counter-irritation by a repetition  of caustic issues made Avith potassa fusa;
this method is  preferable to keeping an  issue open by peas, as there is
greater advantage to be gained by  the primary burning  than  the  subse-
quent suppuration.  If the joint be obliterated, and the  disease entirely
subdued, you  may strengthen the limb by forcibly breaking through the
anchylosing bands; this may be  accompanied  by a loud  crack, but  there
is no danger;  they generally do very Avell.           Part xxxiii.,^?. 144.
  Excision of the Knee  Joint.—The following tAvo suggestions may be
worthy the  attention of practical surgeons in the management of these
cases.  The first is the division of the hamstring tendons, so as to prevent
the displacement of the bones, Avhich is so troublesome in the after-treat-
ment.   The second is the making of an opening into the popliteal space,
for the direct escape of pus, to prevent it bagging and burrowing.
                                                   Part xxxiii., p. 145.
   Excision of  the Knee Joint.—Dr. Yitalis suggests that after the ope-
ration the limb be put up in one of Ester's swinging fracture apparatus,
having  an opening at the posterior part  through Avhich pus may escape,
and the wound be dressed without  disturbing the limb.
                                                   Part xxxiii., p. 307.
   Excision of the Knee Joint.—An error in diagnosis as to the suitable-
ness of a case for excision by no means debars the patient from the likeli-
hood of cure  by amputation.  If the patient be  under  the influence of
chloroform the shock is not greater, and if the bones are found extensively
diseased, amputation should be performed at once.      Part xxxv., p. 67.
  Resection of the Knee Jomt.—There  is  a  great  practical  distinction
betAveen strumous diseases of the knee joint, commencing  within the cavity
of the articulation, and those originating in the cancellous structure of the
heads of the bones entering into the formation of the joint; for every  dis-
eased joint, with the exception of that form of diffuse strumous infiltration
of the head of the two bones, is, in general, well suited for the adoption of
resection in preference  to amputation.  The surgeon should not always
decide which operation he will perform, till he  has obtained a clear view
of the state of the joint.                             PaH xxxy^ p 140<

  Dropsy of the Knee  Joint.—Provided that  the  case be one of simple
uncomplicated  chronic  dropsy,  Dr. Macdonnell's  plan of injection with
iodine will probably prove successful.  The puncture should  bo made at 
JOINTS.
95
the part most remote from the joint.  If the sac is very large the injection
should not be used directly after the first tapping, but time  should  be
allowed for the sac to collapse someAvhat.  When the injection is going to
be used, apply a Avet bandage from below the knee upward to a level Avith
the upper edge of the patella, so as to push the remainder of the fluid above
the joint into the pouch of synovial membrane.  When the fluid is drawn
off, inject about two drachms of the strongest tincture of iodine, with an
equal quantity of lukewarm Avater.  AHoav this to remain, moving the joint
a little, that the fluid may be diffused.  The wet bandage must  now  be
carried further up the limb, the aperture being first closed Avith adhesive
plaster.  A long padded splint should be afterward applied.
                                                  Part xxx\i.,p. 143.
  Removal of the Patella from an Excised Knee Joint.—Mr. Fergusson
is an advocate for the removal of the patella even when healthy,  unless it
is bound to the condyles of the femur by osseous material.   It is  liable to
give subsequent  annoyance.

  After-Management of Excisions of the Knee Joint.—It is not  only
" meddlesome midwifery " which is bad, but meddlesome surgery.  There
is no one  cause  so  productive of ill  effects after the  above operation as
changing the splints too soon, and constantly examining to see if consoli-
dation has commenced.  After the operation the limb should be placed on
a straight back  splint very carefully padded, that there may not be any
unequal  pressure, especially about the heel and the malleoli, Avhere it is
especially liable  to take place.   The two side splints should  be movable,
that the Avound may be readily dressed.  The pads should be secured from
Boiling by being covered with  oil silk.               Part  xxxvii., p. 115.
   Anchylosis of the Knee.—In  the treatment of this affection there has
not hitherto been shown, generally speaking, sufficient patience on the part
of the surgeon.   In infants of six years of age the joints have been excised,
that is, just  at that period of life Avhen successful treatment  by extension is
most to be hoped for.   Even  Avhere  from strumous disease, the tibia is
dislocated backward, by gradual efforts the bones may be restored to their
places, and the disease subdued.   (Cases related.)  As the  result  of rheu-
matic  disease, bony anchylosis is not uncommon, and requires much more
energetic, or  rather forcible  treatment than strumous  disease.   In the
straightening of contracted joints extension is Avanted, not forcible rupture
of contracted tendons and uniting  bands, though subcutaneous tenotomy
may be  practised if necessary.   If the slightest  amount  of motion  be
attainable on  manipulating the joint,  a  favorable prognosis should  be
given.                                           Part xxxviii., p. 130.
  Suppuration of  the Knee Joint—Free Incision.—When suppuration
has taken place in the knee joint, it is absolutely necessary that an incision
should be made.   You will commit  a fatal  error to leave a patient unre-
lieved  of abcess in the interior  of the joint, under the impression that you
are likely to add to the mischief already existing by  opening so large a
joint as that of the knee.  The incision must be free, and the cyst allowed
by its inherent faculty of contraction to force out its oavii contents.   It is
desirable to  leave the opening patent, and  not to bring the edges of the
Avound together  by strapping and bandaging, although this practice  may
sometimes succeed.                                     Part xl., p. 92. 
96
JOINTS.
                       SHOULDER  JOINT.
   a  i.     *j, •  »* th*   A peculiar  form of chronic arthritis sometimes
J^T^X^t Kfay both .t- r, «ja KI
The treatment of these  cases mil vary acco. ding to »he *£=« ° e^lin„8







ciallv withPon°S'turpentine; use also  passive motion  taking care, how-
"er  not  te excite  fresh  inflammation  by doing this too  soon,  and
not to run the risk of anchylosis, by delaymg it too long^ ^ ^ ^


   Peculiar Affection of the Shoulder Joint.-[Sir Benj. Brodie describes a
 most tediouslid annoying affection  of this joint »-«^«*<>t^dm
 many instances on a chronic inflammation of the substance of the deltoid
 muscle, or of the bursa under the deltoid and to be greatly benefited by
 the employment of counter-irritation and the iodide of potassmm.J    #
   « The cases here  referred  to occur  more frequently in private than in
 hospital practice: and  (whether it be  accidentally or not I do not know)
 it certainly has  happened that I have  met with it  more  frequently in the
 female than in the male sex.  The patient complains of pain, which,, how-
 ever, is referred not so much to the joint itself as to the arm a little below
 it near the  insertion of the  deltoid muscle.  At  first the  pain is trifling,
 but it soon  becomes severe  and constant.  The patient describes it as a
 wearing pain, of which she is  constantly reminded.  It is aggravated by
 every motion of the limb, and by pressing the articulating surfaces against
 each other.  Not only is there no  perceptible enlargement  of the shoul-
 der, but after some time, in  consequence of the want of use and wasting
 of the deltoid  muscle, it seems  to be actually reduced in size.   It is not
 long before the  mobility  of the joint is impaired,  becoming gradually
 more and more limited.  When  the  patient attempts to  raise the elbow
 from her side, it  is observed  that the scapula is elevated at the same time
 with the humerus.  She  is unable to raise her hand to her face, nor can she
 rotate the limb so as to place it  behind her.  When  the  progress of the
 disease is stopped at  an  early period, the mobility  of  the joint  may be
 restored ; but otherwise, although the pain and all other symptoms of the
 disease have subsided, the joint remains stiff, and to all appearance com-
 pletely anchylosed.  Whatever motion the arm is capable of, under these
  circumstances, depends not on the humerus, but on the scapula.
    " It certainly is seldom  that this  disease terminates in abscess of the
   ioint, when proper attention has been paid to the treatment of it.
    " Whether it be from  this, or from any other disease, that the joint of
  the shoulder is brought to cuch  an extreme  state of disorganization, one
  result is, that it is liable  to dislocation, or, more properly, to sub-luxation
  in the direction  forward.  In  one  case in which I had the opportunity of
  examining  the parts  after  death, I  found the anterior  margin  of  the
  glenoid cavity of the scapula destroyed by ulceration, the head of the 
JOINTS.
97
humerus permanently resting on the ulcerated surface.  In another case,
in the living person, I  found the dislocation to be  only occasional, the
head of the bone slipping  forward so as to make a  visible projection in
certain motions of the arm, and in certain other motions returning to its
natural situation.
  " I may take this opportunity of noticing  another circumstance, Avhich,
though not of much interest in pathology, is of some  importance in prac-
tice.  An abscess originating in the shoulder joint sometimes  presents a
peculiar appearance, Avhen  it is making its Avay to the surface.  A dissec-
tion, Avhich I once had the opportunity of making, will explain at once the
nature and the cause of this peculiarity.  The abscess, taking the course
of the tendon of the long head of the biceps flexor cubiti muscle, had sud-
denly emerged from the joint at the loAver end of the bicipital groove of
the humerus: then, having taken  a direction forward, on  the  anterior
edge of the deltoid  muscle, had presented itself under the integuments,
having a spherical form, so that it might have  been  mistaken for an en-
cysted tumor.  I met with one case, in which this  mistake respecting an
abscess of this kind, Avas actually made by a surgeon  of considerable ex-
perience, who proposed the removal of the tumor by the knife.
                                                    Part xxiii.,^3. 272.

   Shoulder Joint, Disease of.—In a case which  required excision of the
head of the humerus, Mr. Syme enlarged an opening existing on the inner
side of the  shoulder;  he then,  by means of a probe-pointed bistoury,
guided on his finger, detached the connections of the  spinati muscles,  and
pushing  the arm upward, protruded the head of the bone, which was then
removed.  We may remark that ball and socket joints are most  liable to
chronic  inflammation, suppuration, and caries; Avhile  the hinge joints are
more subject to  ulceration of the cartilages, and gelatinous degeneration
of the synovial membranes.  But the shoulder joint is apt to suffer from
disease entirely peculiar to itself; one is, removal of the osseous substance
by absorption, so that  a cavity is left in place of the round  extremity,
from inflammation affecting the head of the humerus, independently of the
scapula.  Again,  excessive action of the biceps Avill produce an injurious
effect upon its osseous attachments, leading to exfoliation of the  coracoid
process,  and disease of the humerus, along which  the long  head of the
muscle passes.                                      Part xxxiii., p. 134.

   Shoulder Joint—Resection of.—Resections of the shoulder, unlike those
of the knee, generally necessitate the removal of but one of the  articular
extremities entering into the joint;  it is very seldom that more  than the
head of the humerus need  be removed, either from disease or injury,  and
this, from the very nature of the affections of the joint, which, while they
seriously damage or even  destroy the  head  of the humerus, rarely attack
the glenoid cavity of the scapula.  Again, the exposed position  of the hu-
merus, which renders this bone so peculiarly liable to injury from gun-shot
wounds,  forms a protection for the scapula.  Fortunately, the full benefit
of resection may be secured by the removal of one articular extremity, as
it is not our object to obtain bony anchylosis.
  This operation is applicable to compound  dislocations, to cases  Avhere a
bullet may have lodged in the head of the bone, and to all wounds of the
shoulder joint complicated-with crushing or fracture of one or both hones
entering into the articulation, unless, of course, the severity of  the injury,
     vol. n.—7 
98
JOINTS.
by division of the great vessels,  or  by extensive  laceration of the soft
parts, necessitates ex-articulation of the limb.   Nor need the extension of
the injury to the shaft of the humerus deter the surgeon from attempting
the operation.
   In disease, either one or both articular extremities of the joint may be
removed for caries, or, indeed, for any other incurable affection of the ar-
ticulation,  Avhich renders it not  merely useless as  a  joint, but by itd
presence either  destroys  the utility of the Avhole extremity, or seriously
affects the general  health of the patient.  Lastly, this  operation  may be
substituted for ex-articulation, in cases where  tumors affecting  the head
of the humerus do not by their extension to the shaft  necessitate the re-
moval of the entire limb.  We apprehend  that resection of the joint is
by no means justifiable  for mere anchylosis, provided that this is the only
inconvenience the patient suffers from.
   The operation is contra-indicated where, together with compound frac-
ture, there is any excessive destruction of the  soft parts, or injury to the
great vessels or  nerves.  Neither should cases of necrosis or caries be sub-
mitted to operation, unless the disease  be confined  to the  articular ex-
tremity of the bone, or at any rate be Avithin reach of removal.
   It appears, from the history of former operations on this articulation,
that, previous to its performance by Professor  Langenbeck, the long ten-
don of the  biceps had  always been  divided.  He  it Avas who first prac-
tised an operation which had  for  its  object  the  preservation  of this
tendon.  Langenbeck's method consists in an  incision commencing at the
acromion, and extending downward on the anterior aspect of the joint for
three or four inches; this should fall  just over the  bicipital groove, which
is then opened,  and the tendon  drawn inward ; the muscles inserted into
the tuberosities  are now divided,  and the head of the bone thrust out of
the wound and removed by an ordinary saw.  The  operation is sufficiently
easy of execution Avhen the head of the bone  retains its connection Avith
the  shaft, and the  soft  parts are not tense  or sAvollen.  On the other
hand, it is difficult by this incision to  remove the disconnected head of the
humerus, and especially when the integuments are  swollen and  cedema-
tous.  To remedy this,  and to provide a more dependent aperture for the
escape of the secretions from  the Avound, Stromeyer  made use of a semi-
circular incision, commencing at the  posterior  edge of the acromion, and
extending doAvmvard and outward for three inches, having its concavity
forward ; the joint  is thus freely opened from  above and behind, the ten-
don of the biceps can be preserved, and a free and  dependent aperture is
left for pus.  Stromeyer states that patients recover from this operation
much more quickly than from Langenbeck's,  owing to the much greater
facility it affords for cleansing  the wound.  That perfect  recovery may
take place after  division of the tendon of the  biceps is well known, and,
indeed, Esmarch relates three cases of resection in which it had been torn
across by a ball, and yet in each  case  the patients  recovered, with o-0od
use of their arms.  It may also be gathered from similar evidence°that
transverse division of the  fibres of  the deltoid but little affect the ultimate
success ot the case.   Whatever mode of incision be adopted, the  deltoid,
with few exceptions, becomes much atrophied after the operation ; perhaps,
this is caused by the division of its nerve,  which, with  the posterior cir-
cumflex artery, are the only nerve  and vessel of importance that are liable
to injury. 
JOINTS.
99
   The after-treatment of these cases is far more simple and  more easy of
execution than that of excision of some other joints.  Absolute rest, clean-
liness, and appropriate constitutional support  constitute the  principal
measures to be adopted; but we will refer to the plan pursued during the
Schleswig-Holstein Avar.  Absolute quiet was maintained by bandaging
the arm  to the side.  Ice Avas freely applied to the parts, and maintained
there until suppuration  Avas fully  established.  Bleeding, both  constitu-
tionally and locally, was unsparingly employed during the stage of reaction,
and upon this Stromeyer strongly insists.  The wound was never, if pos-
sible, disturbed, all cleansing Avas effected by  allowing water to flow over
the wround.   Matter, if it  formed,  Avas  let out  by incisions,  and  not
squeezed out.  Cicatrization  Avas promoted by dressings of nitrate of sil-
ver lotions; flannel bandaging Avas employed  to  consolidate the  parts ;
passive motion Avas commenced as  soon as the cicatrix had formed, and
Avas continued at the  discretion of the surgeon, and as the patient could
bear  it,  until considerable voluntary motion  of the  extremity had been
regained.                                          Part xxxvi.,p. 129.

                          WRIST  JOINT.
   Endermic use of Morphia in Articular Contractions.—[Dr. Haygarth
published  an  account of an  arthritic  affection, Avhich he termed " Nodo-
sity of the Joints."   lie described  it as almost  peculiar to women, as
occurring at the period of cessation of the menses, principally affecting the
fingers,  and considered  it an affection of the Avhole of the tissues com-
posing the wrist, and near akin to gout.  The joints Avere painful at night,
often tender to the touch, swollen, and, in old. cases  sometimes actually
dislocated.  Dr.  Thompson has  met  with  an affection much resembling
this, Avhich he has successfully treated by the endermic application of some
of the salts of morphia.   Cases of  real nodosity he has also found much
benefited by the same treatment.]
   The disease Avhich is the subject of this communication does not  display
itself at any particular period of life, nor is it confined to either sex.
   Dr. T. has never seen it in persons under the age of puberty.  It  ap-
pears, in every instance, to  be the  sequel  of  repeated  severe attacks  of
acute rheumatism;  and has great affinity to inflammation of  the  synovial
membranes, as described by Sir Benjamin Brodie.
   [A number of cases are  given, from Avhich the following conclusions
may be drawn.]
   1. That in painful, SAVollen, and contracted joints, depending on rheum-
atism, or other causes the topical application of hydrochlorate, or acetate
of morphia, to a blistered surface, on the affected joint, is capable  of
reducing the  swelling, abating  pain, and  restoring the  motion  to  the
joints.  2.  That these  salts seem to  produce these beneficial effects, by
reducing the sensibility of the nerves of the joint, and favoring absorption
by their  counter-irritant  influence.  3. That  they do not  act as general
narcotics, until the joints are relieved.  4.  That they frequently excite a
pustular  eruption over the body; but this disappears spontaneously, soon
alter the use of the topical application is discontinued.  Part xii., p. 252.
   Wrist Joint, Excision  of.—Mr. Erichsen and Mr. Fergusson ha\'e"
removed the bones of  the  Avrist by  lateral  incisions.  Mr. Simon  has
removed them by making tAvo long incisions in the  anterior and posterior 
J0Q                      KIDNEY AFFECTIONS.

aspects  of the joint,  reaching  from about two inches above  the,  wrist
back  and front, to the centre of the palm  and dorsum of the hand  the
incision being so managed as to run between the tendons conning down to
their destination on the metacarpal bones and fingers.
Part xxix., p. 195.
   Carpal Bones, Excision of.-In cases of partial  disease of the wrist
joint! fn place  of amputation of  the  forearm,  excision of the diseased
bone's is sometimes preferable, as  by this means the disease is equally-re-
moved,  and a very useful hand preserved.   It should be conjoined Avith
the use  of cod-liver oil and tonics, etc., especially in strumous cases.
                                                  Part xxx\\\.,p. 145.
                   KIDNEY  AFFECTIONS.
  Treatment of Renal Disease.—Dr. Bright gives the following outline of
his treatment of renal disease :
  In the first steps, and the more acute forms of disease, bleeding may be
considered the most important remedy ; but this is, of itself, Avholly inade-
quate to cure unless Ave purge freely, and at the same time call upon the
skin to do its duty.  Of all the measures for effecting this latter purpose,
the strictest confinement to bed is the most effectual; and Avithout  that,
I do not believe that in this climate we have a chance of cure.   That pre-
liminary, however, being adopted, antimonials are probably the best dia-
phoretics ; but the liquor ammonise acetatis is likeAvise very useful; and  a
simple saline draught of citrate of potash or soda is, I believe, Avhen  dili-
gently persisted in, of muq^,»%vail, and the Avarm bath, in its various forms,
may in many cases be brought to act most beneficially.
  Amongst the purgatives, I  »hall only mention that elaterium  and jalap,
Avith the bitartrate of potash, appear to be the most effectual.   When the
disease  has  made further  progress,  and has  become  chronic,  perhaps
organic, I should  still recommend the greatest attention to the full effects
of purgation, and to the state of the skin, and to  protection from atmos-
pheric changes.   A voyage to the West Indies, and a residence in one of
the more healthy  islands, often produce a great change in the constitution,
acting chiefly upon the pores  of the skin.  We have, at least, the negative
experience that confirmed cases rarely recover in  this country, whatever
treatment be adopted.
  There are certain remedies whose actions in this disease are less obvious
than those to AA'hich I have referred; but many of them probably act by af-
fording a degree  of stimulant or astringent action to the kidney ;  of these
I may mention the mineral acids as applicable  in the  declining stages of
more acute attacks; the  uva ursi,  in its  different  preparations, in tho
chronic disease; the pyrola nmbellata, and thediosma crenata Avhere great
irritability of the urinary organs exists—a remedy which I have been led
to adopt, in many cases, from the very favorable reports of Sir Benjamin
Brodie; nor have I been  disappointed  of some  good effect, though  I
should perhaps employ with greater confidence a long-continued course  of
soda, conium, and uva  ursi.
  Dr. Barlow one of the editor? of " Guy's Hospital Reports,"  strongly re- 
KIDNEY AFFECTIONS.
101
commends tartarized antimony in this formidable disease :  with respect to
which li\ says:
  " I have never found it necessary to give more than half a grain at a
dose to an adult; neither have I attempted to push it to the greatest ex-
tent possible; the object not being to give heroic doses of the remedy, but,
if possible, to cure the patient."                           Part i.,p. 55.

  Ischuria Renalis.—Dr. Theophilus Thompson has recorded an unusual
example of complete interruption of the renal secretion, unattended Avith
the  urgent  symptoms which protracted anuria usually induces.   Death
will generally ensue within three days of such an event: Dr. Prout thinks
that five days will often elapse before coma takes place.  In this case of
Dr. Thompson's, no urine was secreted for about 120 hours, and during
the  next 48 hours, only half an ounce Avas  passed, and the  natural quan-
tity Avas not restored for a month, and yet no urgent cerebral symptoms at
any time occurred.   Dr. T. attaches some importance in the treatment of
the case to the application of nitrate of silver.  The final result of the case
does not seem to invalidate the value of this opinion.  The  case Avas that
of a lady aged 45, who had  for five years  suffered in the region of the
colon from frequent and severe attacks of pain.  January 28th, the secre-
tion of urine Avas suddenly suspended, so  that only half a drachm Avas
obtained on introducing the catheter.  Nine ounces of blood Avere removed
from the loins by cupping, and small doses of tincture of cantharides were
administered.  In the evening, tAvo drachms of turbid urine were passed.
The loins Avere cupped again, and blistered:  prussic acid, creasote, etc.,
Ave re given, but still, on the 3d  February, i. e., seven days after the first
suppression, little or no urine had been voided.  The nitrate of silver was
now freely applied to an old issue on the loins Avhich had lately been dried
up, with the view of restoring it: in the evdUkg, a drachm of urine  was
discharged, and during the night 3£ ounces.  The secretion became gradu-
ally restored.                                          Part ix.,p. 67.
  Injuries of the Kidneys.—The kidney may be  injured in a variety of
ways, giving rise to very different symptoms.   1. It may be  lacerated and
cause death  by hemorrhage  into the cavity of the peritoneum, with the
addition likewise of urine  escaping into the same cavity.  2. It may be
lacerated, with its capsule,  and  both blood and urine may escape into the
cellular tissue around it, Avithout the serous membrane being torn ;  and
the fatter the person is, the more distant the peritoneum will of course
be  from  the gland.  In  these  cases it has happened  that death  has
ensued from secondary hemorrhage into the parts around the  kidney,
behind the  peritoneum, many days (in one case as late as the 10th day)
after the accident,  and Avhen the  patient appeared to  be doing well.
3. There may be no laceration of the capsule of the kidney,  but an injury
may extend  into the infundibula and  pelvis of the gland, so  that  the
effused blood escapes into the interior, and  hence there is hematuria.   A
great quantity of blood may be lost in this Avay; as much as  three pints
at once.  4. Another consequence of injury of the kidney is suppuration
Avithin  the organ.  5.  And  another effect is illustrated by tAvo examples
published  by Mr.  Stanley, in Avhich,  besides suppuration, there were
formed fluctuating tumors  or cysts, containing a clear, yellow fluid, resem-
bling urine.  With respect to the treatment of some of these cases, Mr.
HaAvkius says: 
102
KIDNEY AFFECTIONS.
   " In the first place, Avith regard to the hematuria, it is seldom that its
amount causes any alarm; but if the blood comes aAvay in great quantities,
you have the same resources as in other internal bleedings, to which alone
you can look for checking  hemorrhage from the kidney Avhich does not
pass doAvn Avith the urine.  You can cause  syncope by bleeding, and  you
can give styptics, wdiich I have seen do much good in some cases of hema-
turia.  Of these, the best is lead ; so that you can give three grains of the
acetate with a quarter of a  grain of opium every three or four hours for a
time.   In some cases, in  which the lead failed, or alternately Avith it, I have
seen the powdered galls stop the bleeding.
   " This medicine is, hoAvever, rather nauseous, and sometimes irritating
to  the  stomach.  You  can  also  give a  dessertspoonful  of Ruspini's
styptic every three or four hours.  You might reasonably expect that, if
these  medicines have poAver in any case of hemorrhage, they Avould be of
especial service in hemorrhage from the kidney, to Avhich organ so large a
quantity of blood  is constantly passing.  Another styptic—turpentine—
Avhich is useful in passive bleeding from the kidney, does not seem to be
applicable to cases of injury in Avhich inflammation is  present.  The pre-
sence of blood in the bladder does not usually occasion much trouble ; it
did so in the patient from whom this blood  passed, and I was obliged to
Avash  out  the bladder to free  it from coagula and enable  the urine to
escape, not  after an accident,  indeed, but  for fungus nematodes of the
kidney.  With a double catheter and warm Avater, there is no difficulty in
doing this, if you are obliged;  at all events, there can be no occasion to
perform the high operation, as  for lithotomy, Avhich Avas done in one case
by Mr. Copland Hutchinson, Avhere blood lodged in the bladder.  In most
cases, however, you  may disregard the amount of hemorrhage, and treat
the case as you Avould another in Avhich there  Avas  no bleeding, and  you
will find it cease graduallyjp two or three days.  I need not say that  rest
is necessary,  and Avith this you  must  employ antiphlogistic remedies.
You see that our patient noAV in the house has  been cupped once, and has
had leeches also once, and fomentations to the painful side; and such means
are usually enough.  In the case, however, which I read to you, of recent
suppuration, I was obliged  to bleed as often as five times;  cupping, how-
ever,  is generally sufficient.  Then you  saw  that  I  gave calomel  and
saline purgatives ; and if you have occasion for purgatives in these cases,
and particularly when the lithates abound, as they did  here, the salts  you
select  should be the vegetable ones, the potassio-tartrate of  soda, or  the
tartrate of potash, so that the alkalies may at once pass to the kidney  and
neutralize the excess of acid.  Then, again, you may give saline draughts,
and add to  this sometimes some colchicum if  the inflammation does not
easily yield.
  "After  the first symptoms have subsided, you must  next look carefully
for remaining  pain and  Aveakness in the loins, and use counter-irritants ;
apply blisters, taking the precaution  of using some muslin or tissue-paper
under them, in order that the cantharides may not  be absorbed and  pass
to the injured or inflamed  kidney; and finally, if such pain and Aveakness
continue long, you should insert a seton or an issue over the affected part,
Avhich you will do with the view of preventing the formation of abscess or
other  chronic disease of the kidney, and  also  to obviate another future
mischief, Avhich has been pointed out  by Mr. Earle,  in a paper in  the
' Medico-Chirurgical Transactions,' namely, the formation of calculi in the 
KIDNEY AFFECTIONS
103
kidney;  though it does not seem very probable that these bodies would
be deposited  unless the  patient's  urinary secretion Avas otherwise dis-
ordered."                                              Part x., p. 135.

  Granular Disease of the Kidney—BrighVs Disease, or Albuminuria—>
Treatment.—Enjoin a general tonic regimen; avoid as articles of food, fat
and other highly carbonized materials; attend to the functions of the skin
and bowels; relieve congestion of the gland, and, if necessary, use  small
bleedings.   (Dr. Johnson.)   Make  use of  cautious small blood-lettings
in the early stages, particularly if acute;  give hydragogue cathartics,
and  improve  the  general  health:  do not  deplete where the disease  is
chronic.   (Dr. Williams.)  In the very early stages change the mode of
life and habits of the patient, enjoin pure air and careful attention to diet
and  exercise; in this  stage, application  for relief is seldom made.  In
the  second  and third stages,  relieve congestion; promote  the  flow of
urine and the  action of the skin, and prevent the deposition  of fatty mat-
ters  by a diet  which contains neither fat, nor butter, nor any of those non-
azotized  substances nearly allied to it, as starch, sugar, potatoes, etc.  (Dr.
Todd.)
  In the acute form, remove congestion of the kidneys  by blood-letting,
regulated according to  the intensity of the  disease and the patient's
strength; restore  the  function of the skin, by keeping  the  patient  in a
warm atmosphere, giving mild diaphoretics, and the use of  the Avarm or
vapor bath.   Dr. Barlow gives tartar emetic.   Next,  remove the dropsy,
by diuretics and purgatives, nitrate of potash, in doses of two  scruples
or more, with digitalis and cream of tartar; the nitrate should be largely
diluted.
  In the chronic form, first attend  to the function of the skin by warm
clothing, diaphoretics, and the warm bath.   Give  tincture of cantharidea
in doses  of from four to twelve drops, in some emulsion (Dr. Bright); Dr.
Wells and M. Monneret advise thirty to sixty drops in twenty-four hours;
or give ioduret  of iron (M. Gutbrod); or hydriodate of potash, and use
iodine ointment (M. Aiken);  or give chalybeate tonics, saline purgatives,
and  nutritious diet (Dr. Rees); or equal parts of tinct. of cantharides and
tinct. of  sesquichloride of iron (Dr. Copland).
  Treat  the dropsy with cream of tartar and digitalis  (Dr. Christison),
give from a drachm to a drachm and  a half of the former three times a
day, and at  the same time a pill containing one or two grains of powdered
digitalis, or  twenty drops of the tincture  in cinnamon Avater: give a blue
pill (grs. 5) every night for four or five nights.  Diuresis may often be
established by an emetic of ipecac, and tartar emetic, or  by a hydragogue
cathartic; should these fail, give squills,  broom, spirit of nitric ether, or
Hollands and  Avater,  or carbonate, nitrate, or acetate of potash; or decoc-
tion  of horse  radish (Rayer).  Diuretics do not  cure the disease; they
can only relieve the dropsy.
  Try seidlitz or  Pullna  Avater; cream  of tartar in  half  ounce doses
(Rayer)  ; give five, seven, or nine  grains of gamboge,  once every two
days, triturated  with bitartrate of potash, to prevent griping.   Combat
the  concomitant affections  of the  digestive organs  Avith creasote (Dr.
Christison) ; give it as a pill, one drop of creasote, two grains of rhubarb,
and  one  grain of extract of gentian, for the mass ; or with the sedative
solution of opium; or  with extract  of opium and  nitrate of silver, half a 
104
KIDNEY AFFECTIONS.
grain of each in a pill.   Apply sinapisms, turpentine epithems, or  a can-
tharides blister, externally ; sprinkle the blistered surface Avith muriate of
morphia; check  diarrhoea by chalk,  astringents,  and opiates; or  give
acetate of lead Avith opium, or strychnine with opium (Dr. Wood).
                                                     Part xiii., p. 108.

   Case of Excessive Secretion of Earthy Phosphates by the Kidneys,
with  long-continued Irritability of the Stomach.—{This  case, recorded
by Dr. Bird, is an excellent illustration of the  relation existing  betAveen
the function of the stomach and  kidneys.  The  patient,  in  1841, was
attacked with vomiting, after dinner, with  severe pain at  the pit of the
stomach.  This Vomiting occurred after every meal for six months, being
always preceded by  intense  pain, which  was  relieved as  soon  as the
stomach  was emptied.  The next eight months the vomiting became less
frequent, only recurring after dinner.  He  Avas admitted into Guy's Hos-
pital  on  the" 9th of April, 1845.   The following was his  condition at
the time:]
   On admission  into Guy's Hospital, the lad's  complexion A\ras pale and
bloodless, Avith a slightly icteric tint; he  was  emaciated to an extreme
degree, his bones being barely covered ; and his face bore no small resem-
blance to a  fleshless  skull, over which  a skin of  parchment  had  been
tightly drawn.   His general appearance Avas that of a person Avorn out by
malignant disease.  He chiefly complained of a burning, gnawing pain, at
the  scrobiculus  cordis, and of  a  heavy pain  across the loins.  Tongue
clean  and red;  pulse quick and sharp;  skin dry and  imperspirable.  He
vomits shortly after each meal, bringing up his food slightly  changed, and
according to his OAvn account, has never passed a single day, during four
years, without  vomiting once, and  more  frequently  several times.  He
complains of great thirst.   The bowels act daily.  Flatulent  eructations
frequent, and possessing  the odor of stale fish.  Urine copious, pale, loaded
wdth crystals of the triple phosphate, not albuminous, alkaline ; specific
gravity 1.020, and evolving a disgusting fishy odor.  The abdomen is dis-
tended Avith flatus ; there is  some  tenderness  at  the  scrobiculus cordis,
where no  tumor  is  perceptible.   He had, shortly after  his admission,
vomited nearly four pints of thin, acid, yeast-like matter.
   Misturae magnesia?, §j. ter in die.  Milk diet.
   April 11th.—Has  vomited  daily after dinner, the vomited matter pre-
senting the same yeast-like appearance.  Urine  has an ammoniacal odor,
and deposited crystals of phosphates.
   R  Strychnia?, gr. j.; acidi  nitrici dil. 3j.; aqua?, gxij; solve et sumat
seger, ft. |j  ter in die.
   He Avas  strictly confined to milk diet, consisting of eighteen ounces of
bread, an ounce of butter, and two pints of milk daily, and  ordered to
take the medicine fifteen minutes before each meal.
   [On the  16th, a liniment of croton  oil was applied to the scrob. cord.,
after which he ceased to vomit; the  pain also  ceased, the  urine became
neutral, and contained but few phosphatic  crystals.  On the 22d, the urine
was free from deposit, and the skin acted freely.  Dr Bird adds :]
   From the date of this report the  same treatment was continued, and
the  patient  steadily  improved; the vomiting  ceased, the  urine became
acid, he  recovered his flesh—indeed became decidedly fat; it was scarcely
possible  to recognize in him the Avretched  skeleton admitted but a month 
KIDNEY AFFECTIONS.
105
before.   On May 19th, he suffered a slight relapse both of pain and vomit-
ing, folloAving a severe paroxysm of pains in the region of the left kidney,
and relieved by a copious discharge of urine loaded Avith triple phosphate,
and rapidly becoming alkaline and fetid.  He appeared to recover from
this in a tew hours, and left the hospital  strong  enough to attend to his
work,  and apparently well; having continued the strychnia during six
weeks, and taken altogether about  eleven grains of that alkaloid.
  I am not aAvare of attention having been previously directed to thexjonnec-
tion of this condition of urine, and attending  diuresis, with intense irrita-
bility of stomach,  or, at all  events, of their standing to  each other in the
relation of cause and effect.   I  may venture to express my own convic-
tion of the etiology of the case in a few  words.   A lad of  delicate frame
is engaged  in laborious  occupations, often far beyond his strength for
years, during that part of life which  is most  susceptible to marked influ-
ences ;  functional  derangement of the spinal marrow ensues, marked by
the pain  across the  loins, and altered state  of the urine.  The  stomach
thus rendered irritable scarcely retains food, emaciation results, the patient
is unable to obtain a sufficient  supply through the  medium of the sto-
mach for the sustenance and reparation, much  less for the increase of tissue.
The necessary result is, his stunted growth, extreme  emaciation, and the
excretion of an unhealthy fluid from the kidneys, the necessary result of
the impaired condition  of the vital chemistry of these organs, itself an
almost constant, although often transitory, result of the slightest mechani-
 cal injury to the spine.
   The strychnia Avas administered in consequence of  its well-known influ-
 ence upon the functions of the spinal marrow, and believing that Avhere
 alkaline urine is really secreted as  such by the kidneys, independently, of
 course, of the character of the  ingesta, there is ahvays some lesions of
 that important structure.  Its effects were certainly most satisfactory; for,
 alter years of almost incessant  vomiting, the patient soon acquired the
 power of retaining his food, the urine sloAvly  losing its alkaline character.
 I would, indeed, venture to press this important  remedy upon the notice
 of surgeons,'to whose province cases of alkaline urine following injury to
 the spine more immediately  belong.  Nor can  I avoid here taking the
 opportunity of alluding to the value of the drug in the distressing \-omit-
 ing so  frequent in uterine affections, especially in the irritable stomach of
 hysteria, in Avhich it is almost always successful as an important palliative.
                                                       Part xiv., p. 98.

   Bright*s Disease.—The diet must be free from fat, and from those non-
 azotized  substances which  are easily converted into fat;  as starch  and
 sugar.   Enjoin a removal to pure  air, regular exercise,  attention to clean-
 liness, and temperature of the skin; and give  tonics and other chalybeates.
The  congestion of the kidney will be relieved by attention to  skin  and
bowels, but local bleeding may sometimes be  cautiously employed.
                                                      Part  xv., p.  126.
   Depuration of the Blood.—It is found that the  kidneys can depurate
the blood, not only of matters generally regarded as proper to their func-
 tion, but of substances  usually separated by other emunctories; in fact,
 they remove all  soluble noxious matter.   When,  therefore, disease  is
 excited or aggravated by noxious or lethal effete matter in the blood, Ave
 should  endeavor  to procure  the  decomposition and elimination of this 
106
KIDNEY AFFECTIONS.
matter, by stimulating the depurating functions of the kidneys. _ And thia
may be accomplished^)- the exhibition of the alkalies, and their  carbon-
ates,  citrates,  acetates,  and  tartrates, Avhich  not only stimulate  the
kidneys, as  do the vegetable diuretics, but  also increase the metamor-
phosis of tissue going on in the capillary system.  (Bird.)  Pt. xvm., p. 57.
   Case of Injury to the Kidneys—-In consequence of death in general so
speedilv folloAving the suspension of the excretion of urea by the kidneys,
owing to  its consequent quick absorption into the  blood, and poisonous
influence on the brain and nervous system, it  rarely happens  that  time is
given  for  a practitioner to  determine decidedly,  both  chemically  and
pathologically, that the comatose  symptoms depend  altogether  on the
non-elimination of urea by the kidneys.  The following case, by Dr. Shear-
man, from the attending circumstances, elucidates this point fully:
   Edward C----, aged eight years, in perfect health, while at play Avas
run over across the loins by a  heavy truck.  In two hours after the acci-
dent I saw him.  He Avas then in a state of collapse, and my impression was,
that some internal  hemorrhage was then  going on, for he Avas blanched,
cold, and pulseless.   He complained of acute pain in the left lumbar region,
which was very tender to the  touch, spreading to both the inguinal and
the pubic region.   I gave him stimulants, and kept him  Avarm, by Avhich
means, in the course of thirty-six hours, he gradually improved;  and he
then passed a large quantity of blood Avith  his urine, not having previously
voided any urine since the accident.   This  was repeated several times
during the next twenty-four hours.
   I examined this urine and blood most carefully, but failed to detect the
least  particle of urea or urates in it.   My little patient became restless;
fever set in, with a  pulse at 130 ; and the pain in the region of the kidneys
increased,  notAvithstanding  the application of leeches, etc.   But these
symptoms, in the course of tAvo days, Avere succeeded by coma; he could
not be kept awake.
   I noAV bled him in the arm, and reapplied  leeches to the  tender part.
On examining this  blood, urea Avas most distinctly  detected  in it, and in
considerable quantity.   The urine, at the  same time, contained not a par-
ticle  of urea, urates, uric acid, or albumen, and  its specific gravity Avas
only 1.005.
   I got him under  the influence of mercury as quickly as possible; as soon
as its specific effect was apparent, urea gradually reappeared in the urine,
and its specific gravity increased.  By degrees the comatose symptoms
subsided,  and in the course  of five Aveeks the usual health Avas reestab-
lished.  He continues quite well.
   The mode of detecting urea in the blood, Avhich I adopted, Avas the one
recommeded by Dr. G. O. Rees ("On the Analyses of Blood  and Urine,
in Health and Disease," second edition, page 40).    Part xviii., p. 135.
   Diagnosis of Renal Disease.—An observation of great importance in
the diagnosis of renal disease has been  recently made by Dr. Johnson, viz.,
that disease of the  kidney, of a recent  acute nature, is indicated chiefly by
the presence of fibrinous matter entangling " entire epithelial cells " Avith
albumen,  and very  commonly  blood ; while, on the other  hand, " granular
particles of disintegrated epithelium "  indicate a disease of a chronic cha-
racter.                                             Part xxiii., p. 13Q.
   BrighVs Disease.—Ascertain  AA'hether the coagulability  of the urine 
KIDNEY AFFECTIONS.
107
present depends on albumen, by the aid of heat first, and then by the ad-
dition of nitric  acid.  All intercurrent diseases are more unmanageable,
and more apt to prove fatal, in consequence of the renal disorder.  The
most mortal of all  signs are, a very scanty urine of very low density, an
extremely impoverished condition  of the  blood corpuscles, and stupor
gradually verging toward coma.  The treatment of Bright's disease is
two-fold; to remove the fundamental disease, and  to cure the secondary
diseases.   The main remedies for the former object are general and topical
depletion, local counter-irritation, diaphoretics, diuretics, and astringents.
The best diuretics are digitalis, squill, and bitartrate of potash, but when
all these have failed, diuresis has been established by Hollands.  The
cathartic plan should not be adopted for the  dropsy; it is apt to excite a
permanent diarrhoea, and  mercury should be shunned as inducing in this
disease excessive action.   The best remedy for the diarrhoea is the Edin-
burgh lead and  opium pill, in a dose of five  or ten grains, tAvice or three
times a day, to which  may be added, in severe  cases, a fatty suppository
of morphia.  Vomiting may be removed  sometimes by bismuth, more
frequently by morphia, hydrocyanic  acid, creasote,  chloroform,  or  little
fragments of ice ; Avhen these fail, by a blister applied over the epigastrium.
                                                   Part xxix., p. 142.

  BrighVs Disease.—Dr. Jones looks upon the fibrinous cylinders Avhich
are found in the urine in this disease to be produced by congestion, caus-
ing effusion of liquor sanguinis, and thus fibrin and albumen being effused
together, the fibrin coagulating in the ducts producing the cylinders, and
the granular  matter Avithin them.   When these appear in the urine, Dr.
Jones always suspects the presence of granular disease of the kidney.  Dr.
George Johnson Avas the  first avIio attempted the solution of the problem
between this  deposit and granular degeneration.   Dr.  Johnson  subse-
quently extended his vieAvs, and distinguished four conditions of the kid-
ney:   1. Acute desquamative nephritis.  2. Chronic desquamative nephri-
tis.  3. Simple fatty degeneration.  4. Fatty degeneration Avith desqua-
mative nephritis.  He imagined that the microscope wTould enable us to
distinguish the sediments peculiar to each of these several diseases, but
the sediment unfortunately in the same case varies exceedingly at different
periods.  Sometimes even microscopic examination fails altogether Avhen
the chemical eA'idence has been decided enough.
  [With regard to  the treatment.]
  The  intense action of mercury in Bright's disease has so frequently and
so forcibly been presented to my notice, that  I have formed a general rule
never to give mercury in cases of albuminous  urine.   I have seen the most
violent salivation from single doses even of grey poAvder, and on this ac-
count,  even in  serous inflammation  consequent on  Bright's  disease,  I
advise  you not to give mercury.   Why mercury should act so energeti-
cally in this disease is  probably explained by  the altered state  of the kid-
ney.   In health, most probably, mercury no sooner passes into the system
than it begins to pass out  again by the kidney, like hydriodate of potash
or the  salts of iron.   For example, if a single grain of hydriodate of potash
is taken in an ounce of distilled Avater, in twelve minutes it can be detected
passing off" in the urine ; but if the kidney is diseased, then most probably
this rapid excretion does not so  easily take place, and the intensity of the
action  of this aud other medicines may thus be greatly increased. 
108
KIDNEY AFFECTIONS.
  In the treatment of urinary poisoning, I knoAV no single remody which
has produced an effect at all equal to that of a blister  on the back ot the
neck.  This appears to me to indicate that there is some local congestion
of the brain, as well as some  poison in the blood.  I have as yet had no
good opportunity for trying what  the free  administration  of vegetable
and mineral acid's can do Avhen head symptoms are present;  in one case,
large quantities of lemon-juice appeared  to  have a beneficial effect, The
theory of Dr.  Frerichs indicates the acid treatment, and it is worthy of a
fair trial.
  Dr. Watson is, Avithout doubt, right in  saying that these  head symp-
toms may arise from  insufficient  supply of blood.   Just, as in children,
symptoms  resembling hydrocephalus  may arise  from anaemia, Avhen, in-
stead of depletion, counter-irritation  and stimulants are required.  On
this theory, no poison is considered to be present in the blood.   The truth
probably is, that  too  little blood, too  much blood, and poisoned blood-
each of these  states, in different cases, is the cause of the head symptoms
in Bright's disease.
  As I cannot make any separation  of Bright's disease into  different dis-
eases, so I am unable, from  observation, to  find that  different kinds of
treatment  are desirable.  The indications are, first, to relieve the con-
gested kidney ; and, secondly, to improve the general health.   Gentle but
decided action on the skin and bowels appear to me best to fulfill the first
indication ; cupping, vapor-bath, and elaterium, are the three most ener-
getic remedies; cream of tartar, compound jalap poAvder, and  abstinence
from stimulants, are the  milder  agents.  To improve the  health, proper
air, exercise, food, and small  doses of iron, are essential.
  Specific treatment by gallic and  nitric acid has not benefited my pa-
tients in St. George's Hospital.  In so-called chylous urine, I knoAV Avell
the use of gallic acid, in doses of tAvo drachms daily; but, in  Bright's dis-
ease, when ten-grain doses Avere  given, I have more than once known bad
symptoms to occur.   In one case, violent convulsions made their  appear-
ance  soon after  the gallic  acid Avas taken.  In  no  case have  I found
that it  stopped  the albumen from  passing aAvay.  I may here mention,
that tannic acid appears to affect the stomach much more than gallic acid
does.
  With regard to the treatment by nitric acid, Avhich has been extensively
tried in Germany, I  have not found  any good result,  even when dilute
nitric acid  has been taken daily for  many weeks.
  As to the result of treatment, omitting the cases which folloAV scarlet
fever, which constantly recover perfectly, temporary relief is generally all
that is obtained.   Life may be prolonged for years.  Even Avith ascites, I
have knoAvn a patient in and out of St. George's Hospital for ten years.
Usually, although every complication  may be removed, the albumen con-
tinues in the urine.  The patient  resumes his work, and considers that he
is recovered;  but heat and nitric acid sIioav  that this is not the case; and
it is only by great care that the tendency to  a return of the former symp-
toms, or to gout, can be prevented.                   Part xxv., p. 126.
   Bright's Disease.—Urea  in this disease  accumulating in the  blood, is
best eliminated by  the administration of colchicum.     Part xx\.,p. 142.

  Renal Disease—Acute.—Dr.  Johnson  correctly remarks, how very
frequently acute  renal  diseases, with  dropsy and  albuminous urine, are 
KIDNEY AFFECTIONS.
109
preceded by chills upon the surface, produced often by working or stand-
ing in Avet clothes.  The same in cases occurring after scarlatina: hence it
is, that the chief means of preventing consequences  ensuing after scarlet
fever, are protection from cold until the period of desquamation has passed
by.  The circumstances under which these attacks of acute renal disease
occur,  and of the appearances observable in the urine and in the kidneys,
warrants the inference, that the renal changes are the  result of an effort to
eliminate some abnormal products,  which  have been conveyed to the kid-
neys by the blood.  In cases of scarlatina, for instance, it is probable that
exposure to cold has the effect of checking the process by which the fever-
poison, or ferment, or the product of fermentation, is eliminated from the
skin, and that the morbid materials are then transferred to the kidney, in
accordance Avith the Avell-known tendency to vicarious action of the skin
and kidneys.   An instructive illustration of this principle  is afforded by
the fact of several medicines, such as, for instance, the acetate or citrate
of ammonia, acting either as diaphoretics  or  diuretics, according as the
tendency is imparted to them by the skin being  kept warm, or the con-
trary.  These tacts may assist our  comprehension  of  Avhat probably hap-
pens when a patient is exposed to cold too early after the onset  of scarla*
tina.   The work of elimination is then transferred from the skin to the
kidney ;  and, as a result of this, there is, in some instances, a free  desqua-
mation of the renal epithelium, analogous, as it  appears, to the cutaneous
desquamation which follows the eruption of scarlatina.
   Where we  have albuminous urine  and  dropsy, the  greatest possible
care should be taken  to guard against cold, because it is the chief  cause
in the  production of renal disease,  and therefore must tend to perpetuate
it, if it already exist.  In cold Aveather the  patient  must be absolutely
compelled to  keep in bed, both on account of insuring the horizontal po-
sition, and also the equable warmth of the skin.   The diet should be scanty,
and, unless specially indicated, alcoholic stimulants should not be given.
The next thing is to obtain free action of the skin and bowels ; the first by
the hot-air bath and diaphoretic medicines, the  latter by saline aperients,
and the pulv. jalapae comp.
   The free action of these great excretory surfaces is a very efficient means
by which to lessen the injurious over-Avork of the kidneys.  It scarcely
need be said, that hoAvever scanty may be the urine,  no stimulant  diuretic
is to be given ; indeed, the more scanty the secretion, the more injurious
would be the effect of any irritating drug.
   During the convalescence, the  urine is usually twice as abundant as in
health, in consequence, probably, of the naturally  diuretic influence of the
urea and other urinary products which, having accumulated in  the  blood
during the acute stage of the disease, find a free outlet Avhen that stage is
passed.  A practitioner who has been perseveringly  giving diuretics, and
Avho is ignorant of this pathological fact, will  be likely to attribute to the
influence of his drugs this abundant flow of urine, which is, in fact, only a
natural and a spontaneous diuresis.
   It Avill be understood that, in deprecating the use of diuretics, it is only
with reference to cases of acute renal disease.   When the disease has be-
come chronic, and when an  excessive dropsical accumulation  constitutes
the most distressing and  dangerous symptom, Ave must endeavor to re-
move  the  dropsical accumulation  by means  of diuretics, whether these
accelerate the progress of the disease in the kidney or not. 
110
KIDNEY AFFECTIONS.
  After the acute stage of nephritis has passed, Dr. Johnson recommend*
that the patient, especially in winter, be kept in-doors, until no albumen
can be detected in the  urine.  If he rebels, he will very probably bring on
a relapse, of which  he should be warned.  If, after every precaution  has
been taken, and the period of confinement prolonged, still the  urine con-
tains albumen, though natural in other respects, gallic acid may be given;
and if after this the quantity of albumen continues, Dr. Johnson advises
that he should be  removed to the sea-side, and alloAved to take a daily
airing.  If the malady still  persists, and  assumes  a chronic form, the pa-
tient must be urged to take a sea voyage as early  as possible.  As to the
treatment of cerebral symptoms, consequent on acute inflammation of the
kidneys, as after scarlatina, or exposure to cold, Ave must relieve the con-
gested state by cupping over the region of the kidneys, and abstracting a
moderate  quantity of blood, and by exciting free  action in  the mucous
membrane  of the boAvels, by means of elaterium or pulv. jalap, co., Avith  a
few grains  of calomel sometimes added.
  If we can excite copious discharges from the  mucous membrane of the
bowels, we shall by that means eliminate  some of the  excreta Avhich are
poisoning the blood, for urea has been detected in the watery stools pro-
duced by elaterium.
  If the patient's appearance be not decidedly anaemic, we may venture to
abstract a small quantity of blood;  but we shall do this Avith much caution,
if Ave  bear in mind Dr. Watson's suggestion—sanctioned, too, by the high
authority of Dr. Todd—that an impoverished condition of the blood may
favor the tendency to coma  and the poisonous action of urea.  Cold lotions
may be applied to the head when  the scalp is  hot, and blisters Avhen the
skin is cool. Since, in any case, it is a more hopeful task to prevent drowsi-
ness from  passing into coma, than to bring  a  patient  out of a comatose
condition Avhen once he has fallen into it, it is important to keep a Avatchful
eye upon the  premonitory symptoms.  In some cases, it appears that the
most  successful mode of keeping them in check is to give a nutritious but
unstimulating  diet, Avith moderate  doses of steel, and, at the same time, to
keep  up a free action of the  boAvels.
  Can the kidney perfectly recover from an acute inflammatory attack 1
Dr. Johnson answers, yes, if the case has  come early under treatment, and
yielded to it in moderate time.  No harm will  result, except the spoiling
of a few of the tubes and Avasting of the parts, unless  the disease has been
so long prolonged as to destroy the epithelial lining of the tubes and ren-
der them liable to be converted into cysts.           Part xxviii., p. 134.

  Passive Hemorrhage from the Kidneys.—[It is not  always  easy, when
we  are quite certain that the urine contains blood, to be able to state defi-
nitely from what part of the urinary apparatus it proceeds.  Dr. Crooke is
of opinion that it often precedes that condition in Avhich  albumen is present
in the urine, viz., "chronic albuminous nephritisy" and that  it often in-
sidiously folloAvs " acute desquamative nephritis^ AA'hich is supposed  to
have  yielded to treatment.]
  Symptoms.—Passive renal hemorrhage offers to our notice two classes
of symptoms—the general and the  local.  The general are those of anemia,
the result of a continual draining aAvay of that vital fluid, the blood ; the
local  refer chiefly  to  the bladder.   The  general symptoms  are, a pallid
complexion, of a dirty-Avhite or muddy color; with  dilated pupils;  occa 
KIDNEY AFFECTIONS.
Ill
sional headache and singing in the ears; the tongue is large, flabby and
furred, the edges thereof indented by the teeth; the boAvels are open and
loose ;  there is much flatulence and nausea, wdth irregular appetite; palpi-
tation is frequent; the surface of the body is cool;  the skin  soft and re-
laxed, but dry ; the pulse full, soft and bounding, or small and soft, putting
on the former condition upon change of posture; there is gradual but pro-
gressive emaciation, irritability and gloominess of temper, Avith great dis-
inclination  to any exertion, bodily or mental.  These  symptoms vary in
degree according to the longer or shorter duration of the disease.
  2d. The local symptoms are  in  some cases an aching pain  in the loins,
but this is, perhaps, rather an exception than the rule.  They, the loins,
are rather the seat of an uneasiness and feeling of weakness, which is in-
creased upon  pressure;  the  calls to  micturate are  frequent  and urgent,
attended Avith pain, sometimes  referable to  the penis, sometimes to the
inside of the thighs and to the perineum;  the urine is not much, if at all,
increased in quantity when compared Avith  the amount of fluids imbibed.
   Treatment.—The therapeutical indications are three  in number.   First,
to check the hemorrhage by relieving the congestion;  secondly, to restore
the general health; thirdly, to guard  against relapse, and this  is an import-
ant point, as there is a great tendency thereto upon  the application of any
exciting cause.  The first indication may be  effected by rest, daily use of
the warm bath, with friction to the  bodily surface, local depletion, absti-
nence from diuretic drinks, bland farinaceous diet, and the use  of astringent
remedies.  To relieve  the gastro-hepatic derangement, a small quantity of
blue pill, Avith a sedative saline  draught, Avill be found useful at intervals \
during the exhibition  of astringent remedies, the best of Avhich  is  gallic
acid.  It  has been given  in the  folloAving form: Gallic acid, a drachm;
dilute hydrochloric acid, tAvo drachms ; solution of hydrochlorate of mor-
phia (E. P.), one drachm ; distilled water, five ounces and a half, as a mix-
ture ; a tablespoonful  to be taken  every fourth hour.  The therapeutical
effects of gallic acid are well described by Dr. Golding  Bird :  " Gallic acid
acts as a direct astringent, reaching  the renal  capillaries, and finding its
Avay into  the urine, Avhich  becomes  strongly charged Avith  it," etc.  To
relieve  the irritability of the bladder, five grains  of soap-and-opium pill
should be used every night as a suppository.  These medicines  should be
continued until the hemorrhage ceases, and the vesical irritability Avdiich
remains for some time after the cessation of the hemorrhage is relieved by
tincture of cantharides, in doses  of-from  ten to twenty drops, combined
Avith an anodyne.  When the urine is free from blood discs, the general
hygienic rules for restoring tone to the system should be enforced; animal
diet, with a few glasses of sherry daily, may be alloAA^ed, and  quinine Avith
iron prescribed.  As  preventive measures, the Avarm  bath with friction
should be daily persisted in; flannel should be worn next the skin, and all
exposure to exciting causes studiously avoided.         Part xxix., p. 147.

  Kidney—Irritation and Inflammation  of, from a Calculus.—Prevent
the increase  of the concretion  by correcting the unhealthy  state of the
urine according as acid, alkali, or oxalate of lime,  predominate.  Avoid
severe exercise.  Allay pain by the hottest hip-bath, at a temperature of
110° or 112° Fahr.; by chloroform internally and  externally;  by opium
and the injection of Avarm Avater into the rectum.  Guard against inflam-
mation, by general or local bleeding ; by aperients and sudorifics. 
112
KIDNEY AFFECTIONS.
  The complaints which may be mistaken for a nephritic attack are lum-
bago and colic.  The absence of vomiting in lumbago, and the seat of pain
in colic, may lead you to a correct opinion; but the presence of blood-
globules Avhen the urine is examined Avith the microscope, is the sure indi-
cation that the attack is caused by the descent of a renal calculus, and the
affection of the testicle may be generally found confirmatory of this opinion.
Do  not  think that in every case in which blood is found by the microscope
in the urine a calculus necessarily exists in the kidney.  Blood globules
may appear in the urine from simple congestion of the kidney in many dis-
eases—from Bright's disease, from inflammation of the mucous membrane
alone, from congestion or disease of the prostate, from scrofulous disease,
or malignant disease ; and in some of these diseases  the difficulty of dis-
tinguishing between them and renal calculus is by no  means easy. (Jones.)
                                                     Part Xxx., p. 85.

  Malignant and Scrofulous  Renal Disease.—Renal diseases are  often
very difficult of diagnosis.   We ask ourselves first, perhaps, whether it be
Bright's disease;  next, whether any concretion be  present, or whether in-
flammatory action exist; and,  lastly, Ave ask Avhether  the  case  be one of
malignant or scrofulous disease.  Neither malignant nor scrofulous disease
admits of easy relief, and, therefore, the medical attendant should be care-
ful in giving his prognosis.
  Sometimes, says  Dr. II. B.  Jones, no urinary symptoms whatever are
observed, the malignant disease existing in another more vital part, caus-
ing the renal disease to be entirely overlooked.
  Sometimes another urinary disease exists at the same  time, and thus the
symptoms are. made obscure.  Thus  granular disease of the kidney may
exist  with encephaloid disease, and the secondary symptoms produced  by
the former may alone force themselves on the attention.
  As far as I have hitherto observed, the  microscope  has  not enabled me
certainly to predict the presence of malignant  disease  of the kidney.  I
must  say the  same of incipient malignant disease of the bladder. The
symptoms of this disease  are more distressing than Avhen the kidney is
affected; but even Avhen I have felt confident of my diagnosis, I have some-
times been unable to confirm it by the microscopic discovery of malignant
cells,  in consequence of the highly alkaline urine acting on the cells.  In
other cases, in Avhich  small masses of malignant matter Avere passed, the
microscope has confirmed the diagnosis Avhich the  general symptoms had
made most probable.   Nor has the microscope as yet  enabled me to speak
certainly regarding the commencement of scrofulous  disease.  The means
of distinguishing betAveen scrofulous disease and calculus of the  bladder
or kidneys, are very insufficient; but  by careful attention to the  progress
of the  symptoms, more certainty  may be  attained than  by  help of the
microscope.
  In conclusion, then, as no certain microscopic or chemical test exists for
the early stage  of scrofulous and  malignant disease, it  will be  best, in
doubtful cases, to refuse to give a positive opinion.  Suspend your diagno
sis until, by carefully watching the progress of the case, you find sufficient
evidence of the nature of the disease.                   Part xxx., p. 87.
  Morbus Brightii.—According to  Dr. Handheld Jones, this is net an
inflammatory affection, but purely a disease of depraved nutrition; there-
fore, you must endeavor to improve the general vigor  and power of the 
KIDNEY AFFECTIONS.
113
system, and  thereAvith its nutrition, in every  possible way.   After the
dropsy is removed, you must still continue your treatment until the urine
is restored to its healthy condition, the  blood improved, and the  system
reinvigorated.  The folloAving is very useful in these cases: R Acid, nitrici,
miij.; tinct. cinchon., 3j.; inf. gent, co., §j.   Ter die.   R Tinct. ferri raur.,
rax.; aqua?, jj.   Ter die c. cibo.                      Part xxxi\.,p. 100.

  Iodide of Potassium in Dropsy, with BrighVs Disease of the Kidney.
—In the sub-acute or  chronic  form, give five grains  of iodine  and five
grains of bicarbonate of potass in one ounce of water three times a day.
It has been very successful in reducing the general anasarca and improving
the condition of the health.                          Part xxxii., p. 103.
  Supra-Renal  Capsides—Disease of.—The combination of the bronzed
state of the skin with great systemic debility may be held indicative of dis-
ease of the supra-renal capsules; and the more marked these conditions
are, the more positively may the opinion be formed.  A differential diag-
nosis may sometimes be requisite, hoAvever, as regards the folloAving dis-
eases : 1. Jaundice.  In some states of chronic  jaundice, the skin may be
broAvn rather than yellow, and great vital  depression  may exist.  Here,
however, the conjunctiva and the matrices of the nails Avould, by their dis-
colored state, prevent  the possibility of deception.  The  tint in jaundice
is also a diffused one, and does not occur in patches, as in true bronzing.
2. Browning from exposure to  the sun, etc. In  these,  the  examination of
parts protected by  the clothes would generally be sufficient to prevent
error.   3.  Pityriasis versicolor. The patches of pityriasis versicolor some-
times remarkably resemble those of the bronzed  skin.   Their  limitation
to the abdomen and chest, their defined outline, their furfuraceous surface,
the slight  itching Avhich attends them, their contagious character, and
aboAre all,  the microscopic examination  of  the  cuticle, furnish, however,
abundant means by  which to  distinguish between the two.  4. IVie dif-
fused brown muddiness of some other cachexia}.  The dark areola round the
eye, so often seen in states of disordered menstruation, is in rarer cases
found coincident Avith  a loss  of healthy  tint  in  the skin generally, Avhich
assumes a  dirty, sallOAV  brownish appearance.  This,  in  exaggerated in-
stances, might be mistaken for  bronzing.
  It should be borne in mind that in all cases, in which bronzing is to be
held as positively indicative of  diseased capsules, there ought to be traces
of patching and mottling in some parts,  and that in proportion as the tint
is equally diffused over the Avhole body is the diagnosis doubtful.
  We can  never give any other than an  unfavorable prognosis—no re-
covery from true bronzing of the skin has  ever been recorded;  but as we
believe that the changes Avhich the supra-renal bodies undergo, are allied
to inflammation, Ave should expect the most  benefit from mercury, in very
small doses, or the use of iodide of potassium—the patient's strength be-
ing meamvhile supported by a  nutritious, but non-stimulating diet.
                                                   Part xxxiii., p. 129,
  BrighVs Disease.—Liquor ammoniae acetatis, by acting on the skin and
relieving the  congested condition of the kidneys, is the best of all remedies
for this disease ; diuretics at the same time being strictly avoided, but not
mercurials.  (Dr. Addison.)                         Part xxxiii., p. 237.
  Frequent Micturition.—Dr.  G. Owen  Rees, gives the following:
     VOL II.—8 
114
KIDNEY AFFECTIONS.
  Among the causes of frequent micturition is rena. calculus.  In this dis-
tretr"^iffection little  or nothing can  be done.  To the patient's own
feelings the bladder is often  the seat of the disease, and even by medical
men tliese cases have been mistaken for  irritation of the neck of the blad-
der caused by stricture, and the most lamentable results brought about by
the violent measures resorted to for relief.  A correct diagnosis may how-
ever generally be formed.                                       .
  Frfquent micturition, with small quantities of pus in the urine, loin pain
and lassitude, if we have an early history of hematuria, should guide us to
diagnose renal calculus;  and  even  if  frequent micturition  and a  small
quantity of pus be the only symptoms,  we shall generally be right in giv-
fncr the  above  opinion, even if history  fail to afford us evidence of  hema-
turia.  The presence of a small quantity of pus in the  urine would appear
easily explained in its relations to renal  calculus.                   >
  The hollowing out of the nephritic structure, which we find occurring m
order to make room for calculi about to become encysted in the kidneys,
must have been effected  by  a gradual process of  disintegration, and this
we know is preceded by inflammation.  The  purulent discharge  would
thus seem to attend the formation of a convenient  cavity for the lodgment
of the calculus.   So long as this action is going on, the patient will pass
pus in the urine, and  it may be some  years before matters are adjusted.
The constitution has much to go through.  A scrofulous taint leads to ab-
scess in  the kidney, and death.  The more fortunately constituted  gene-
rally do Avell, provided they  can be induced to avoid the catheter and  the
sound.
  In speaking of the condition of the urine in this calculous affection of the
kidney,  I have  made use of a someAvhat indefinite  expression, viz., " a
small quantity of pus."   By this I would wish my readers to understand
a urine depositing a yellowish-white sediment, but not  in such  quantity
that the patient's  attention need be attracted by it.   It renders the urine
but slightly turbid as it is passed, or Avhen the deposit is shaken up
in it.
   This is the  general state of things when nephritic calculus is encysting,
or  Avhen it fails to find  its Avay doAvn  the ureter, provided constitutional
causes do not interfere to produce suppurative disease, \Arhich may appear
in the form of pyelitis or of  general abscess of the kidney.  This purulent
impregnation is constant, and, if it fail to shoAV itself so as to be evident to
the unassisted eye, the microscope rarely fails to demonstrate the presence
of pus so long as the bladder is irritable.
   There is  a cause for frequent micturition  so  nearly  connected in its
symptoms with that last noticed, that  it  naturally suggests  itself in  this
place.  It consists in a state  of kidney  known  as strumous kidney, or
phthisical kidney, as some authors have designated it.  If calculous disease
develop itself in a strumous  subject,  Ave find  very  early that  abscess
results; but in all subjects some amount  of pus  may  be expected during
the time of encysting.  In  phthisis of the kidney, however, the bladder
becomes irritable without any  evidence of a calculous disposition ; and we
find that pus can be clearly proved in the urine.   The symptoms are gene-
rally at first considered to depend  on  calculus, and it too often  happens
that the disease has made great progress before the real state of the  case
becomes evident.  The  symptoms are at first nearly identical Avith those
of nephritic calculus.  The same degree of sharp  lumbar pain, however, is 
KIDNEY AFFECTIONS.
115
 not present, and there is no history of hematuria; but the symptoms pre-
 senting themselves at  the  time of examination bear a striking similarity ;
 and if the previous history  be not ascertained, a diagnosis is next to impos-
 sible.   It is both for the advantage of the practitioner and of the patient
 that this distinction should be  early made;  for if calculus be the exciting
 cause, of course our prognosis will be more favorable.
   The two points for consideration are—1st. The diathesis of the patient.
 2nd.  The history as to hematuria.   If frequent micturition and purulent
 urine, such as I have  described, be present in a strumous person,  and we
 have  no history of hematuria, Ave  may diagnose phthisis of the  kidney.
 If frequent micturition and  purulent  urine coexist with a history  of hema-
 turia, then, in all probability, there is  calculus.  We must not  conclude,
 however, that because calculus is  present we have no fear of the worst
 results, for if the patient be of strumous habit, abscess may result as a con-
 sequence.  In all  cases, however, the history of hematuria is an advan-
 tage, inasmuch as even should the patient be  strumous, the calculus may
 be voided, and, the exciting cause of mischief being  thus removed, the
 kidney may recover itself, and the patient do well.
   Amongst causes for  frequent micturition,  we find diabetes enumerated.
 The quantity passed on, each occasion is, however, so  large, compared Avith
 that characterizing most of the other states  I have described, that the pa-
 tient's attention is attracted by the large discharge, as Avell as by the frequent
 call, and the former is related as the more prominent symptom. This should
 lead at once to the examination of the urine for sugar, and if that be not
 found, we may perhaps determine the presence of insipid diabetes by the
 low specitic gravity, the increased flow, great thirst, and other character-
 istic symptoms.   It does, however, now and then happen in diabetes that
 frequent call  to  pass  urine has  been the symptom most noticed by the
 patient, and then, if due care be not taken, the practitioner is a long time
 led astray.  Cases such as these by no means infrequently occur.  They
 are sometimes treated as dependent on the gouty  diathesis, a  uric acid
 deposit having attracted the attention of the  medical attendant.  Treat-
 ment is then persevered in  until all the more aggravated symptoms of dia-
 betes appear.  The early detection of this disease, which is so important
 for its reliefj is thus prevented.
   I now have  to speak of two forms  of cancerous affection which may pro-
 duce  frequent micturition, viz., malignant disease of the kidney and of
 the bladder.   These two states  are characterized by hematuria.   It some-
 times happens that the irritability of the bladder is so  great, Avhen the
 kidney alone is involved, that this sympathetic affection may be mistaken
 for the  primary disease, and the  nephritic mischief entirely overlooked.
 What I  would wish to enforce is, that  these  two  symptoms, hematuria
 and frequent  micturition, taken together, should be regarded (the pros-
 tate being excluded) as indicating calculus or malignant disease, and that
 either the  kidney or  the  bladder may  be  in fault.  The indications of
 cystitis, shown by the urine Avhen calculus exists, have been already dwelt
 upon; but when malignant  disease is present, there may be none of these.
 The  urine  may be clear, or may only contain  such a small quantity of
blood that very careful  examination  is requisite in  order to detect it by
 the naked eye. Here  the  kidney might  be considered in  fault, and the
 diagnosis is not always to be made. 
116
KIDNEY AFFECTIONS.
  If we  have a tumor of the abdomen over  the region of the kidney,
then Ave may safely diagnose  that organ involved ; but this indication 13
not  always  afforded us, and then Ave should  examine the bladder very
carefully. If, on sounding, hemorrhage occur to an extent exceeding that
usually  produced by exploration, there is most  likely a growth on  the
mucous surface of the bladder.
  Before leaving this part of my subject, I must  say a Avord  or  two
respecting the seat of tumor in these forms of disease.   First, Avith regard
to the kidney.  It is necessary to guard against being led astray by the
tumor appearing in a position someAvhat removed from that in which it
ordinarily exists.  Nephritic enlargement sometimes occurs at the upper
portion of a kidney, and in abscess of the organ especially, there  is  often
considerable bulging upward.  This may occur to such an extent that the
tumor eventually may be felt in that  part of the abdomen  usually occu-
pied by the liver, and in malignant affections also, if the right kidney be
involved, the tumor may exist over nearly the whole of the right hypo-
chondriac region.  An able paper will  be found  in the "Guy's Hospital
Reports," in which Dr. Bright has given sketches illustrative of this tact.
  As regards the production of frequent micturition by malignant disease
of the bladder, the tumor must be situated near the neck of the organ in
order to cause the symptom.  I have had two cases Avithin the last few
years especially illustrative of this  point.  In  the one, so little  inconve-
nience was felt that had it not been for the microscopical indications of the
urine, I should have inevitably  mistaken the  disease.  There was no in-
creased desire to pass urine, and no pain ; and  hematuria Avas  only an
occasional symptom.  Post-mortem examination showed the  advantage to
be derived from microscopic research, the diagnosis being verified by the
presence of a large mass of villous growth on the fundus of the bladder.
The situation of the tumor, far removed from' the neck of the organ,
explained the absence of the symptom of frequent  micturition.  In  the
other case, a tumor of the same kind existed near  the neck of the bladder,
and the irritation was most  torturing.   The symptoms otherwise exactly
resembled those of the former  case.   There Avas the same hemorrhage
after sounding, and  hematuria Avas of very frequent  occurrence.  I have
spoken of certain microscopical appearances Avhich determined my diagno-
sis : these Avere merely such as I have  detailed in  former lectures, consist-
ing in the presence of those  corpuscles or  cells  which are found in the
villous growths  from mucous membranes, and which, when they can be
satisfactorily determined to exist in the urine,  are always most significant.
  Before leaving the analytical symptomatology of frequent  micturition,  I
would speak of the influence of habit and of nervousness in continuing the
symptom, even after the obvious causes producing it are removed.  With
regard to habit, it is in some cases of the greatest  importance to inform the
patient  of his position, and to instruct him to restrain himself as  much aa
possible.  If he will do this, his malady becomes of  necessity of shorter
duration.  We often find the subjects of this symptom acquainted with
every corner suitable for the relief of their wants. They are reminded of
their malady on approaching their Avonted haunts.  An  effort is required
to pass  them, and it is well  to  instruct such  patients to make a point of
doing so if they possibly can.  The nervous feeling which arises  in suffer-
ers from this  infirmity when they find themselves in company is very dis-
tressing.  They are certain to feed the inclination when  there is the greatest 
KIDNEY AFFECTIONS.
117
difficulty in gratifying it.   They  consequently refuse  to  go into  society.
They are, perhaps, urged to do  so ;  they suffer  great misery, and their
complaint becomes aggravated.  This should never be alloAved.  Let them
airoid company, and as their complaint improves they  get more courage ;
and  there is no fear of a return of this nervousness, except they again
become the  subjects  of those physical ailments which originated  the
disease.                                            Part xxx v., p. 310.
  Movable Kidneys.—A knoAvledge of the  fact that  the kidneys may, in
a healthyperson, be in abnormal position in  the abdomen, and detectible
by external manipulation, is important, lest any errors  in  diagnosis should
be caused from suspecting the presence  of some  malignant or otherwise
dangerous tumor.  In these cases the  mass is smooth,  hard, and resisting,
rounded in outline, can be moved upward and slightly downward.
                                                   Part xxxvii., p. 84.
  BrighVs Disease.—Our diagnosis as to the state of advancement of this
disease Avill be materially assisted by observing the size of the waxy casts,
which increases in  diameter as the disease progresses, owing to the  tubes
becoming denuded of their epithelial lining.
  The larger casts, which have the full diameter of the uriniferous tubes,
and a remarkably sharp outline, having been formed in tubes which haATe
lost  their epithelial lining, and  with  it their proper  secretory function.
These large casts then indicate a more serious degeneration of the tubular
structure than the  small ones.  They are often combined in the urine of the
same patient, but the  existence of a large proportion of the full-sized Avax-
like  casts in the urinary sediment is usually a sign of  serious  impbrt, and
indicates an advanced form of disease.                Part xxxvii., p. 89.

  Employment of Sugar in the Dyscrasia attending Bronzed Skin.—Dr.
Todd, in a case of bronzing  of the skin under  his treatment in King's
College Hospital,  ordered the free dietetic employment of sugar.  The
patient, a woman,  is believed to have  derived considerable benefit from it
in relief to the malaise and debility from Avhich she suffered.  The theory
of the treatment is, Ave believe, based on the  belief, founded on analyses of
the blood, that the sugar-making function of the liver is interfered  Avith by
the disease.                                       Part xxxvii., p. 104.
  Addison's  Disease—Case  of Diseased  Super-renal  Capsules,  with
Asthenia.—A young man died lately at Guy's Hospital, Avho Avas affected
Avith the asthenia or debility to which Dr. Addison has drawn attention in
his curious monograph—an affection now pretty generally knoAvn  in prac-
tice as " Addison's Disease."  The duskiness or blotching of the skin  Avas
peculiarly Avell  marked, for a period extending over tAvo years, and of a
deeper tinge  at the navel, nipples, and  scrotum.   He had dizziness and
failure of vision on attempting to Avalk, and no appetite.  He was laboring,
in tact, under what is  called at Guy's,  by some, as "Asthenia Addisonii."
  We believe the term "Melasma" gives a  very  absurd  idea of the dis-
ease  ; and the word " bronzing"  Dr.  Addison has, over  and  over again,
repudiated, as not  occurring in any of his Avritings on  the disease.
  Post-mortem Appearance.—The color of the darker portions of the skin
was  very deep, something  between the  tinge of the quadroon,  am'  the
greenish brown of some bodies long kept in the dead-house ; the axilla,
umbilicus, and genital organs, Avere  particularly dark  or blotched: the 
118
LABIUM.
margin of the lips also were dark; the hair darkish ; eyes grey; the mucles
were red and of good size; the contents of the chest presented nothing
abnormal; the brain was healthy ; the  lungs—Avith the exception  of the
apex of the right lung—were healthy; the heart was small, but firm, red,
and healthy; the veins full of blood; the mucous membrane of the stomach
AA'as very much injected, and the surface covered Avith tenacious mucus, as
if a low form of gastritis existed ; intestines healthy ; mesenteric and other
glands healthy, as were the liver, spleen,  and  pancreas.   Coming to
the suprarenal  capsules, they were found to  be entirely destroyed, by a
deposit of an albuminous cretaceous  deposit; there appeared, also, signs
of inflammation of their investing capsules, as the  latter were firmly adhe-
rent to surrounding parts; the right capsule was thus united to  the liver
and top of the kidney, and the surrounding fat could not be removed in
the ordinary Avay; the  right capsule Avas about the size  of the healthy
organ, but the left Avas puckered into  a roundish mass about the size  of a
walnut; both, in fact, seemed filled Avith a cretaceous  matter, or white
amorphous substance like tubercle ; the right capsule Avas  softened in its
middle, containing a fluid like pus.  In rough terms Ave would say the cap-
sules, as is usual Avhile they are diseased, in  this  affection, Avere full  of a
chalky, tuberculous matter that injured the nervous tissues around  them.
The  most  suggestive feature  in  the  case, in fact, was the  condition of
the semilunar ganglion, the nerve branches of which ran quite into the
diseased capsules, and were lost in them.
  We need only say the pigmentary matter in the skin presented nothing
of importance, being  found in the rete mucosum, where it Avas probably
deposited in a passive manner; the destruction of the  semilunar ganglia
prevented its normal assimilation or absorption.
  This disease is not so much due to any vital action which the supra-renal
capsules perform in the economy, as to the pressure  or  injury exerted by
the enlarged organs on the semi-lunar ganglia and solar piexns, Avith both
of Avhich the capsules are intimately associated.  Dr. Habershon  adopting
this view, first proposed by Dr. Copland, treated this easy by the use of
electricity, together with bark and iodide of potassium. Considerable relief
was afforded.                                     Pan xxxviii., p.  114.

                              ---»-*-•---
                           LABIUM.
   Case of Encysted  Tumor of the Labium.—Dr. Macdonnell ivas con-
sulted by a lady on account of a tumor in the labium, of  three years' du-
ration, which presented some of the characters of hernia.  It differed, hoAV-
ever, from that disease in so many respects as to justify, in Dr. Macdonnell's
opinion, exploration. The folloAAdng is the account he gives of the treatment:
  March 20th. An exploratory puncture Avas  made, and water of a dark
olive color, devoid  of odor, escaped.   The  opening Avas  enlarged, and a
tumblerful of  thick fluid floAved out, which Avas of a creamy consistence,
aud on microscopic examination was found to be composed of decomposed
pus globules, ^ with a large quantity of  what  appeared  to be  epithelial
scales  intermixed.  The sac of the  tumor was  freely  cauterized Avith
nitrate of silver conveyed on a probe, and the  orifice kept open by meand
of a plug of hnt. 
LABOR.                            119
   27th. The sac of the tumor has  been filled up Avith solid secretion, and
 has undergone great diminution in size; no general disturbance.
   April 1st. Scarcely any trace of the tumor to be detected, except some
 thickening of the labium, giving to it a greater fullness and prominence
 than  the other.  Ordered to apply mercurial ointment.
   10th. Perfectly recovered; no traces of the disease left.
   Four plans of treatment have been recommended for the cure of these
 tumors: 1st. Complete dissection out of the Avhole cyst—a plan which must
 be extremely difficult in most cases, in all  extremely painful, and in such
 a case as mine quite impracticable.   2d. Laying open the  cyst, and fill-
 ing it with charpie.  3d. Seton.  4th. Removal of the fluid, and then com-
 pression, so as  to bring the walls of the cyst into close apposition.  The
 plan  of treatment Avhich I have employed for some years past has been to
 cauterize Avith nitrate of silver the lining membrane of the cyst, so as to
 cause adhesive inflammation, and this process I have found to be so readily
 excited by the  caustic, that I have never been obliged to repeat it a second
 time.                                                Part xix., p. 211.

   Fibrous Tumor oft/ie Labium.—In a case of this nature, in Guy's Hos-
 pital, Mr. Massey made an incision in a longitudinal direction from one ex-
 tremity of the labium to the other, to the inner side of the large venous
 trunk, and just Avithin the mucous surface.  A  finger was then introduced
 between the integuments and tumor, and its loose  connections Avith the
 surrounding tissues forcibly torn  through, and the mass completely enu-
 cleated.   It is of some practical importance to remember that these tumors
 are closely coated with cellular tissue of a dense character, and it is neces-
 sary to cut through this in order to turn out the growth.   It is quite easy
 for the operator to mistake the capsule for the surface  of the  tumor, and
 to be trying to separate the integument from it, which Avould be a long
 process; and to  prevent this it is better to cut slightly into the tumor
 itself, Avhen the edge of the capsular covering is at once indicated, from
 whence the enucleation is readily completed.           Part xxv.,p. 290.

                              —•-•-•—


                            LABOR.
   Case of Complete Detachment of the Os Uteri during Labor.—[In this
 extraordinary case the os uteri remained obstinately closed for a consider-
 able period, and notwithstanding the regular  action of the Avomb, aided by
 the gentle use of ergot, it remained but little  dilated to the last.  Mr. Car-
 michael proceeds to say:]
  The os uteri  did not  yield, but  the head Avas  propelled fully into  the
pelvis, pushing the cervix before it.   In the course of the evening of the
second day the patient's  condition grew w;orse, she became delirious, the
pulse  quick and irregular; and, in  a word, she must have quickly sunk if
interference had not been resorted to.  To apply the forceps,  I can only
say, the circumstances of the case Avere such  as decidedly to preclude it.
The perforator was resorted  to, and the cranium evacuated of its contents ;
the crotchet was then  introduced, and traction, of a \rery gentle nature,
made  on one of the parietal bones.  During this, however,  a strong con-
traction of the uterus succeeded, when the head Avas at once expelled, car- 
120
LABOK.
rying before it the os uteri and a part of the cervix of the womb, the dia-
meter of which measured about three inches and a half.
  The placenta came away in the usual manner ; there Avas, hoAvever, con-
siderable hemorrhage, and  such difficulty in getting the womb to contract
that the cold affusion  became necessary.  Two hours after the delivery I
became much alarmed for my patient; jactitation, restlessness, difficulty of
breathing, etc.   I gave her a full anodyne, and having procured tranquil-
lity and given all the necessary instructions to a competent person as to th«
state of the uterus,  Avhich Avas padded, and other parts to be attended to,
left her for the night.   On  my visit the next morning, to my surprise, she
Avas sitting up in bed, eating her breakfist, expressing Iioav comfortable her
condition was compared with that  of the preceding day.   Part \\.,p. 148.

   Use of the Perforator and Crotchet.—The following series of aphorisms
from the researches of  Dr. Churchill, will be found useful to be knoAvn at
the bed-side.
  It  may be asked, when the  responsibility is so serious, Avhat evidence
will be sufficient to  satisfy a conscientious practitioner that he may not be
committing a crime in his anxious endeavors-to afford relief?   To this it
may be ansAvered:
  1. That the continuance of strong labor pains for a certain time, Avithout
any advance  of the  head of the child, is so far evidence of a fixed obstacle
to the passage of the child.
  2.  The failure of a cautious attempt to  introduce the forceps will, to a
certain extent, demonstrate the amount of the disproportion betAveen the
head and the pelvis;  and the failure of a careful, yet  firm attempt at ex-
traction  by the forceps  (when the  application has been effected), will prove
that the  disproportion cannot be remedied by compression.
  3.  A- well  educated finger will enable us in most cases to ascertain Avhe-
ther the  diameters of the pelvis are such as will allow of  the  passage of a
living child.   And  even though this mode be uncertain, Ave have a means
of correcting our estimate, by comparison Avith the child's head in apposi-
tion Avith the pelvis.  If the natural efforts after several hours, or  the for-
ceps Avith a proper  and safe amount of compression and force, cannot  bring
the widest part of  the head of the child  through the narroAV part of the
pelvis, Ave may fairly conclude that the only resource is craniotomy.
   4. The general condition of the mother will also aid our decision.  If she
be much exhausted, if fever be present, the uterus powerless, the life of the
child doubtful, and the  success of  the forceps dubious, Ave may shrink from
inflicting the double shock of an unsuccessful application of the forceps and
subsequent delivery by the crotchet.  But these cases are very rare: they
only happen  Avhen the patient has  been mismanaged, and it requires expe-
rience and judgment to decide upon the propriety  of terminating them by
embryotomy.
   The cases  in which the operation  is demanded are:
   1. When the child is dead, and the labor tedious.  But Ave must be quite
sure that the child be dead, before this is made the ground of interference.
   2. In  distortion of the pelvis, when the antero-posterior diameter of the
brim is less than three inches, we  have no chance of delivery by the natu
ral efforts, or by the forceps; so that to save  the mother  Ave must destroy
the child.
   3. When the transverse diameter of theloAver outlet is diminished to tho 
LABOK.
121
same extent by the approximation of the tubera ischii, if the forceps, applied
antero-posteriorly, are insufficient to move the head, Ave must have recourse
to craniotomy.
  4. When the calibre of the pelvis is diminished to a certain degree by a
fixed obstacle—as, for example, a fibrous tumor, or an exostosis  groAving
from the bone or periosteum, it may not be possible for the natural efforts
ulone, or aided by the forceps, to expel the child.  In such a case, it will
be necessary to lessen the head, and apply  the crotchet.
  In these three latter classes of cases, the passage through the pelvis may
be so much diminished as to render it necessary to break up the skull,  or
to eviscerate the  child.
  5. In some cases of ovarian disease, where the tumor has formed adhe-
sion within the pelvis, so as to prevent its being pushed above the brim, it
has been found necessary to lessen the head before the child could be ex-
tracted.   We are not, however, to decide upon  this measure until the
natural powers have had a fair trial, as it sometimes happens, that in the
progress of labor, the tumor is so much displaced as to alloAV of the passage
of the child.  Further, it will be worth while, before sacrificing the infant,
to ascertain Avhether the contents of the tumor may not  be draAvn off', by
passing a long trocar into it.  If  a small quantity of fluid escape, it may
allow of the application of the forceps, and so enabje us to save the child.
If, hoAvever, the tumor prove to be solid and immovable, Ave  must, as a
" dernier ressort," have recourse to the perforator and  crotchet.
  6. When a child is hydrocephalic to such an extent as to prevent its en-
tering or passing through the pelvis, Avhether distorted or of the natural
tize, there can be no question as to the propriety of opening  the head.
  7. In some cases of convulsions, rupture  of the uterus, etc., where imme-
diate delivery is necessary, and where the forceps cannot be applied, crani-
otomy must be performed.
  8. If an arm descend along with the head, the  diameters of Avhich corres-
pond closely to those of the pelvis (Avhether the latter be of the usual
size  or not), it may be necessary  to terminate the labor  by opening the
head.
  9. I have already alluded to a  class of cases, Avhere, from mismanage-
ment the patient  has been allowed to continue'too long Avithout help, and
in consequence is greatly exhausted Avith fever, quick pulse, delirium, etc.
In such cases the patient will die if she be not assisted ;  and from the un-
favorable state in Avhich she is, she cannot bear a prolonged or very painful
operation.   Now, if there be sufficient space for  the forceps, they ought to
be preferred, and it would be very wrong to use  the perforator ; but if this
be doubtful, and the probabilities against our succeeding with that instru-
ment, then the consideration of the patient's inability to bear a severe ope-
ration may in some cases decide us in favor of embryotomy.  These cases,
however, are but fe\vr, and they must be Avell marked, to justify our adopt-
ing at once such extreme measures.
  10. In footling or  breech cases, Avhen the head (separated  or not from
the body) cannot be extracted, Ave must evacuate its contents.
  The  next question to be decided, is the period of  labor at Avhich the
operation should  be performed.
  1. In all cases where  the  diminution of  the  pelvic  diameters is  so
great as to render it impossible that a living child, can be born naturally
or extracted, there can be no hesitation in recommending that the head 
122
LABOR.
should be opened at an early period  of the labor, say as soon  as  the o»
uteri  is  dilated, or  fully dilatable.
  2. When the  distortion is less, Ave cannot be sure as to the result of the
natural efforts, and we must wait until it is evident that  they are  inade-
quate ; then an endeavor should  be made to use the forceps, and  if this
fail, there should be no delay in the performance of embryotomy.
  3. These observations will apply  equally to the case of morbid growths,
ovarian disease,  etc., obstructing the passages.
  4. In cases of convulsions, ruptured uterus, etc., the time for the  opera-
tion is determined by circumstances connected Avith those accidents, and
which will be found laid doAvn in the Avorks on the subject.
  5. In the mismanaged cases to which I have alluded, the condition of the
woman, Avhich determines the necessity for the operation, will also point
out the importance of promptitude.  If the case be so bad  that Ave dare
not risk a failure Avith the forceps, it is clear that  Ave cannot afford to delay
embryotomy.
  After  the head is  extracted,  the body generally folloAvs Avithout much
difficulty ; but should  this not be the case, we must have recourse  to evisce-
ration.   The scissors  must  be plunged into the chest  and  the contents
broken up; the crotchet hooked  upon the ribs, and  traction exerted.
The contents of the abdominal cavity  may be evacuated in a similar way,
and after this Ave shall generally be able to  extricate the child.
                                                      Part hi., p. 121.

  Parturition without Consciousness.—Mr. Rawson was called to this
case immediately on the waters  being  discharged.  No pain Avas present,
and she Avas asleep on his arrival.
  On examination, I found the os uteri dilated, and the head presenting.
The child  Avas slowly and unintermittingly,  but forcibly, expelled.  She
betrayed no symptoms of uneasiness Avhatever, and though I watched her
countenance, she did  not exhibit the least consciousness  of the child's ex-
pulsion, but expressed her surprise on  seeing it.  The child Avas strong and
lively, and, Avith the  mother, did Avell.  The mother was  about  tAvo-and-
twenty, short, plethoric, and healthy.
  I conceive the above case is interesting in a medico-legal point of view.
Dr. Montgomery doubts the possibility of such an occurrence, " excepting
under peculiar circumstances, certainly not in a first delivery."—(Dr. M.'s
"Exposition  of the  Signs and Symptoms of Pregnancy.")' In Beck's
"Medical Jurisprudence," it is said that " the possibility of a Avoman being
delivered Avithout  being  conscious of it,  is  disbelieved,  excepting some
extraordinary and striking cause intervene."   But if such a circumstance
can happen with & first child, it  must have its full Aveight in cases of infan-
ticide.                                                 Part iv., p. 135.

  Advantages of keeping the Umbilical Cord whole for some short time
after  Birth.—In all cases Avhere the infant  is born Aveakly or  in a state of
asphyxia, M. Baudelocque recommends not to cut the umbilical cord for
some  time at least after birth.   He relates  that since he has folloAved the
opinions of Smellie, Levret,  Chaussier, etc., on  this subject, he has not
lost a single case, although Avhen born the child might  be in a state of
pretty complete asphyxia or apoplexy.  He states that,  though a child
be  born in an apoplectic or asphyxiated  state, the circulation  still con- 
LABOR.
123
 tinues  through the umbilical vein,  even though the umbilical  arteries
 should  have ceased to beat, and that premature section of the umbilical
 cord takes away one of the chief aids to its revival.       Part iv., p. 135.

   Remarkable Birth of Twins.—Dr. Schroder gives  the  following case :
   On the 16th of November, I Avas sent for, to a robust healthy  woman,
 who, three days before  had been delivered of a first child about 29 Aveeks
 old, in order to remove the after-birth. I very soon discovered that there
 Avas a second child in utero.   The woman appeared to be vigorous ;  there
 had been no pain since  the birth of the first child ; there Avas no hemor-
 rhage ; the bladder Avas not distended; the situation of the child  Avas not
 high, the head  presenting:  and I saAv no reason for forcing  delivery.   I
 visited  the woman several times, to ascertain the progress. At last on the
 sixth day the second child was born,  and immediately  afterward the after-
 birth came aAvay, Avithout any assistance.  Both children are living.
                                                       Party., p. 160.

   Alternate  Warmth and Cold  as an Excitement to Uterine Action.—
 Mr. C.  Simpson writes as follows :
   Some little time ago I had under  my care a case of puerperal  convul-
 sions which  terminated Avell. The  patient  became  conscious, but Avas
 obstinate.   With great difficulty I forced some liquid into the mouth, but
 she Avould not swalloAv; I therefore dashed cold water  in the face,  and the
 contents of the mouth Avere instantly gulped doAvn.  This novel mode of
 making patients sAvallow Avas repeated, 1 should say,  a dozen times, and
 with the same invariable effect.  During the convulsions the labor stopped.
 There Avas,  as it Avere, a metastasis of muscular action, from the apparatus
 of parturition, distributed over the whole' system.  Every resource in this
 state of things Avhich  Avas employed to produce uterine pains did but
 aggravate the general  convulsions  Avithout  acting on the uterus itself.
 After the lapse of many hours, however, the labor Avas resumed, and now
 the cold Avater, applied suddenly to  the abdomen, Avas most  effective in
 producing uterine contractions.  After a little  Avhile, hoAvever, this lost its
 utility.   The abdominal surface becoming cold from the repeated applica-
 tion,  the Avater no longer acted  as an excitant.  Accordingly warm flan-
 nels were applied  to restore the temperature, and then cold water AATas
 again applied Avith decided effect.  This alternate application  of cold and
 heat is of great value in cases of hemorrhage from the uterus.
                                                     Part vii., p. 182.

   Tartar Emetic in Tardy Labor.—Ramsbotham, speaking of rigidity of
 the os uteri, says that antimony, in doses sufficient to keep up  a feeling of
 nausea,  has been exhibited in these cases Avith marked effect.   Dr. Gilbert
 also highly recommends the same in doses sufficient to induce and main-
 tain emesis, retching, etc., in cases of  tedious labor consequent upon insuf-
 ficiency of uterine contractions, and rigidity of the os tincae.  These  cases
arc most frequently found to occur in patients of tense fibre  and  robust
constitutions.                                          Part ix., p. 203.

  Injection  of the Uterus as a means of Expediting Delivery.—The
editor of the " Medical Gazette " mentions a singular  process Avhich was
adopted near  Edinburgh, at the suggestion  of Mr. Dick,  the veterinary
surgeon, to expedite the delivery of a cow. The animal had been in labor 
124
LABOK.
a considerable time, and was nearly exhausted ; six or eight quarts of
tepid water were now injected  into the  uterus, which in hve minutes
caused such vigorous pain  that  the animal was  speedily released.  11ns
plan has since been adopted in the human subject, by a surgeon, in a case
Avhere nothing but  the long forceps could have  effected  delivery.  He
iniected about a  quart of tepid water, with similar success.
 J              H                                     Part x., p. 195.

   Obstructed Labor—Division of the Symphysis Pubis in certain Cases
0fi—Dr.  Smith says that division of the symphysis  pubis is a much less
formidable operation than  either cesarean section or craniotomy, and ad-
vocates its adoption in certain cases.  The operation Avas  founded on the
opinion that the  ligaments of the pelvis relaxed during labor, a fact well
known to occur  in many of the  lower animals, and Avhich  authors of the
highest respectability, as Ruysch, Harvey, and Denman, affirm to be not
uncommon in- the human female ; Dr. Denman also mentions a case where
it  existed  in. a  Avoman Avho died three or  four  days  after delivery.
Dr. Churchill  mentions three cases in Avhich the operation was performed,
and all the patients  recovered, after having the ossa pubis separated for
three inches, two inches and a  half, and tAvo  and  a sixth respectively.
Dr. Menzies and Dr. Smith made  a number of examinations on recently
dead females, and found that an inch and a sixth Avas the  greatest extent
to which the pubic bones could be separated Avithout injuring the sacro-
iliac ligaments.   But experiments on the recent subject are far from satis-
factory, since in the  one case the ligaments seem possessed of an unusual
degree of elasticity, while in the other they have the rigidity of dead
animal fibre.  They  satisfied themselves also that the antero-posterior was
the diameter  least increased by it; that the distance to which the bone
could be separated was greatly influenced by the position of the trunk
and limbs ; that the force  required to  separate them, such  as  drawing
doAvn a foetus into and through the pelvis, Avas much greater than could be
justifiably applied to the structure  of the living female, and lastly, that,
Avith care, neither bladder, peritoneum,  nor  urethra,  need  be injured.
The fatal result of many of those  cases in Avhich this operation was per-
formed on the continent, show that these structures had been injured.
   [The gist of this paper rests on the assumption, that in the  human race
the maternal passages and foetal  head are  so adapted, that a slight devia-
tion from their relative normal proportions becomes a cause of obstructed
labor, and Professor Simpson has shown that the slight difference between
the head of the  male and female child  is quite  sufficient  to  account for
many of the difficulties and dangers of parturition.]
   The conclusions may be summed up as folloAvs:
   1. Craniotomy is, in  all  cases of obstructed  labor, justifiable Avhen the
entire foetus cannot be extracted through the pelvis, from deformity at the
 brim, from osseous and  certain  other tumors, and from great contraction
of the outlet by the near approach  of the tuberosities of the ischia to each
other—the obstruction being more than can be overcome by the forceps,
or other means, yet not so much but that a mutilated foetus may pass.
 2.  The caesarian  section must be resorted to Avhenever the deformity is so
 great  that  a  mutilated  foetus cannot be extracted  through  the natural
 openings ; and for  Avhich  operation symphysotomy  can never be  substi-
tuted.   3. Symphysotomy  is only  applicable  to  cases in which the de- 
LABOK.
125
livery cannot be accomplished by the forceps, and would require that cra-
niotomy should be performed—the obstruction  being  dependent on the
funnel-shaped  form of the pelvis, and satisfactorily ascertained to be such
that a slight increase to the contracted diameter would permit an entire
child to pass;  but in no  instance Avould it be  justifiable to resort to this
operation if any uncertainty existed either as to the degree of deformity
of the pelvis, or the vitality of the child.                Part xi., p. 205.

   Turning.—[Many writers on midwifery recommend that in the ope-
ration  of turning,  both feet  should, if possible, be grasped and  pulled
down.    We entirely agree Avith Professor Simpson in  the following very
judicious remarks.]
   In most cases I hold this method to be improper and unjustifiable, be-
cause it is almost always more difficult  to  seize both extremities than to
seize one ; because one is quite sufficient for our purpose, and more safe for
the  life of the  mother; and because by pulling at one extremity (Avhen
pulling does happen to be required after the version is accomplished) Ave
more perfectly imitate  the natural oblique position and passage  of the
breech of the  infant, than when Ave drag it down more directly and more
upon the same plane, by  grasping and dragging  at both limbs equally.
The infant also assuredly incurs less risk  of impaction of the head, and
above all, less  chance of fatal  compression of the umbilical cord, when the
os uteri  and maternal canals have been  dilated by the previous passage  of
the  breech, increased in size by one of the lower extremities being doubled
up  on the abdomen, than  when both  extremities being seized and  ex-
tended,  these same passages are more imperfectly opened up by the lesser-
sized Avedge of the breech alone.   Notwithstanding, hoAvever, the great
difficulties, and consequently the greater dangers attendant on the opera-
tion, when Ave search for and grasp both lower extremities, instead of one,
it is still so dogmatically laid down  as a rule by most obstetric authorities,
that many practitioners seem to deem it  a duty,  not to attempt to turn
the  child Avithout having previously secured both feet.
   In few or no cases of turning is it proper or requisite to bring doAvn both
extremities, unless  in the  complication  of turning under rupture of the
uterus.   In that  case, but in  that  only, ought Ave  to folloAV  at once this
procedure—and here we  folloAV it because, if we left the other extremity
loose in  the uterus  or abdomen it  Avould be apt to increase the lesion in
the Avails of the organ, if  it happened to get involved in the aperture,  or
impacted against its  edges.  In  some very rare instances in Avhich, after
version by one  leg has been effected, and immediate delivery is necessary,
the cervix and  os interum occasionally contract so forcibly and  strongly
upon the protruded  limb, Avhenever Ave  drag upon  it, as not to allow a
sufficient  amount of  traction  being applied to this extremity  Avithout
fear  of lacerating its structures.   In such cases  it may be well to attempt
to repass the hand to secure the other extremity,  for then by pulling at
both extremities together,  we  incur less chance  of injuring  them than
if we applied the  same required amount of force  to either of them singly.
  I believe the seizure of the knee to be preferable, in most, if not in all
cases, to the seizure-of the foot, or, rather, as it  should be more correctly
stated, to the seizure  of the ankle of the child.  I speak, you wil 1 recollect,
of turning in -cases  of shoulder  or  arm presentation, in which the liquor
amnii has been for some time evacuated, and the uterus by its tonic con- 
126
LABOR.
 traction, has clasped itself around the body and head of the child.  Under
 such circumstances, it is an object of importance not to be obliged to in-
 troduce our hand further than is absolutely necessary, into the cavity of
 the uterus, because the contraction  of the  organ, in many cases, opposes
 its introduction, and the forced introduction of it is apt to produce lacera-
 tion.   It is an object also of equal moment to attempt to turn by a part
 wThich produces  as little change as possible in the figure and form of the
 infant; because, if Ave  thrust any  of the angulated  parts of  the  child
 against the  interior of the contracted uterus,  Ave should also thus be still
 more liable to produce rupture of that organ.   Noav, holding those points
 in view, it appears to me, that the turning of the child, by seizure of the
 knee, presents several  decided advantages  over turning of the child by
 seizure of the foot.  For, 1st. The knee is more easily reached.  As we
 slip our hand along the anterior surface of the  protruding arm, and along
 the anterior surface of the thorax of the child, Ave ahvays, if the attitude
 of the child has not been altered by improper attempts at version, or very
 irregular uterine action, find the knees near the region  of the umbilicus of
 the infant—the lower extremities, as you are  aware,  being folded up in
 utero so that the knees are brought up to that part, and the legs flexed
 upon the thighs in such a manner that the heels and feet lie nearly in appo-
 sitiou with the breech of the child.   To seize a foot, therefore,  Ave should
 require to pass our hand about three inches (or in fact, the whole length
 of the leg) further  than  Ave require to  do  in order to seize a knee.
 2nd. The knee affords the hand of the operator a much better hold than
 the foot.  By inserting one or tAvo fingers into the ham or the flexure  of
 the knee,  Ave have a kind of hooked hold Avhich is not  liable to betray us.
 Every one, on the other hand, who has  turned by the  foot or feet, knows
 how very apt the fingers are to slip during the required traction, and how
 much in this Avay the difficulties of the operation are sometimes increased.
 3rd.  We produce, I believe, the necessary version of the body of the child
 more  easily by our purchase  upon the knee—because  thus  Ave  act more
 directly on the pelvic extremity  of the infant's spine, than when Ave have
 hold of a foot.   4th. Turning by the foot appears to me to  endanger
 greatly more the laceration of the uterus than turning  by the knee.  The
 reason of this is  sufficiently evident.   When Ave turn by the  foot, Ave have
 to flex the leg round upon the thigh, and thus  at one stage of the opera-
 tion and during one part of the flexion of the leg, we are obliged to have
 the leg bent  to  a right angle with the thigh, and the foot  of the infant
 thus projected and crushed against the interior of the uterus.
  It is needless to say how much all  this danger is increased, Avhen, after
 haying brought doAvn one foot, we  pass  again our hand, and attempt to
 bring down a second foot (as is recommended  by some authors), for thus
 we only double  the  danger of the  laceration of the uterus/from  the
 forced and obstructed passage along  its interior, of this other extremity.
  One point  remains for our consideration.  Granting  that it is proper to
 seize a knee  I think it  matter of the very first moment to know which
knee should  be seized.   On this point you will  find no directions in any of
our modern  obstetric works, British or foreign, as far  I know them; and
 yet I believe  the  secret of turning with facility and  safety in a case with
the waters evacuated and the uterus contracted—depends upon the knoAV-
ledge of which of the two  lower  extremities of  the infant  should  be
ecized.  If we turn with one of the extremities—and whether the foot
w-
be
or 
LABOK.
127
the knee—it should be the foot or knee of the limb on the opposite side
of the body to that Avhich is presenting.  Thus, if the  right shoulder or
arm presents, Ave should take hold of the left knee or foot; and if the left
arm or shoulder presents Ave should take hold of the right knee or foot.
  When Ave do this, by carrying the  knee  diagonally across, if I may so
speak, the abdomen of the child to the os uteri, we both^ex and rotate
at the same time the trunk of the infant, and  in  doing so, the semi-rota-
tion of the trunk inevitably carries  up the  presenting  arm, in proportion
as the knee Avhich is laid hold of is pulled down by the operator.
  I have insisted upon the advantages of taking  hold  of the knee that is
highest and furthest from you, and believe this to be a matter of the very
first moment.  Both  knees of the  child, as the infant lies folded up in
utero, are generally in juxtaposition, and lying upon the abdomen of the
infant, near the umbilicus.  If, therefore, in passing your  hand into the
uterus, you insinuate it as you ought to do, along the anterior surface of
the thorax and abdomen of the child, you come in contact with  both
knees at the same time.  And the  rule which I would  give you is  this,
that instead  of hooking your finger  or fingers  into  the  flexure of the
lower or nearer knee, you hook them instead into the flexure of the
upper, more distant, or opposite one.   Both are so far, in general, equally
near, or equally distant, and  you seize the  one or the other according as
you take care to turn  your  finger so as to hook it into the flexure of the
loAver or the flexure of the upper.                      Part xi., p. 213.

   Protracted Labor from Insuperable Rigidity of the Os  Uteri—Opera-
tion.—Dr. Lever makes the folloAving observations respecting the propriety
of incising the rigid ring-like edge of the os uteri in cases of protracted la-
bor arising  therefrom:  The  operation itself is  exceedingly  simple and
painless; and,  if performed  in  the Avay I  shall  recommend,  unattended
ivith  hemorrhage.   The  patient  should be  on her left side, in  the  usual
obstetric position, and brought to the  edge of the bed; the forefinger of
the left hand should, in the absence of pain, be passed to that part of the
os uteri intended to be incised, and, if possible, its point should be slipped
within;  then, directing a probe-pointed bistoury or hernia-knife  along the
finger, we should wait for the occurrence of pain, Avhen the incision may
be made by passing the cutting edge  of the instrument against the indu-
rated margin of the os.  The immediate effects of the incision will be the
discharge  of a  small  quantity of thin Avatery blood;  especially in  those
cases where oedemarof the cervix is present.   In  the case under consider-
ation, the  external tissues of the uterus contracted  more than  the inter-
nal, so  that the Avound seemed longer without than Avithin.  I selected
the sides of the mouth for  the  situation  of the incision, for several rea-
sons : firstly, at the sides of the Avomb, the rigidity Avas  the  greatest;
secondly, it is at the sides of the Avomb we  usually find lacerations, when
they  take place spontaneously, as is frequently seen in protracted labors.
Where the waters pass off early, and when the os uteri is thin and tense,
such a lesion is by no means unusual.
   Again, in making the incision at the sides there is no danger of Avound-
ing the bladder in  front, or the rectum  behind ; and, lastly, as in most
cases there will be found an  elongation, SAvelling, and congestion  of the
anterior lip, serious hemorrhage might result if this  part of  the womb
were divided.   Some  writers have recommended a crucial incision; but, 
128
LABOR.
in my opinion, such will be found  unnecessary.  A further tearing of the
parts may take place during  the  passage of the head ; but it is usually
slight, and confined to the vagina.   Before the operation a careful examU
nation of the os uteri should be made; for Ave sometimes find this part of
the womb communicating to the finger a strong pulsation, from  the pre-
sence of a large vessel coursing along the rim; and in the truth of this
observation I am confirmed by the experience of Mr. PoAver.  After the
incision the pains may moderate, or may subside for a time ; but on their
renewal the obstruction will give Avay; and,  if there exist no pelvic  de-
formity, they will  suffice to terminate the delivery.  Not unfrequently a
slight  and temporary degree of faintness follows the operation, during
which uterine contraction is lulled.
  [Dr. L. concludes his  paper by a  few remarks on artificial dilatation,
Avhich  are well Avorthy  of attentive perusal.   He affirms that, when at-
tempted in cases like the foregoing, it is almost certain to produce lacera-
tion Avith irritation,  inflammation,  gangrene, or  even  death.   At a
post-mortem  on a female at Avhich  he was present, who died Avithin forty-
eight hours after her delivery, in Avhich this  practice was used, extensive
peritonitis with effusion of lymph, and lacerated os uteri in several places
Avere found.  This affords strong  confirmation of the above  opinion.   At
the  same time it is needful to Avarn the young and  enthusiastic practi-
tioner that none of the  gentler modes  of producing relaxation,  such as
tartar emetic, the  warm  bath, etc., should be neglected; nor should the
use of the knife be delayed until  symptoms  indicative  of an approaching
state of collapse appear.  The following propositions are submitted as the
result of experience on this subject:]
   1. That insuperable  rigidity of the os uteri occasionally occurs, over
Avhich the usual remedies exercise no influence.  2. That such insuperable
rigidity may lead to a partial or  complete  separation of the  cervix,
3. That to prevent such a serious  lesion, tAvo methods of treatment have
been recommended: the one  consisting in artificial dilatation; the other,
in incising the  rigid and contracted os uteri.   4. That artificial dilatation,
in most cases, is unjustifiable,  from the serious injuries it occasions, and
the consequent irritation and inflammation.  5. That,  under such  circum-
stances, an incision of the os  uteri, in one or more places, should be per-
formed. 6. That the operation is unattended with danger, unaccompanied
by pain,  and, if rightly performed, free  from  copious  or dangerous
hemorrhage.   7.   But  the  operation,  to  be  successful, must  be  per-
formed before there are symptoms of approaching collapse.
                                                      Part xii., p. 290.

   Use of the Forceps—How to Apply.—Having ascertained the exact posi-
tion of the head,  introduce the hand well smeared Avith lard, within the
os uteri;  search for, and pass the fingers over the ear, so as to guide the
blade  over  that  organ,  whatever  may be its position.  When the in-
strument  is  locked, do  not  tie  the handles with  tape,  as it  keeps
up  a   degree  of pressure  on   the  child's  head not consistent  with
its safety.  In acting with the forceps, always bear in mind  the  different
axes of the pelvis, viz., of its brim, cavity, ;md outlet; therefore, keep the
handles of the instrument back to the perineum, till some part of the oc-
cipital bone has cleared the arch of the pubis, and when this occurs, grad-
ually bring the handles toAvard the  pubis, when  the  chin Avill pass  ove* 
LABOR.
129
the perineum. The three poAvers of the forceps are brought into operation,
viz., compression, traction, and  leverage;  but compression ought  never
to  be made  beyond  diminishing  the  child's  head  to three inches,
indeed, instruments are  seldom constructed to admit of more.
                                                     Part xiii., p. 349.
  Inversion of the  Uterus from Short Funis.—[Mr. Smith's patient was
enduring very severe labor-pains, which suddenly subsided as soon as  the
©hild's head rested upon the perineum, and the most violent rigor set in.
She became deadly pale, and covered Avith a cold clammy perspiration.
Mr. Smith suspected rupture of the uterus to have taken place ; he gave a
stimulant, and aftenvard an opiate.  The rigor soon ceased, but  as soon
as it had done so, she  gave a most  terrific scream, and the child's head and
shoulders were born.    The bystanders, apparently suspecting, by their
looks, that there Avas some  mismanagement, could scarcely be persuaded
to stay to give assistance.   The patient still endured agonizing pain, and
begged for the child to be taken away.   Mr.  S. extracted the arms, and
on turning  down the bed-clothes, the following appearances presented
themselves:]
   The infant, a boy, was lying on his back, apparently lifeless, his legs and
part of the thighs retained  in  the vagina,  and the funis so  much on the
stretch, that the skin of the abdomen was dragged out about an inch and
a half.  Having used  smart friction over the region of the heart, he gave
a slight scream, and having lifted  him up toward the body of the mother
so as to relax the cord, the  extremities passed out Avith a little assistance.
The child was immediately separated, and handed to an assistant; but the
mother still continued to complain  of the most acute pain.   On making an
examination, I found the placenta so near the os externum, that I  thought
I had nothing to  do but to lift it  out; but such  was  not the case, for  I
found it attached to the uterus.  I immediately nibbled aAvay the attach-
ments with my finger and thumb with the greatest caution, and on remov-
ing the placenta,  the pain still continuing with great severity, I  immedi-
ately  examined again and found the uterus (fully three fourths, according to
the feel of it) inverted, the  os girding it round like a cord, and of  course I
lost no time in reducing it; this was done with the greatest  ease ; and in
order to insure permanent contraction, I thrust my hand into the cavity,
which gave no pain, and having kept my doubled  fist there for about half
a  minute,  it  gradually closed upon it,  and thrust   it  out, precisely
as if  it  had  been  another  placenta.   The  mother  was   immediately
bound up firmly,  the pains having entirely ceased, and in the  evening  she
was sitting up in  bed, suckling her baby as if nothing had happened.
   The patient lost very  little blood, and complained of no pain Avhatever
after the uterus Avas reduced.  The funis Avas not more than six inches long,
perhaps about eight when on the stretch.   The placenta wras remarkably
small; the child was of  full size.                    -   Part xiii., p. 359.

   Diversion  of the Uterus.—Syncope without hemorrhage may depend^
according to Dr.  Mitchell, upon the folloiving causes:
   1st. The labor may have been tedious and the patient faint from mere
exhaustion.   2nd.  From rupture  of the uterus or bladder.  3rd.  From
internal uterine hemorrhage ; or 4th. From inversion of the uterus.  How
necessary, therefore, that the practitioner should at once be  aAvare of the
cause  of syncope.  In the three  first to Avhich I have  alluded, the uterus
    VOL. II.—9 
130
LABOR.
may be felt over the the pubes; in the last it cannot.  As a general rule, it
will be well in every case of doubt, at once to make a vaginal examination,
as it has ere this occurred that the accident has not been detected until
after the woman's death, or where it has not proved fatal until  all chance
of reduction has passed by.  In cases of this description, the  accoucheur
should be  certain that there is no escape of blood externally, to ascertain
which, he  ought not to be content with merely examining posteriorly, but
in every instance he ought to look if any has escaped in front, as I have
several times found  the bed soaked with blood in consequence of a constant
stream running over the woman's thigh, although none  appeared to come
from between the vulva.
  Inversion of the womb may be mistaken for polypus,  prolapsus uteri, or
vaginse.  It has also been ignorantly removed by the crotchet, supposing
it to be the head  of  a child.   It  may  be distinguished from polypus
by being rough externally, and very sensitive to the touch.  Polypi are
smooth and glistening, and the mouth of the uterus can be felt by encir-
cling their necks.  From prolapse of the uterus it  may  be known by the
absence of the os uteri,  and  from that of the  vagina (Avhich  rarely
assumes so large a size), by our being  able to discover a second opening
above the tumor—the true os.   I may mention,  however, that many first-
rate practitioners have mistaken polypus for inversion—accounts of which
will be found in the different periodicals.
   The treatment of inversion of the uterus will  greatly depend upon the
fact, whether the placenta be attached to the inverted organ, or if it has been
expelled.  In the former case—viz., Avhere the  placenta is attached, there
is less danger to the patient from flooding, as the uterine sinuses are closed
by the adherent placenta.  In either case, as soon as the accident is disco-
vered, reduction should be accomplished as soon as possible ;  but a very
important practical question remains to be decided.  In the event  of the
placenta being adherent to the displaced uterus, ought we first to detach
it, and then reduce the uterus;  or,  on the other hand, should we attempt
the reduction, the placenta being still adherent ? Noav, in answering this
question, I should state that there  is considerable difference  of opinion
amongst the highest authorities.
   I think the practitioner can have  no difficulty in making up his mind as
to the proper plan  of treatment, Avhich appears to be in every  case to at-
tempt the reduction  of the  displaced  organ without  detaching  the
placenta,  but  if that  be  impracticable,  he should  then detach it  and
proceed with the greatest promptitude to  reduce it.
   There can be no doubt that in all cases of inversion,  Avhether attended
with hemorrhage or not,  the  presence of syncope renders  the  reduc-
tion much easier than it would be Avithout  it.   Sir C. M. Clark  says that
he has been called  by  other practitioners to  cases  of inverted uterus,
where the patient has  expired from  hemorrhage before the  accident
was discovered, and  that  in  every instance the  displaced  uterus  was
reduced with very little trouble, all  difficulty being removed  by the de-
pressed condition of the woman prior to death.  Upon the same principle
we find that Dewees recommends bleeding to syncope in cases of inversion
unattended with hemorrhage.
   Noav as to the termination of this difficulty we have  seen that it may
prove fatal in  a few hours from flooding.  In some instances  the hemor-
rhage has been followed by inflammation terminating in gancrene, induced 
LABOR.
131
by a kind of strangulation of the uterus in its cervix.  There are several
cases mentioned by Rousset, in which recovery took place after the spon-
taneous separation of the mortified  organ.   It may become chronic, and
either prove fatal by exhausting discharges, or as in some rare instances be
spontaneously cured.  It has been fully proved  that the inverted  organ
may be removed with impunity by ligature  or excision ;  successful cases
are given by Granville, Gooch, Newnham, etc.         Part xiv., p. 276.

  Hemorrhage during Labor.—When the patient is sinking from loss of
blood,  administer ether vapor as  a stimulant; and after the labor, even if
the uterus has contracted well, give a dose of secale cornutum.
                                                    Part xvi.,p. 251.

   Treatment of  Post-Partum Hemorrhage—Dr. Torbock proposes  to
arrest flooding  by the injection of stimulants into the uterine cavity.  He
gives two cases in support of the proposed practice.
  The first was the subject of recto-vaginal fistula; the head was delayed
at the mouth of the womb by bands of adhesion, the results of violence
used in a previous labor, but after these were divided, the uterine  efforts
were inefficient to effect delivery, which was therefore accomplished by
the aid of the forceps.
   It was at this moment, from the  atonic  state of the uterus, frightful
hemorrhage followed.   The ordinary means Avere used to produce uterine
contraction, as pressure, grasping the uterus, secale, and the introduction
of the hand into the uterus.  At this critical moment Avas  suggested  the
introduction of a piece of rag,  saturated Avith brandy, diluted one-third
Avith water, into the uterine cavity, Avhich was very promptly done; Avhen
 on a second application it Avas grasped by the contracting  uterus, all he-
morrhage ceased ; the patient progressed favorably.  The stimulant used
in the second case was rum.                           Part xvi., p. 273.
   Rigidity of the Os Uteri.—When there  is a hot skin, and a quick, full
pulse, Ave  may bleed, and nauseate with tartar  emetic, give a turpentine
or emollient enema  to clear  out the bowels, and  then  a full  opiate, and
smear the os and cervix  freely with extract  of belladonna.  IT these
means fail, incise the os uteri on each side with a probe-pointed bistoury.
                                                   Part xvii.,  p. 241.
   Turning as an Alternative for  Craniotomy and the Long  Forceps, in
Deformity of the Brim of the  Pelvis.—It  is proposed to turn the child,
and extract by the feet, instead of performing embryotomy, or applying
•the long forceps.  By this  operation, the narrowest  portion of the cone
formed by the foetal head is first engaged in the contracted brim, and the
skull will  usually become so indented  and compressed in its biparietal
diameter, as to alloAV of its extraction  by such force as  may be safely
applied to  the child's neck.  Thus the best chance of life is  afforded to the
child,  while, from the  early period of labor at which the operation is per-
formed, the  mother is spared all the evils  which  result  from protracted
pain and long-continued pressure on the  soft parts.

   When the head is prevented from entering the brim of the pelvis by
reason of  the  diminished diameter of the  latter, turning  should  be  had
recourse to, in preference to embryotomy or the long forceps; and should
be performed early—the earlier the better.  But it should not be under- 
13i2                            LABOR.
 taken when labor has been long continued—when the strength is exhausted
 —the uterine energy  gone,  or the uterus  painfully and  permanently
 contracted;  nor is it recommended Avhen the child is dead, the pelvis very
 much contracted, or when the  accoucheur is not familiar with the opera-
 tion.                                                Part xvii., p. 242.

   Deformity of the Brim.—When the use of the long forceps comes into
 competition  with the employment of craniotomy, the  former is generally
 to be preferred.  Noa\t, Avhen the  pelvis is contracted in its conjugate or
 antero-posterior diameter,  the  long or fronto-occipital  diameter of the
 child's head  occupies the transverse diameter  of the brim.  The blades
 of the long forceps should, therefore, be placed obliquely upon the child's
 head; one, the posterior, over the  side of the occiput; and the other, or
 anterior, over the side of the broAv or  temple; or, in other words, they
 should be applied in the oblique diameter of the brim, for in this situation
 there is the most room for them.                     Part xviii., p.  21Q.

   Unusual  Cases of Utero- Gestation.—On  the 16th of Nov.,  1822, a
 woman in the  parish of Farnham,  Surrey,  after  Irnvdng  had irregular
 uterine action for two days, was delivered by a midAvife of a dead foetus,
 of a little more than thirteen inches long, and having the appearance  of a
 seven months' foetus.  The  placenta Avas shortly afterward expelled, and
 it Avas then  found that there  Avas a second  foetus, living and active, in
 utero: but as there Avere no pains and no  hemorrhage, it Avas determined
 to wait the event.  The woman recovered favorably: and on the  14th of
 January, 1823, or fifty-nine days  from  her premature accouchment, she
 Avas again taken in labor, and delivered  of a fine healthy child.  She  had
 been regularly unwell on the last Aveek  of March, and expected her  con-
 finement to take place about Christmas.
       ********
   In the "London and Edinburgh Monthly Journal of Medical Science,"
 Dec, 1842, a case is  related  by Dr. Jameson of a blighted  tAvin being
 retained, with its placenta and membranes, for seven Aveeks after the birth
 of its fellow  twin alive, and  which was presumed to have  arrived at the
 full period ofrutero-gestation.  This is very remarkable!   We can easily
 conceive the uterus to be endowed Avith the power of ridding itself of a
 blighted or dead foetus before the period of utero-gestation is accomplished,
 even  allowing the second foetus to be retained to the full period; but to
 throw off the healthy, and retain the blighted one, and that beyond  the
 usual period  of pregnancy, is an anomaly proving that the laws of  nature,
 m many cases, are extremely difficult of explanation.  In  the " Lancet,"
 Jan.,  1843, a Mr. Vale recites the case of a Avoman, being pregnant with
 tAvms,-giving birth to the first alive, at the seventh month; and the second
 also  alive,  two  months  afterward, being  the completion of the  proper
 period of utero-gestation.  Drs. M'Clintock and Hardy, in their work,
 entitled, "Practical Observations on Midwifery," 1848, record the  case of
 a  female at  her sixth pregnancy producing twins, both children being
 girls,  the first of which was strong and healthy, and apparently at  full
time—the second  much smaller, dead, copper-colored, and in a state  of
putrefaction.   In this case there was but one placenta, and that part of it
which was inclosed  by the  membranes of the  dead  child was slightly
darker and more consolidated than the rest.   We (the Ed.) have in  our
practice experienced three cases in which the births  of twin children we;e 
LABOR.     *                       133
 Beparated by a space of time; in two  cases an  interval of three weeks
 occurred, and in the other fourteen days.  In all three cases the first-born
 foetus Avas dead.  Such examples  go far to prove that  in cases of plural
 births each foetus possesses its independent involucra.  We do  not detect
 any of the characteristics  of super-foetation  in  these cases; in fact,  Ave
 experience considerable doubts respecting the majority of cases published
 under that title.—Ed. Brit. Record.                 Part xviii., p. 284.

   Hysterocele.—[Hernia  of the  uterus, whether inguinal,  femoral,  or
 ventral, is a very  rare occurrence, but Mr. Bell has met Avith two cases.]
   I attended Mrs. M----, at her fourth  confinement.  At five o'clock,
 a.m., after a tolerably severe labor of sixteen hours' duration, a fine female
 child was born.  As soon as the cord Avas separated, and the child handed
 to the nurse, in accordance Avith my usual practice, I applied  my hand to
 the abdomen, when, to my astonishment, I found the anterior-superior
 part of the uterus protruded through a rent in the linea alba, Avhich Avas
 completely torn  through from the ensiform  cartilage to  pubis.   The
 uterus felt  so  large and  firm, that little doubt existed of its containing
 another child.
   On making  a vaginal examination, a second  set  of  membranes Avas
 detected, on rupturing which the child Avas ascertained to present with
 nates to mother's abdomen.  The uterus was  pressed back into  the abdo-
 minal cavity, and firmly maintained in this position with both hands until
 the child (a male) Avas born; this occurred half an hour after the first
 birth.  The conjoined placenta came aAvay immediately—the uterus con-
 tracted  firmly, and descended into the hypogastrium.   A compress Avas
 placed on each side of the rent  along  its Avhole extent, and a bandage
 firmly applied.  A smart attack of peritonitis occurred, but it Avas fortu-
 nately subdued  by  the  ordinary treatment.   Three months after deli-
 very I carefully examined the abdomen, and could detect no trace of  the
 rupture.
   The great distention to which  the  abdominal parietes were  subjected
 from the uterus containing two very large children, must have  stretched
 the fibres of the  linea alba to the utmost extent, the contraction of the
 abdominal muscles  during labor  producing the  complete  separation of
 the tissues.                                          Part xviii., p. 301.
   Treatment of Rigidity of the  Os Uteri.—Dr.  Scanzoni, who has care-
 fully examined the conditions of the os and cervix, in the latter months of
 pregnancy, believes that the constriction, which sometimes declares itself
 in the first  stage  of labor, is due  to rigidity of the  upper orifice of the
 uterine neck, and not the loAver, which is  generally sufficiently dilatable.
 Instead of the  treatment  usually  recommended, viz., bleeding, antimony,
 belladonna, frictions, etc.,  he advises a continuous douche of warm water
 upon the os and cervix, directed by means of an appropriate instrument.
                                                     Part xix.,p. 225.
  Excision of Malignant Tumor  of the  Os Uteri during Labor.—When
 the disease involves only a portion of the os uteri, and proves an impedi-
ment to the dilatation of the latter during labor, it  may be excised Avith
safety and advantage.                                 Part xix.,p. 226.
   Use  of Ice in  Promoting  Uterine Contraction.—Dr. Mackall, in a
communication to the committee  of the American Medical Association, 
134
LABOR.
atates, that  for several years past he has been in the habit of employ-
ing pounded ice in cases  of suspended or protracted  labor,  that  wnen
this  had  been swaUowed freely, the  pains  had immediately  returned,
the uterus had  contracted strongly,  and the labor been speedily com-
pleted.                                       -, -i /.      i
  In cases where labor  pains had been  suspended for twelve or twenty-
four hours, they have been renewed promptly and efficiently.  In cases ot
inevitable abortion, where the uterine contractions are feeble  and inef-
ficient, and where hemorrhage  is considerable; in  retention of the pla-
centa from imperfect contraction of the uterus, and in cases of alarming
hemorrhage after  delivery and  expulsion of the after-birth, it  is equally
applicable—in short, whenever the firm contraction of the uterus is de-
sirable, that object will most certainly be attained by the administration
of ice.
       ********

  Decoction of the Roots of Cotton Plant.—Dr. Blackburn of Barnes-
ville, states that he has used  a strong decoction of the roots of the cotton
plant in two cases of labor with successful issue, to promote uterine con-
traction where ergot  failed.                           Part xix.,p. 233.
   Treatment  of After-Pains.—Consists  in the removal of coagula from
the vagina and os uteri, the avoidance of  all  the extra-uterine causes
of uterine contraction, and the administration of opiates.   Gentle fric-
tion  with the linimentum opii  over the abdomen  is  often very useful;
but I have found  still greater benefit from the application of this liniment
to the mammae.  By a reflex action,  it allays the  excessive sensibility  of
the uterus, when thus applied.
   In excessive  after-pains, without hemorrhage, without the presence  of
 coagula, and in the absence of other signs and consequences of inertia, the
 infant should never be  applied to the breast for some hours after delivery;
 not,  in fact, until  the uterus has become calmed from its state  of morbid
 excitability.  Early and constant stimulation of the breasts by the child ia
 a common  cause  of  irritable uterus for  many days after  delivery.  This
 agent, so salutary in all cases of impending inertia, is often made, unneces-
 sarily, a cause of  suffering, at a time when the patient is little  able to en-
 dure it, and  without any counterbalancing good, if  the  uterus has con-
 tracted healthily. I repeat, we  want no more than safe contraction ; every
 after-pain beyond this  point is both unnecessary and mischievous.
                                                      Part xix.,p. 258.
   Breech Presentations.—The child dies from hemorrhage into the pla-
 centa, caused by compression of the umbilical vein.  To obviate this,  tie
 the cord early, before  the complete birth of the child ; and endeavor to
 get respiration carried on while the head is still in the vagina.
                                                     Part xix., p. 275.
   Impropriety of Frequent  Operative Interference in Midwifery.—Never
 be  anxious  to  promote  hasty  delivery, and use all operative measures aa
 seldom as it is possible.  The late Dr. J. Clarke, of Dublin, who used the
 forceps only once in 3,847 labors, was singularly successful in  saving the
 lives of both mothers and children.                      Part  xx.,p. 193.
   Hemorrhage—Post-Partum.—In extreme cases, pass one hand into the
 uterus; introduce the  pipe of an enema apparatus by  the side of the arm a 
LABOR.
135
little way into the vagina, and inject  suddenly ice-cold water, which will
pass up into the uterus.   By the ordinary plan of injecting the vagina, we
are not sure that the injection enters the uterus ;  but by having one hand
introduced into this organ, we learn whether it is really injected, and we
ascertain also the effects of the injection.  This method is very much bet-
ter than that of introducing a bladder into the uterus and then distending
the former, as it is the influence of the cold, and not the pressure, that we
want to employ.                                      Part xx., p. 194.

  Labor— Use of Chloroform in*—The careful inhalation of chloroform is
quite innocuous.  It may therefore  be given in natural labor, simply for
the purpose of allaying pain, if the patient requests it.  And it ought to
be  given when the regularity and  efficiency of the pains are interfered
with by emotion,  nervous excitement,  or cerebral congestion.  In all such
cases the inhalation must only be carried to  the extent of allaying pain—
not to make  the  patient unconscious.  In  operative midAvifery, chloro-
form should be given in difficult cases of turning, and of retained placenta ;
and the full surgical effect, of unconsciousness and muscular relaxation,
should be produced.  In forceps and craniotomy cases, chloroform should
not be used.                                         Part xxi., p. 315.

   Prolapsus of the Pregnant  Uterus.—Mrs. P., a delicate woman, had
already two children.   After  the birth of the second, she was  much
troubled with a sensation of bearing down, and sometimes of a slight pro-
trusion of the uterus, which she endeavored, very ineffectually, to remedy,
by Avearing some kind of bandage.  The protrusion became greater when
she next became  pregnant, but  diminished, and Avas  at length wholly re-
moved, as the uterus enlarged from gestation. When, however, the labor
dreAv near, she was again sensible of much Aveakness  and bearing down ;
and at length when the pains actually came on, she Avas much alarmed by
finding that a large fleshy mass had passed through the os externum with
a good deal  of fluid discharge.   She sent for Mr. Gristock, Avho found
that not only  a considerable portion of the vagina Avas protruded, but that
the os uteri was  to be felt considerably Avithout  the os externum.  He
ordered her to bed, had the parts freely fomented, and requested a friend
to visit the patient Avith him.  They found  her  much alarmed, but pre-
senting no symptoms indicative of danger.  It was, therefore, determined
not at present to  employ any active interference.   The pains at first were
not strong, but as they increased in strength, it was thought advisable  to
expand the hand over the protruded part, so as  to make the ends  of the
fingers afford five points of support to the prolapsed vagina.  By degrees
it appeared to recede during the pains, and, at last, during a very stron<*
pain, the Avliole mass slipped up into  the pelvic cavity ; the infant was
speedily born, the placenta came aAvay, and the uterus contracted firmly,
remaiuing in its proper situation.   This woman got quite well, and in less
than two years became pregnant again ; she then came under the care of
Dr. Hugh Ley.   The same procedentia again took place,  and was ma-
naged in the same Avay, Avith the same happy result.
                                                    Part xxii., j>. 274.

   Entrance of Air by the Open Mouths of the Uterine Veins After Par-
turition.—Dr. Cormack arrives at the following conclusions.   He says:
   1. The entrance of air into the  veins does not  necessarily give  rise to 
136
LABOR.
exactly the same symptoms; the intensity of the effects depending upon
the degree in which the action of the right side of the heart is arrested or
impeded by its over distention, and upon the degree of asphyxia induced
by the impediment to the passage of the blood through the lungs.
   2. The indications of treatment are three-fold ; first, to relieve the dis-
tended right auricle; secondly, to treat the impending or actually present
asphyxia; and lastly, to prolong  life by every possible means, in the hope
that the  air may be all absorbed, and the passage of the blood through the
small vessels of the lungs again be made easy.
   3. In the most rapid class of cases, in which death is suddenly threatened
from paralysis of  the  heart from over-distention, we must first strive to
relieve the organ from that condition ; Avhen the phenomena are chiefly
those of asphyxia from more gradually increasing obstruction  of the lungs,
the various means for treating asphyxia must be resorted to, and among
these,  in many  cases, I believe the alternate  use  of the hot and cold
douches  will  be found to  be very valuable, especially if combined Avith
stimulants judiciously varied  and skillfully administered externally  and
internally.  In many cases, repose, dashing cold water in the face, keep-
ing the surface warm, and time may be the only means which ought to be
used.
   From the facts already stated, it is plain that the  treatment, both pre-
ventive and curative, is to obtain natural  and permanent contraction  of
the uterus after delivery.   As it is extremely probable that loss of blood,
and the entrance of air, in many  cases conjointly cause death,  it is satisfac-
tory to feel assured that the proper treatment for the one is the best also
for the other, so far as the one thing primarily  essential is to  strive to get
the uterus to contract. Plugging will also be specially proper Avhen there
is convulsive  contraction and expansion of the uterus, Avith  or  Avithout
much hemorrhage ; for then there exists the  greatest  aptitude for the
atmospheric air to enter, or be forced into the uterine veins.
   If a large quantity of air have entered  the circulation, unequivocal  evi-
dence of this will be found by listening to  the  heart, when the churning
sound will be heard.                                 Part xxii., p. 309.
   Indian Hemp as an Oxytoxic.—The administration  of the  Indian hemp
seems  markedly and  directly  to  increase parturient  action, and  Dr.
Churchill states that it possesses powers similar to those of  the ergot of
rye in arresting hemorrhage, when dependent   upon congested states of
the impregnated uterus.                              Part  xxii., p. 316.
   Ergot of Rye in Labor.—Dr.  Meigs, of Philadelphia, only  uses ergot
of rye at the  moment or just before  the birth of a  child;  in order to
secure, if possible,  a permanent and good contraction of the womb after
labor, in women who are known in their preceding labor to have been
subject to an alarming hemorrhage.                  Part xxiii.,p. 257.
   Head  Presentation—Turning in.—On  this  subject,  Dr. Ramsbotham
says, the folloAving are the circumstances only under which  he would re-
sort  to  this operation: If the clear available  space in the conjugate
diameter were about 3\ inches, or from that to 3£—if the Avoman's chil-
dren had all previously been born  dead—if the membranes Avere  still
whole, or the liquor amnii having been evacuated, the uterus  had not  con-
tracted closely round the child's body,  the head  being perfectly  free
above the pelvic brim, not having as yet descended into the pelvic cavity; 
LABOR.
137
and if the  attendant, by being in the habit of  performing obstetrical
operations, had acquired a certain dexterity in regard to them, and had
perfect confidence in himself.                         Part xxx., p. 276.
  Galvanism in  Obstetric  Practice.—Do not  employ the  apparatus in
which two currents are produced, but simply the single current machine,
for  a direct current tends  to produce contraction, an inverse current,
paralysis.  In using the single current machine, place the positive conduc-
tor over the lurabo-sacral region, and carry the other over the abdominal
surface, Avith a gentle friction.  In this Avay powerful uterine contractions
may be easily excited.                                Part xxv., p. 278.
  Treatment of unavoidable Hemorrhage.—In treating  unavoidable he-
morrhage, attended with exhaustion, Dr. Murphy very much prefers hav-
ing resource to Dr. Simpson's plan of artificial separation of the placenta,
to turning; and thinks this last operation is quite unjustifiable, on Smellie's
plea that the Avoman must not die undelivered—the very attempt to pre-
vent her doing so being, in fact, sometimes the cause of her death.   His
rules are thus summed up.   (l.) In cases Avhere no exhaustion has taken
place, or Avhere this is only  commencing, the child should be turned and
delivered the moment  the  os is sufficiently  dilated or dilatable.  When
this is not so, the placenta should  be  compressed by the plug and by the
discharge of the liquor amnii,  and. other  means employed to prevent
exhaustion,  until delivery  is practicable.  (2.) In extreme  exhaustion,
turning should not be  performed, but  the placenta should be  separated,
and the child  left undisturbed until  decided  reaction takes place.   (3.)
When the os is rigid, means should be employed to compress the placenta
and increase the action of the  uterus, so as to  give time for dilatation
and turning.   Should  exhausting hemorrhage, hoAvever, come on in the
meantime,  the placenta should be removed, rather  than  the hand be
forced into  the uterus.                               Part xxvi., p. 312.
  Hemorrhage after Delivery  accompanied by  severe After-pains.—In
several cases Avhich  Dr. Ramsbotham has  met Avith, there have  been
most severe after-pains, wdth great hemorrhage, though the uterus Avas
still firm  and comparatively small. His explanation is, that a clot  having
filled the cavity of the uterus, the womb is unable to expel the offending
mass.  The more fluid parts are squeezed  out, and the firmer  remain
behind, clinging Avith such tenacity to  the uterine Avails as to be almost as
difficult of removal  as a piece of adherent placenta.  The treatment of such
cases is  to  introduce  the  hand, remove  the clot from the cavity of the
uterus, and immediately the after-pains  and the hemorrhage  dependent
thereon will cease.
  Dr. R.  gives the  following, among other cases:
  My assistance  Avas sought by a medical practitioner, for Mrs. C. H.,
who had been delivered of her first child three hours.  The placenta had
been retained by irregular  contraction, and removed from the uterus by
the hand; previously to which  she had lost  about  tAvo pounds of blood.
When I arrived,  she Avas faint,  cold, and pale; the pulse was very small;
the uterus was excessively hard, and rather larger than natural; there Avas
an uninterrupted draining  going  on, and she Avas suffering excruciating
pains at  intervals, evidently proceeding  from uterine contractions.  She
had takeji three drachms of laudadum A\dthout relief.  I passed my hand
into the cavity Avith considerable ease, notAvithstanding the strength of the 
138
LABOR.
uterine contractions, and removed a quantity of tough,-fibrinous coagula,
considerably  larger than an  orange.  She felt immediate freedom from
pain, and the discharge ceased almost as suddenly.  She became a-little
faint, but  soon rallied ; at  four she was sleeping  comfortably; and her
recovery Avas uninterrupted.                         Part xxvii., p. 180.
  Peculiar Accidental Uterine Hemorrhage.—Sudden syncope  or  faint-
ness, with great distention and pain of the abdomen, supervening in cases
of advanced pregnancy,  should lead  you to suspect  internal uterine
hemorrhage.   Mr. Harrinson asks:
  What would  stop  the bleeding  most effectually for the time till tho
patient could rally ? . The coagulum at the mouths of the vessels supported
in its position as it  Avould be by the foetus, membranes,  etc.   Withdraw
this plug, and the hemorrhage Avould almost certainly return.  Therefore
the practice  would naturally be  to  keep the  plug  there  till Ave saw a fit
occasion to allow it to come aAvay.   Bringing  the child away,  and empty-
ing the womb by artificial means, would insure the  separation  of this plug
at a time perhaps Avhen the woman was  not fit for  such  a process.  We
should say, therefore, in such a case :
  1. Give stimulants in moderation and keep the Avoman horizontal.
  2. If syncope continued, rupture the  membranes, give a dose of ergot
of rye, and keep up the patient as well as you can by stimulants and food,
but don't bring aAvay the child yourself—let  the womb  expel it, and be
ready the moment the child  is born to compress the fundus  uteri with a
cold hand or  cold wet toAvel, so  as to  compel  it to  contract rapidly
and to expel placenta and coagula.   If you save the Avoman from the first
gush of blood, you will probably  save her altogether.  Part xxvii., p. 183.
   Galvanism in Obstetric cases.—A continual current is  by no .means so
effectual as  repeated shocks; these rarely fail to  excite muscular  con-
tractions, for this  stimulus  acts directly on  muscular fibre.   The discs
of the apparatus may be covered with thin flannel, and applied  on either
side of the uterus, the flannel being moistened Avith Avater.  This plan is
equally effectual as the application of the discs to the spine of the cervix
uteri.
  In cases of hemorrhage before  the birth of the child, apply the poles of
the galvanic battery to  the side of the uterus.          Part xxix., p. 259.
   Galvanism as an Obstetric Agent.—[Dr. Radford was  first led to the
use of galvanism in midwifery from observing its value in a case of  atony
of the bladder.  He has used it]
  1st. In cases of tedious labor arising from uterine inertia.
  2d. In cases of accidental  hemorrhage, either before or after the rup-
ture of the membranes, and especially Avhen exhaustion from loss of blood
exists.
  3d. In cases  of " placenta prsevia," in which the practice of  detaching
the placenta is adopted, and the vital powers are greatly depressed.
  4th. In cases of internal flooding before or during labor.
  5th. In cases of post-partum flooding*.
  6th. In cases of hour-glass or irregular contraction of the uterus.
  7th. To  originate, de novo, uterine action,  or in cases in  Avhich it  is
desired to induce premature labor.
  8th. In cases  of abortion, when  the indications  show the necessity, oi
justify the expulsion of the ovum. 
LABOR.
139
  9th.  In cases of asphyxia in infants.
  Galvanism is especially advantageous as a general stimulant in all those
cases in Avhich the vital poAvers are extremely depressed from loss of blood.
Its beneficial effects are to be observed in the change of the countenance,
restoring an animated expression; in its influence on the heart and arteries-^
in changing the character of respiration;  and its -warming influence on the
general surface.                                     Part xxix., p. 268.
  Uterine Douches in Tedious Labor.—The tepid douche, used in the Avay
adopted to induce premature  labor, may sometimes stimulate the uterus
when inactive.  You  may use the douche for ten minutes or a quarter of
an hour at  a time.   The same means may assist in dilating a rigid os uteri.
                                                   Part xxxi., p. 207.
  Flooding after Delivery.—Inject cold water into the womb.  Use a
Weiss's syringe, and introduce the nozzle of the tube an inch or tAvo fairly
into the os uteri.                                     Part xxxi., p. 208.
  Hemorrhage after Delivery.—Generally the more powerfully the uterus
contracts after delivery, the less the danger of flooding ; not  so, hoAveA'er,
in all cases ; if a portion of the placenta, a fold of the foetal membranes, or
a quantity  of coagulated blood, be retained in its cavity, it may be adhe-
rent to the internal surface, so that no efforts of the uterus can dislodge it;
the more fluid parts may be squeezed  away, but the tougher particles
remain, and bleeding still go on so as to  endanger the life of the patient.
By the introduction of the hand, and  the withdraAval of the coagula, the
agonizing pains and the further loss of blood are at once put a stop to, and
instantaneous ease and immediate safety  secured.     Part xxxii., p. 221.

   Uterine Hemorrhage.—When  threatened abortion is from a debilitated
condition  of  the  uterus, Avhich, in its  relaxed  condition, opens the  os,
small doses of ergot act as a tonic, and close the  bleeding orifices of the
vessels.  If the patient be near the full time,  and delivery cannot be pre-
vented, Avhether a case of placenta  previa, or not, rupture the membranes
at one side, and  give a good close of ergot, so as to force the presenting
part of the child  firmly down  upon the bleeding surface, and thus to dam
up the stream; if this be not successful, deliver, if you can pass the hand ;
but if you cannot Avithout much force, plug, until  such time as you can de-
liver.
  In Avomen peculiarly liable to flooding, as soon  as  the child is born, be
careful not to interfere unnecessarily during delivery.  Imitate nature, or
rather  let nature alone.  When the head is expelled, don't  seize upon it
and pull for your  life, like a madman, but Avait  patiently, not only until
nature has  expelled the shoulders, but the hips also, for the body and legs
of the  child will stimulate the uterus to  action as effectually as the hand
of the  accoucheur, and thus preA'ent flooding.   But some  may say, sup-
posing the  head is expelled and the pains  cease,  Avould you not employ
traction then?  No! certainly not! you must not lend so  much as the
strength of a finger  toward  completing the delivery, but  " compel the
uterus  to do its own  work."  Besides  being careful  not to interfere in
these cases, as  soon as the  head presses upon the  perineum, give a full
dose of ergot as a precaution against flooding, and repeat if necessary.
  In cases  of abortion, if the flow of blood be  great, give large and re-
peated doses of ergot, so  that  the  presenting  part  may be forced down, 
140
LABOR.
to act as an internal plug.  In addition to this, it may be advisable to em-
ploy the plug, by  pushing a piece of alum  into  the vagina before the
plug.
  After the child is delivered, the first aim is to secure uterine contrac-
tions ; it is worse than useless to deliver the placenta if this is not effected ;
it must  be excited by ergot, firmly grasping the  uterus, abdominal fric-
tions, ice, the cold and hot  douche  alternately ; if these means are not
sufficient, introduce the hand and remove  the placenta.   In cases of abor-
tion where the  placenta is retained, the  general treatment is to trust to
time; if there is hemorrhage, plug  and give ergot;  but there is a great
deal of uncertainty about  this.   The placenta should be removed if possi-
ble ; some recommend hooking it doAvn with  one  finger, but this cannot
ahvays be done ; in such  cases, perhaps, a pair of polypus forceps Avould
be  best  to seize the placenta, twist it round and  round again so as to
detach it and bring it aAvay.  After the placenta is expelled, there may be
hemorrhage from irregular contraction, loss of poAver and nervous energy,
or from some mechanical impediment to contraction, as a clot of blood.
In all these cases you must introduce the hand, and Avhen it is contracted,
keep it so, by external pressure and ergot.
  In cases of severe  flooding, don't apply the bandage ;  it is in the way,
and prevents more certain manipulations; after  all danger has  passed, it
may be applied for support to the abdomen.          Part xxxii., p. 222.

  Labor—Induction of.—The uterine douche possesses many advantages
over ergot—1st. It will excite  contractions;  2d.  It does not  endanger
either the mother  or the child;  3d. Its action can be  better regulated ac-
cording to the effect required; and, 4th. It may be employed at the com-
mencement of labor, and  in all degrees of dilatation of the neck.
                                                   Part xxxiii., p. 262.

   Turning— Use  of Forceps.—In all cases where the head is  detained
after the delivery of the body, the use of the forceps  is greatly preferable
to pulling by the body or neck of the child.  They may be applied easier
than in  vertex presentation, because you  ha\Te  the head fixed and know
its exact position.   The extracting force is certainly safer.
                                                   Part xxxiii., p. 263.
   Tartar Emetic, in  Obstetric Practice.—In  the early stages of primi-
parse, Avhere the os uteri is hard, undilatable, and fails to yield to time and
the ordinary  remedies, one grain of tartar emetic Avith six ounces of soap-
Avater may be given by the rectum with very beneficial  and relaxing ef-
fects.  It is particularly applicable for the robust and plethoric.
                                                   Part xxxiii., p. 273.
  Post-Partum Hemorrhage.—In cases where women have suffered from
flooding in several previous labors, you should give one or  two doses of
ergot during the last  pains AArhich  expel the  child.  Immediately after
delivery, in suspicious cases, the hand should be placed on the abdomen,
and pressure  made until efficient contraction  is felt  to  take place.   The
uterus should be grasped  and  held  firmly by the hands.  The application
of cold  to the vulva and abdomen,-by douching Avith  a Avet towel, or dash-
in <r the  Avater on,  is very  effectual in  rousing  the  uterus  to  contraction.
If these means fail, the hand should be wrashed and  introduced into the
uterus.   In addition  to  this,  if the uterus appear paralyzed, cold water 
LABOR.
141
may be injected in a full stream into its cavity, or galvanism may be tried
if there be time and convenience.   Cold and heat applied alternately are
much more  efficacious than  cold  applied alone to  excite reflex  action.
When one reflex surface is exhausted you may appeal to another, dashing
cold water on the face, SAvallowing a gulp of cold water, an enema to the
rectum, etc.   Whenever coagula collect in the uterus or vagina, they pro-
duce irritation, keep up the hemorrhage, and must be turned out with the
hand.  If the placenta be only  partly separated, or remain in the  uterus,
it must be immediately removed ; if the patient is very much reduced, do
not wait, pour some brandy down her throat, and proceed at once.
                                                  Part xxxiv., p. 233.

  Elm Tents for Dilating the  Cervix Uteri.—Elm bark  possesses many
advantages over sponge for dilating the cervix uteri.  It is less expansible,
and so dilates more gradually; it  is not decomposed, and furnishes an
abundant mucilage, Avhich protects irritated  or diseased surfaces.
                                                  Part xxxiv., p. 247.
   Metastatic  After-pains.—Among  the different  cases noted by  Dr.
PoAver, Ave find a marked instance of uterine metastasis upon the bladder:
Mrs. P., at the beginning of the labor, had  genuine  uterine contractions,
which dilated the os uteri Avith  sufficient rapidity, when we remarked that
the pains  became  suddenly more distressing, though they had  no  longer
their former influence upon the mouth of the uterus.  Placing our hand
upon the fundus uteri during a  pain, Ave could not perceive any contrac-
tions at all, but  the woman  complained of a very painful sensation just
above the symphysis pubis, Avhich  ceased after some  time, and came back
in regular intervals.  Mrs. P. had  not evacuated  her bladder for a consi-
derable time, and was prevented  from doing so by the  pressure of the
head against the symphysis pubis.  We considered this a case of metastatic
pains in the bladder, produced  by an irritation of this organ, arising from
its being overloaded Avith urine,  and the vain attempts  to empty itself.
We therefore introduced the catheter, and  dreAv off a considerable quan-
tity of water.  This being performed, regular uterine contractions  set in,
and labor Avas soon ended in the  most satisfactory  manner.  Prof. Stein
gives, among  other cases, one of metastasis  to a part of the nervous sys-
tem, which is quite removed  from the sphere of the uterine nerves.  He
says: " In this case a great quantity of liquor amnii Avas  present,  and, in
consequence, the pains Avere very irregular.   Suddenly, all uterine action
ceased, and  the woman Avas taken Avith a violent  facial neuralgia. This
affection lasted  for  one  hour,  when it gave  entirely away, and another
succession of labor  pains  set in ; these, after  some time,  ceased, and  the
prosopalgia commenced,  Avhich  Avas exchanged once  more for activity of
the womb, and so on by turns.  At length the membranes  wrere  ruptured;
after Avhich,  regular uterine action  began and continued till the child Avas
born."
  Another very  singular case  Avas  observed by the  same  author.   A
woman, Avhen at the full term of her confinement, was taken with general
convulsions,  which ceased suddenly, but continued in  the musculus orbicu-
laris of both eyes, so that she  could not open them  for two days.  Noav
the womb began its work, and with the first contraction her sight Avas re-
established.
  Pilger observed that, during  a confinement the pains gave way, and the 
142  .                          LABOR.
patient was  suddenly taken with  an alarming dyspnoea, wdiich  ceased  aa
soon as another contraction of the uterus  commenced.  Others  Avitnessed
that the abdominal muscles Avere  the seat of metastatic labor.
  This kind of dystochia is of rare occurrence.  But there is another very
severe and most tormenting affection occurring after confinement, namely,
those very painful affections of the lower extremities, which commence a
few hours after the child is born,  and last sometimes for tAvo or even eight
days.  The authors who treat of  the said affection, call it " the crural neu-
ralgia of women in childbed," and believe it to be the result of pressure
of the foetal head, or the forceps, or of an inflammatory exudation upon
the crural nerves as they pass through the  pelvis.   This  is the  case in a
feAV instances.  But when these pains follow  after an  easy confinement,
Avhere neither a large-sized head, nor a forceps operation, nor an  inflam-
mation of the bowels, can be referred to as explaining this symptom, then
we have to seek for another explanation.
   [Dr. Noeggerath has had several cases under his observation AAdiich have
exhibited this curious  phenomenon.   In one  remarkable  case,  the pains
began to come on about nine hours  after delivery of a living, full-groAvn
child.]
   This  morning, at  about seven o'clock, the  right  thigh Avas suddenly
seized with  a pain, which soon increased  to such violence, nay,  fury, that
the patient was  afraid to move the leg the slightest degree from its posi-
tion.  The lower part of the thigh was the  seat of the greatest pain, and
especially its external surface extending over the dorsum pedis.  The least
pressure could not be endured.   After the child was born, the woman had
not the slightest perception of after-pains.   She felt as if her abdomen was
empty, or rather not existing.  The uterus Avas enormously distended, its
limit or outlines being scarcely  distinguishable,  texture  remarkably  soft
and relaxed. Considering this  to be a case  of metastatic after-pains, I
thought the chief indication  would be to bring  on uterine activity, after
v/hich the pain  in the  thigh should disappear.  The result of my treat-
ment proved that I was right.
   Shortly after  ten o'clock  I gave her a large teaspoonful of  powdered
ergot of rye (secale cornutum).  Ten minutes after, the patient  remarked
a discharge of blood from the A'agina, the first after her delivery;  a quar-
ter of an hour after the administration of this remedy, the woman became
more quiet, she  ceased to cry, except occasionally, and a painful  expression
Avas noticed in  her-features.  Twenty minutes past ten o'clock she  said
that the former  kind of pain had left her thigh  and yielded  to a very
bearable sensation of smarting.   At half-past ten o'clock she took the same
quantity of ergot, and  fifteen minutes later I had the pleasure to  see that
the patient  moved to lie upon her right side; she could bend  her knee,
and move her leg up and down; she even told me iioav that she had not
the least pain.   When  I left her (before eleven o'clock), I could ascertain
that  the  uterus was well contracted, lessened in size, and considerably
harder  than when I made  the  first  examination.   The  Avoman had  no
relapse afterward.
   In explanation of these singular pathological occurrences, we  must bear
in mind, that there is always  present a limited amount of nervous poAver in
the central organs.  Therefore, if one part of the body receives a nervous
impulse in excess, other organs must be more or less deprived of it;  or,
wdien there is prepared in the nervous centres a certain amount of mate- 
*
                               LABOR.         \                  143

rial for the purpose of setting one department of nerves into action, and
this department being in itself not properly disposed to receive it, then,
another portion of the nerves  must  attract this  amount,  and show a
greater activity.  The same result must happen, when  some other part of
the system is in such  an unnatural condition, that it attracts more nervous
force from the centres than is due to it.  In this case another organ must
lose part of its  activity.
  These  principles applied to the uterine system, we are  able to explain
the pathology of metastatic pains.  When labor begins, the sympathetic
nerves and the spinal cord secondarily are called to a physiological energy,
Avhich is seen in no other instance  of life.  Their activity is provoked by
the uterus, and  in  ordinary circumstances directed to the uterus.  But in
order to perform their duties properly, the  womb must be  sufficiently dis-
posed to attract the nervous fluid to its OAvn sphere.  In case of its being
in a state of weakness, other organs receive the effect of the overloaded
centres, and thus exhibit the phenomenon of metastatic pains.  Therefore,
this complaint is most commonly observed in connection with atonic labor-
pains.  But if some part or other of the system was previously,  or during
parturition, in  an  unhealthy condition, it  would be liable to'attract to
itself the nervous  energy originally due to the uterus, even if the latter
was in a state of health.  Therefore, Ave see that, in very  many instances
of  metastasis,  the affected  organs stood  under some morbid influence
before or during confinement.                      Part xxxvi., p. 230.

   Tedious Labor.—In cases where labor is arrested, not from any obstacle,
but from simple atony and Avant of pains, where in fact the polarity of the
cord is exhausted, try the effect of strychnia; in doses of one-sixteenth of
a grain to commence with, repeated and gradually increased as necessary.
It  induces  uterine contractions in a very remarkable  manner,  each dose
being distinctly folloAved  by this effect; it does not cause violent or con-
tinued action of the womb.   In not one  of nine cases  in which  it  was ad-
ministered, did any bad effects follow, and in all the labor was accomplished
within an hour and a half after commencing the use of this drug.
   Dr. Vernon prepares a solution of strychnine in very dilute hydrochloric
acid, of the strength of one grain to the fluid ounce, and administers in di-
vided  doses, repeated upon  each subsidence of uterine contractions.  He
says:
   In the "Lancet," of June 14, 1856, I published a short letter in wdiich I
incidentally referred  to the  use of strychnia  as an oxytoxic.   Curiously
enough, a letter from Dr.  Matthew Corner  appeared in juxtaposition Avith
my OAvn, detailing a case of poisoning by strychnia.  The patient SAvallowed
two grains of strychnia by mistake.   She was pregnant, and aborted in the
course of the action of the poison.   The case terminated favorably. • I have
since  become acquainted with the case of a lady who  aborted five times
consecutively whilst under the influence of nux vomica given as  a tonic.
                                                  Part xxxvii., p. 234.
   Galvanism in Obstetric Practice.—Individual shocks applied to  the ute-
rus produce no appreciable  effects upon it; and a current directed  trans-
versely through the organ produces only a partial contraction of it in the
direction  of the current;  but a sustained current of electricity directed
longitudinally through the uterus, from the  upper portion  of  the  spinal
cord, excites the action of the uterus, and singularly enough also accelerates 
144
LABOR.
 the dilatation of the os uteri.   A case of placenta praevia is mentioned, m
 which several alarming hemorrhages  had occurred before labor had com-
 menced.  A sustained current of electricity applied in the manner stated
 for six hours, not only prevented further hemorrhage, but so accelerated
 the dilatation of the os uteri, that the handAvas readily introduced and de-
 livery completed with safety to the  patient, although the child, from the
 extensive separation of the placenta, was still-born.  In another case this
 mode of treatment speedily induced  the  expulsion  of an organized mem-
 brane remaining after an early abortion, the ovum having been previously
 expelled.   The patient was much exhausted by repeated floodings.
                                                   Part xxxvii,,p. 271.
   Chloroform in Natural Labor.—The great rule in administering chloro-
 form in natural labor, is to give it so  as to allay  pain, without destroying
 consciousness.   You may  thus, without danger, give chloroform for any
 length of time.                                    Part xxxviii., p. 206.
   Uva Ursi in Labor.—In ordinary delayed labor, fifteen grains given in
 infusion every hour is as efficacious and far more innocent in its  operation
 than  secale cornutum.  When rapid effects are desired, as in metrorrhagia,
 a decoction of 4 drachms to a quart of water should be employed, and given
 in frequent and divided doses.                     Part xxxviii., p. 206.

  Dilatation of the Os Uteri.—The  natural sickness of labor ahvays has a
 beneficial influence in inducing relaxation, unaccompanied by a subsequent
 evil; and for the same reason artificial nausea has a powerfnl influence in
 subduing rigidity of the os uteri or vagina, and is so safe in the adminis-
 tration that it is a Avell-known fact that puerperal or peritoneal inflamma-
 tions are rarely seen where tartar emetic as a nauseant has been judiciously
 given; there seems  an almost perfect immunity of system from these dis-
 eases afterward.   An emetic dose should  be given at first, and the nausea
 continued by diminished doses.  It must always  be first ascertained that
 there do not exist certain unhealthy conditions of system, as  organic dis-
 ease of the heart or lungs,  etc., in which case continued  nausea  might be
 productive of serious mischief.
  [Dr. Gilmour has  omitted what we consider  the most important and
 safest medicines to accomplish dilatation of the  os uteri, viz.,  chloroform
 and ipecacuanha.  We have been highly pleased lately with the effects of
 chloroform.  Early in labor, when the pains are regular  and  the os uteri
 rigid and small, by slightly influencing the patient Avith chloroform during
 almost every pain, the parts become  much more rapidly softened and  di-
 lated. We have  simply dropped a  little  chloroform  on the  pillow, near
 the nose of the patient, and told her to inspire it pretty freely each  time,
 or just before the pain comes on. Instead of waiting six or eight hours for
 the dilatation of the  os, we have  thus accomplished it in less than two
 hours.  One  grain or two grains of ipecacuanha every half hour, will have
 also a good effect; but in  a less pleasing way, and  not so certainly.—Ed.
 " Retrospect."]                                    Part xxxviii., p. 322.
  Passage of the Foetal Head.—The diameter of the different parts of the
 pelvis are so managed that the foetal head  undergoes a screw-like tAvist  in
its transit.  It behooves the accoucheur to be mindful of this in applying
the forceps.                                         Part xxxix.}p. 279. 
LABOR.                            145
                 PLACENTAL COMPLICATIONS.
  Treatment ofPlacentalPresentations.—The practice of removing the pla-
centa, in cases of placental presentation, seems to have been well known
and practised in Manchester for  years, and originated in the practice of
the late Mr. Kinder Wood.  Mr. Wood says :]
  If Ave find so much exhaustion as to make us fear the effects of further
hemorrhage, during artificial delivery, the first step after passing the hand
must be to detach the Avhole of the placenta; by  this the hemorrhage will
be completely suppressed, for the effect of passing the  hand through the
os uteri,  and throAving oft'the placenta, will always be to produce so. much
contraction  as to arrest  the  bleeding from the  small decidual or uterine
mouths.   It is satisfactory to know that the child is rarely living in these
cases of exhaustion, its blood being poured out  through branches of the
placental structure, along with that of the mother; and Avhen brought
doAvn, its appearance, like that of the mother, is bleached and exsanguined.
The time required to separate the placenta is very short, and the loss of
blood during the attempt exceedingly trifling.  I know from experience,
that when the placenta is  Avholly  detached, the hemorrhage wull cease.
  In some cases  I have been called  to  attend, Avhen  the  ordinary method
of delivery has been adopted, the patient died, and this led me to modify
the practice, by detaching the placenta, rupturing  the membranes, and then
delivering the child ;  but after due consideration I was again induced to
vary my plan, and in those cases  where Ave can have no hope in saving the
patient if we proceed to delivery,  hoAvever well the operation be conducted,
I have no hesitation in recommending  that the placenta be separated com-
pletely, and the  membranes ruptured, and that  the hand be withdrawn
immediately upon this being effected, leaA ing the child and placenta behind.
By this practice the patient will  be placed precisely in the situation which
occurs in the most favorable cases of recovery by the natural  efforts. I con-
ceive no fact  in midwifery rests upon  a  more solid  foundation,  than that
this  hemorrhage will  cease  upon separating the placenta,  and by  this
practice  the patient is  placed in as favorable  a situation as is possible for
recovery. Tune va ill be gained to* support her by proper means, and winch
can be  used with  greater freedom, as the hemorrhage  is infallibly sup-
pressed  by this operation.                               Part xi.,p. 195.

.  Placental Presentation—Extraction of the Placenta before the Child
in Cases of.—All obstetric authors agree that no complication in midwifery
occasions more anxiety to  the  practitioner, or danger to the  patient, than
hemorrhage  from placental presentation,  and  the  results of practice fully
support  this  opinion.  Of  174 cases Avhich Dr. Churchill has collected, 48,
or nearly one-third of the mothers died. Dr. Simpson has attempted a still
more extensive analysis, and finds that  of 399 cases  recorded, in 115 the
result Avas fatal to the mother, a  mortality as great as that of malignant
cholera in 1832-33, and tAvice as great as the average in cases of lithotomy.
Looking  at the results, any attempt to diminish  such fearful mortality is _
entitled  to the most careful notice of the profession.  Hitherto two great
principles of treatment, A\diich some have supposed to be applicable to the
two  different  stages  of the complication, have  been pursued, viz.:  1st,
the evacuation of the liquor amnii; an  M, delivery of the child by turn-
ing.
    VOL. II.—10 
146                            LABOR.
   [Some accoucheurs, as Drs. Burns and Hamilton, Baudelocque, Capuron,
 and others, think this the only mode of treatment advisable under any cir-
 cumstances in these cases.  Drs. Merriman, Conquest, Dewes and Denman,
 are unanimous in the opinion that turning must be resorted to.]
   Cases of placenta  praevia, says  Dr. S., frequently occur in practice in
 which neither of the two preceding  plans  can  be successfully adopted—
 where the artificial evacuation of the liquor amnii is insufficient to moderate
 the hemorrhage to a safe degree, and Avhere forced delivery by turning ia
 inapplicable or extremely dangerous if adopted.   In these and other cases,
 I Avould beg to submit to my obstetric brethren an additional principle of
 treatment, viz.:  The complete separation, and, if necessary,  extraction of
 the  placenta before the child.  Obstetric pathologists seem  unanimous in
 the  opinion that all the more formidable varieties of hemorrhage,  Avhich
 occur from the uterus in the latter months of utero-gestation, or the earlier
 periods of labor, are attributable to the separation of the vascular connec-
 tions between the placenta and the interior of the uterus, and  the escape
 of blood from  the Aressels Avhich are  laid open in consequence of this separa-
 tion.  Paradoxical as it may  appear, there  are sufficient grounds and facts
 for believing,  that Avhen the placenta is separated slightly and partially,
 the  chance of fatal hemorrhage to the mother is greater than Avhen the
 disunion of the organ is more entire and complete.  Various authors have
 detailed cases in Avhich the death  of the mother speedily took  place
 though the portion of the* placenta separated from the uterus was exceed-
 ingly small.
  Dr.  S. has collected notes of 141  cases  in which the placenta was ex-
 pelled before the child,  Avhich he throAvs into  a tabular  form, and divides
 into—1st, Cases in Avhich a considerable interval elapsed between these two
 occurrences; 2d, Cases in wdiich the interval Avas  less than ten minutes;
 3d, Cases in which the child was born immediately after the placenta, or
 along Avith it; and 4th, Cases in Avhich the period is not  mentioned.  I
 believe, says Dr. S.,  that the data Avhich I have collected are amply suffi-
 cient to establish, as  a  great physiological and practical fact, that, when
 the  placenta, in cases of unavoidable hemorrhage, is once completely de-
 tached from its connections Avith the interior of the uterus, the accompany-
 ing flooding in general entirely ceases, or become  quite  moderate and in-
 considerable in quantity.
  Summary of Results.—1. The total separation and expulsion of the
 placenta before the child, in cases  of unavoidable hemorrhage, is not  so
 rare an occurrence as accoucheurs appear  generally to believe.  2. It is
 not by any means so serious and  dangerous  a complication as might a
priori  be supposed.   3. In nineteen out of twenty cases in which  it has
 happened, the attendant  hemorrhage has either  been at once  altogether
 arrested, or it has become so much diminished  as  not to  be afterward
 alarming.  4. The presence or absence of flooding after  the complete
 separation of the placenta, does not seem in any  degree to be regulated by
 the duration of time intervening between the detachment of the placenta
 and the birth of the child.  5.  In  ten out of one  hundred  and forty-one
 cases, or in one out of fourteen,  the mother died after the complete  expul-
 sion or extraction of the placenta  before the child.  6. In seven or eight
 out of these ten  casualties, the death of the  mother seemed to have no con-
 nection with the  complete detachment of the placenta, or with results aris-
 ing directly from it, and if we do admit the three remaining cases (which 
LABOR,                             147
are doubtful), as leading by this complication to a fatal termination, they
would still only constitute a mortality from this  complication  of three in
one hundred  and forty-one, or about one  in forty-seven cases.   7. On the
other hand, under the  present  established rules of practice, one hundred
and thirty-four mothers died in three hundred and ninety-nine placental
presentations, or about one in three.                     Part xi., p. 203.

  Placenta Prcevia—Partial.—Rupture the membranes as soon as possi-
ble, and excite uterine  action by friction, the application of a binder, ergot
of rye, or galvanism.
  Complete.—If the os is undilated and rigid, plug Avith a sponge dipped
in vinegar and Avater; when the os is  sufficiently dilated, seize a foot and
deliver cautiously.  In head presentation  Avith a dead child, use cranioto-
my ; and in both this case and that of foot presentation, rupture the mem-
branes early through the placenta, by a silver catheter.  (Dr. Tyler.")
       *      *       *      *       *       *      *       *   '
  When  the vital powrers are much depressed, and the placenta partially
detached, plugging is dangerous.  So are the administration of secale cor-
nutum, and delivery of the child, because they lower still more the poAvers
of the system.  Detach completely the placenta, and employ galvanism,
which both rouses the uterus, and stimulates generally.—(Dr. Radford.)
        ********
  Turn as soon as possible, extract the placenta, and get the uterus to con-
tract: taking care to keep up the  pulse.   If the strength is too much ex-
hausted  for this, or if the os uteri will not admit the hand, separate the
placenta  if possible; rupture the membranes Avith  the nail, and plug the
vagina completely, then  give ergot of rye, and apply cold, or galvanism.
When the pulse rallies Avithdraiv the plug, and if possible turn; if this can-
not be done,  plug  again and wait. It is plain that if Ave cannot deliver, we
must  directly stop the bleeding; and plugging in the case supposed, Avhere
the placenta is low down, is quite effectual.
  Dr. Simpson  advises  when  the  hemorrhage and exhaustion are very
great, and when turning, etc.,  are impracticable, on account of the undi-
lated  state of the os and  cervix, especially in primiparae, or the contracted
state  of the uterus itself, or the narrowness of the pelvis; or when  turning
is dangerous on account of the exhaustion of the mother, or not required
for the safety of the child, on  account of its  death  or prematurity, to de-
tach the placenta,  and  leave  the expulsion of the child to nature, if the
hemorrhage,  as is usually the case, ceases, and no particular complication
arises.                                            Part xv.,p. 274-279.

  Retained Placenta.—Empty the umbilical vein, and forcibly inject cold
Avater slightly acidulated Avith acetic acid ;  or if there is much hemorrhage,
cold decoction of ergot, or solution of tannic acid.        Part xv., p. 280.

  Placental Presentations.—The practice recommended by Dr. Simpson,
of entirely detaching the placenta, and  leaving it, is likely to be of use in
very many instances; as where there  is such  an unyielding  condition of
the  soft  parts as to prevent speedy delivery, or Avhere the flooding has
been going on for  a considerable time,  and the practitioner,  on his arrival,
finds the  bleeding  still continuing, and the Avoman go much exhausted that
the  sudden emptying of the womb would be dangerous.  But this  plan by 
148
LABOR.
no means supersedes delivery by turning, which, if adopted in a prompt
and energetic manner, is a safe and proper method of treatment.
       *       *      *       *       *       *       *      *
  The practice of detaching the placenta is inapplicable in the most formi-
dable cases—is  as difficult to  accomplish  as turning, and  does as  much
violence to the  uterus—is almost certainly fatal to the child, and affords no
increased chance of safety to the mother."  If the cause of hemorrhage is
ascertained to be placenta praevia, rupture  the membranes, introduce the
hand, and turn  and deliver the child—provided  that the  os is sufficiently
dilated, or easily dilatable ; if it is not, wait, and act upon general princi-
ples, till sufficient relaxation has taken place.—(Mr. NeAvnham.)
       ********
  When copious and repeated hemorrhage  occurs in the eighth or ninth
month of pregnancy, and  signs of labor do not appear, evacuate the liquor
amnii, pass a conical  plug  into the  os uteri, fill up the vagina behind it, and
then give one or more doses of secale.  The plug occasions the formation
of a large  coagulum Avithin  the uterus, the presence of  Avhich, combined
with the irritation caused by the plug, excites  uterine contraction.  By
the expulsion of the clot, the os is dilated, and we are then  able to introduce
the hand and turn with more facility.   (Dr. Reid.) Pt. xvii., pp. 225-237.

  Placenta Prosvia.—The chief methods of treatment are: 1. The plug.
2. Puncturing  the membranes.  3. Turning the child. Plugging is adapted
to those  cases Avhich occur at the  sixth or seventh  month, when a continu-
ous drain is going on after the first loss.  The best method of plugging ia
to introduce strips of lint, pieces of sponge, or a silk handkerchief dipped
in vinegar and water.  Do not plug too tightly,  or uterine contraction
may be excited, and further separation take place.  Puncturing membranes
is adapted to those cases, not very severe, where the os uteri is only dilat-
ed to a slight extent, and turning is impracticable; it arrests the hemor-
rhage by lessening the vascular supply, and  bringing doAvn the presenting
part  of the child to act as a plug to the placental site.  Turning is the
grand remedy >in" placenta praevia ;  if performed  at the  proper time, it
affords the greatest chance of safety to both mother and  child.
       ********
  The most prompt  and efficient method in almost all cases is to introduce
the hand, dilate the  os uteri, separate the intermediate portion of placenta,
rupture the  membranes,  seize  one foot, turn, and deliver.  In selecting
the time  Avhen to do this, the great thing is to distinguish the dilatable
character of the os uteri; if this be present, the extent of  dilatation is of
no importance comparatively.  It requires great  care  that the dilating
force  be steadily applied and evenly distributed, so as to  guard the cervix
from  laceration, which  might  prove fatal  from  hemorrhage.  Version is
sometimes prohibited by  the immediate exhaustion of hemorrhage, or from
rigidity of the os uteri, in spite of hemorrhage; in the former case plug and
give stimulants freely, as a temporary resource.   In the  latter case, sepa-
rate the entire connection of the placenta, rupture the membranes, and
excite uterine action.  (Dr. Tyler Smith.)            Part xxxiv., p. 226.

  Encysted Placenta—That is, Avhere the placenta is retained by the con-
traction of the  os uteri after parturition, must be removed by gently dilat
ing the os first by the placenta itself,  if possible, or if this do not succeed, 
LABOR.
149
by the fingers, draAving gently at the cord, and at the same time having
firm pressure made on the abdomen.                 Part xxxiv., p. 227.
  Placenta Praivia.—ln those terrible cases where the os is rigid and un-
yielding, and the flooding profuse, do not delay, but introduce one or two
fingers through the os, and detach all that part of the placenta Avhich ad-
heres  within the cervical zone, or region of dangerous placental seat. The
contraction of the Avomb present in such a case as this, is the very element
which will secure  the success of this operation, as it constricts the mouths
of the bleeding vessels.  If contraction is not present, it must be induced
by  ergot of rye  or galvanism.  By the performance of this operation,
moreover, the os and cervix are released from a mechanical impediment to
dilatation.  If necessary, the hemostatic process may also be  assisted by
the use of the plug.   By these means the  hemorrhage will have been
arrested in the great  majority of cases, but,  if not, time will have been
gained,  and forced delivery rendered more  easy.     Part xxxvi., p. 221.

  Placenta Prosvia.—A case is related  in which, the os being dilated to
the size  of a small teacup, the separation (as advised by Dr. Barnes) of the
Avhole circumference of the placenta Avhich Avas presenting, sufficed at once
to check the hemorrhage.   By further separating the posterior portion of
the placenta the  membranes Avere reached,  and the presentation disco-
vered to be  a footling.  The child was delivered in a short time alive, and
the mother did Avell.                                Part xxxix., p. 292.
  Placenta  Praivia—Air Pessary.—An interesting case is related by Mr.
Jardine Murray,  of Brighton, in  Avhich  the  os uteri being  dilated  suffi-
ciently  to admit two fingers, and syncope impending from hemorrhage,  a
flattened caoutchouc  air-pessary Avas introduced  between the wall of the
uterus and the presenting surface of the placenta.  The pessary being then
inflated by means of the attached syringe, it  acted  admirably as a direct
plug and dilator of the os uteri.  Whenever, from time to time, the trickling
of blood recurred, it Avas  effectually checked by further dilatation of the
pessary, by  a few strokes of the syringe.  In tAvo hours  the os was  suffi-
ciently dilated to admit the hand, and  though turning was  necessary, as
the shoulder presented, the case Avas soon brought to a favorable conclu-
sion.                                                 Part x\.,p. 196.

                      PREMATURE LABOR.
  Mode of Inducing.—Dr. Meissner's mode of operating, which is a modi-
fication  of that by puncture of the membranes Avas the folloAving :  A very
slender canula is provided of about 13 to 14 inches in length, and bent re-
gularly in the form of  a segment of a circle.  It has a ring soldered on the
convex side  of its lower extremity, in order  to give a more secure hold,
and allow of the  point of the instrument being accurately guided.   This
canula is provided Avith tAvo trocars, one Avith a blunt point,  and the other
with a sharp-cutting point.  When the instrument is to be used, the blunt
pointed  trocar is introduced into the canula, and projects beyond its orifice
bo far as to prevent the edge of the tube injuring the parts.   The patient
then stands before the practitioner, who kneels before her, the usual man-
ner in Avhich vaginal examinations are made on  the  continent, or she may
sit on the very edge of a chair, or of the bed.  The forefinger of the left
hand is  then  introduced into the vagina, and the canula guided along it to 
150
LABOR.
the orifice of the uterus, making the convexity of the instrument  corres-
pond to the curve of the sacrum.   The point  of the instrument is  then
pushed slowly backward and upward, so as to make its rounded point
slide betAveen the uterus and the back of the membranes.  When the point
is once past the neck of the uterus, it advances easily, care only must be
taken to detach the  membranes as little as possible.   When the point of
the instrument is about 10 or 11  inches Avithin the os uteri, the blunt-point-
ed trocar is withdrawn, and the handle of the instrument is pressed against
the perineum, to detect, if possible, against Avhat the point of the canula
is pressing.  If it be felt to be a hard body, the point is made to move to
one side or other till  an elastic fluctuating spot be  reached, Avhich shoAvs it
is opposite the  membranes alone; the sharp-pointed trocar is then intro-
duced  and perforation of the membranes  is made.  The trocar is  then
withdrawn, and about a tablespoonful  of the liquor amnii is allowed to
escape; after this the canula also is removed, and  the woman is allowed to
walk, sit, or lie down at her own pleasure.               Part Hi., p. 124.

  The Use of the Plug to produce Premature Labor.—Two modes of pro-
ducing  premature labor are resorted to at the present day.  Either the
membranes are punctured, or a tent of sponge is introduced into the os
uteri, as recommended by Professor Kluge.  The former method is liable
to the objection of causing the too rapid escape of the liquor amnii, and
thus endangering the life of the child when labor  pains are tardy in their
occurrence.  The second is often extremely difficult to accomplish, or even
impossible when the os uteri is directed very much baclcAvard, or when
the patient has never before been pregnant.
  Dr. Scholler  Avas led to try the plug, from  having observed that when
used  to suppress  hemorrhage, in  cases  of placental presentation or of
threatening abortion,  it had a  considerable influence in exciting uterine
action.  He had observed,  also, one case where its employment to restrain
hemorrhage Avas folloAved by premature labor, which it seemed to have
occasioned.  He recommends  filling the upper part  of the vagina  Avith
balls  of charpie,  Avhich, for the sake   of cleanliness, should  be reneAved
every twenty-four hours.  The  action of the uterus is usually very speedily
excited, and, when fully established, the plug may be Avithdrawn and se-
cale cornutum  administered to prevent the  diminution of labor pains.
The finger may likewise be used to  aid the dilatation of the os uteri, but
great care must be taken to leave the membranes uninjured.
  The average length of time which elapsed  between the application of
the plug and the birth of the child  was  five days  and fourteen hours.
                                                       Party., p. 162,
  Induction of Premature Labor.—M. Dubois confines himself to those
cases where the safety of the mother is in  question, not regarding in any
respect whether the  child is viable or not.  This absolute abandonment ol
the interests of the infant,  when the life of the mother is seriously endan-
gered, although not admitted by many accoucheurs, noAV finds less and less
opposition every day.
  The first mechanical condition requiring the operation, is excessive dila-
tation of the uterus  by superabundance of the liquor amnii.
  The second set of  cases sometimes demanding  the operation are  those
Where, in addition  to the pregnant uterus, the abdomen contains a  large
tumor.  Thirdly, cases where, from malconformation of the pelvis and 
LABOR.
IS I
trunk, there is not sufficient space for the uterus to develop  itself.  We
may remark, however, that in these last sets of cases, premature labor
generally comes on spontaneously.
  Fourthly, cases  of retroversion of the  uterus, in which it becomes  im-
pacted in the small pelvis.
  Fifthly, those cases of uterine hemorrhage where  nothing but the eva-
cuation of the ovum, and the contraction of the uterus, will stop the bleed-
ing.   We now come to another series of cases demanding the  operation ;
and, firstly, Ave  mention those nervous diseases Avhich may demand it when
they exist to an excessive  and dangerous degree, as chorea, convulsions,
etc.   But M. Dubois inculcates extreme caution in such cases, as  also in
cases of obstinate vomiting during pregnancy.  Two cases are mentioned
in which cholera supervened  upon pregnancy ; in one labor was induced,
in the other it came on spontaneously ;  both women recovered.
  There is another series of cases sometimes demanding the operation,
namely, Avhere there  exists chronic disease, very much agravated by the
mechanical distention of the uterus, as disease of the heart, of the aorta,
asthma, etc.
  Again, it is proprosed to  bring  on  labor in  cases  where the  child has
been previously found to die at some regular time, before the completion
of the ninth month.  But this ought to be done only wdien the infant is .
alive  and viable, and even then it should be resorted to with  reserve, as
there may be hope that the disease Avhich caused the death of the child in
a former pregnancy may have now disappeared.        Part xix., p. 234.

  Premature Labor.—The following method, proposed by Kirnsch and
Cohen, has been  successful in  inducing premature  labor:  Pass the noz-
zle of a large syringe, containing  11 or 12 oz. of water, at 92° F., half an
inch within the cervix, and inject  the Avater Avith some degree of force for
a number of times (e. g. eight or  ten, up  to seventeen times) ;  and repeat
this process tAvice a day until labor is induced.          Part xxi., p. 308.

  Premature Labor—Induction of.—Dr. Simpson recommends the dila-
tation of the os uteri by  sponge tents, gradually increasing them  in size.
The  membranes are also separated to a certain  extent.   This he had never
found to fail, although he had  employed it  in numerous  cases.  In this
manner the  first stage of the labor is almost entirely accomplished before
labor begins, and consequently, the child is saved from the pressure, etc.,
incidental to the earlier and protracted part of the first stage.
                                                   Part xxiv., p. 348,

  Premature Labor—Induction of.—The following is the method of Pro-
fessor Kiwisch:  A piece of India-rubber tubing, about  eleven  feet  long
and half an inch in diameter, is connected with a straight tube from an in-
•ecting apparatus five  or six  inches in length, the latter forming the ex-
tremity  of the  siphon.  A vessel  containing about two  gallons  of water
of about 110° Fahr., is placed nine or  ten feet from the  ground, the pa-
tient being placed in an empty hip-bath.  The proper end of the tube is
to be passed into the vagina, and directed toward the os uteri, where it is
to be held steadily.   After exhausting the tube, the  other end is  to be
placed in  the Avarm water.  The stream Aoavs wdth considerable force
against the os uteri, and  continues until the whole contents of the  vessel
are discharged.  Two gallons of cold water  are then to be placed in the 
t52
LACTATION.
vessel, and disd irged in the same way.   The douche  may be repeated if
necessary on the next day.
       *.        *        *         *        *       *      *
  In another case the plan adopted was somewhat different.   The common
3lastic bottle-syringe, manufactured by  Roberston, of Dublin,  was used.
To this Avas attached a flexible tube, Avith a bone pipe at the  end.  This
Avas introduced into the vagina, and directed against the os uteri.  Tepid
water Avas then forced, by means of the syringe, along the tube, from some
convenient vessel, another smaller one being placed to catch the Avater as
it poured from the vagina.  The process had to be continued  about five
minutes.   A second and third application Avas made  on successive days;
and on the third, labor came  on at half-past three o'clock  r. m., and ter-
minated  at half-past ten at night.                     Part xxvii., p. 170.
  Premature Labor.—There is a great and undoubted sympathy betAveen
the breasts and other parts of the sexual apparatus.  It Avas supposed that
irritation of the mammary nerves might induce uterine action.  This was
tried.  Sucking pumps, made  of caoutchouc, were applied for two hours
seven times during three days: after the third application the cervix uteri
Avas shortened, after the sixth severe  labor  pains came on, and after the
seventh the child Avas born.                          Part xxviii., p. 263.
  Premature  Labw—Induction of.—To give the child the best  chance
of surviving, instead of  rupturing the membranes, you must separate them
from their connection in the vicinity of the os.  Various plans have been
devised for this purpose ;  but perhaps Dr. Weir's instrument, which com-
bines the uterine introduction of a female catheter, with the injection of
tepid Avater, is the best.   It consists of a large flattened female catheter,
to which can  be attached a common  injecting syringe. In using it, the
tube is first cautiously  introduced  Avithin the os for  about  three  inches,
and then by means of the syringe a quart of tepid water is injected so  as
to act by slowly separating the membranes.  A sponge tent  should  now
be introduced Avithin the os, and the injection may be repeated, at inter
vals of two or three hours, until successful.           Part xxxii., p. 229.
  Premature Labor—Induction of.—In the early months, while the cer-
vix uteri is as yet undeveloped, and the ovum is contained in the cavity
of the fundus uteri, the douche cannot be relied upon, and the better plan
will be to  introduce the uterine sound and turn it round once or  twice;
this will  never fail to produce expulsion.  When th, life of the  child  is no
object, as before the seventh month, the stilette i~v - be used,  but before
the fifth  month this is a dangerous instrument.        Part xxxv., p. 208
                          LACTATION.
  Use of the Bofareira, Ricinus Communis, or Palma Christi.—In cases
of child-birth where the appearance of milk is delayed, a decoction is made
by boiling well a handful  of the white  Bofareira (Ricinis Communis ol
botanists) in six or eight pints  of spring water.  The breasts are bathed
with this decoction for fifteen  or  tAventy minutes.  Part of the boiled
leaves are then spread  thinly over the  breasts,  and allowed to  remain 
LACTATION.
153
until all moisture has been removed from them by evaporation, and pro
bably,  in some measure, by absorption.   This  operation is repeated at
short intervals, until the milk Aoavs upon suction by the child, which it
usually does in the course of a few hours.  If the milk is required to be
produced in the  breasts of women who have not givep birth to or suckled
a child for years, the mode of treatment is as follows :   <V similar decoction
is made, and it is poured, while yet boiling, into a larg.  vessel, over Avhich
the woman sits so as to receive the vapor over her th.ghs and generative
organs, cloths being carefully tucked around her, so  as to prevent the
escape of the steam.   In this position she  remains for ten  or twelve mi-
nutes, or until the decoction cooling a little, she is enabled to bathe the
parts with  it, which she does for fifteen or twenty minutes more.  The
breasts are then similarly bathed and gently rubbed Avith the hands, and
the leaves are afterward applied to them  in the manner described.  These
operations  are repeated three times during the first day, on the second the
process is repeated  as to the breasts three or four times; on the third day
the Avhole process is repeated.  A child i3 noAV put to the nipple, and, in
the  majority of instances,  it finds an abundant supply of milk.   In the
event of success not following, the treatment is continued for another day;
and if there be still want of success, the case is abandoned.
                                                     Part xxii., p. 316.

   Case of Lactation in a Male.—Dr. Horner gives a case of lactation
occurring in an  adult  male, aged 22 years.  The patient's  attention Avas
first drawn to his left  breast, Avhich appeared to be  enlarging, and con-
tinued to increase in size  for three Aveeks, when he came to Philadelphia.
After being in this city for three Aveeks, he became quite anxious in regard
to his  condition; for, although he suffered very little pain, the mamma had
become quite as large as that  of a female nursing.
   He'Avas  induced  to apply at the Clinic of the  Jefferson Medicai  College
to consult  the faculty of that  Institution.  His case came up before Prof.
Mutter, who, upon examination, found the mammary  gland largely  deve-
loped, and  filled Avith lacteal secretion, Avhich differed in no Avise from that
of a mother.   He  could assign no cause for this freak  of nature : his
health Avas very good, and the other breast  natural.  A soap plaster was
prescribed, and compression ordered to  be kept up, ivhich he persisted in
for full six  Aveeks, when the gland returned to its usual size.
                                                    Part xxiii., p. 258.
   Suckling—Impairment  of Vision during.—This affection arises from
the  drain there  is upon the system ; therefore, if severe, the  child should
be immediately AATeaned; if slight, it should not be  put to the breast more
than twice  in the twenty-four hours.  The amcmic condition of the patient
naturally indicates the employment of  a stimulating plan of treatment.
You must  give iron in some form, combined Avith ammonia, Avhich  is the
most generally  useful of all stimulating medicines; quinine  also  maybe
necessary.   If the  patient does not improve, t;y mercury,  but you must
give it very cautiously in these cases.  Leecho* or blisters should  never
be applied  ; you must increase the quantity and improve the quality of the
blood.
   [Whatever reduces the powers of the syste n, and impairs the quality
of the blood, such as diarrhoea, leucorrhoea, or t tcessive natural secretions,
so as to act as a drain on the system, may be bllowed  by impairment or 
154
LACTATION.
loss of vision, which, Avhen detected early, is very amenable to treatment,
whereas, Avhen neglected, it not unfrequently terminates in total blindness.]
                                                    Part xxxii., p. 237.
  Effects of Belladonna in arresting the Secretion of Milk.—Dr. Burrows
of Liverpool cites the following striking case :  The child was dead owing
to the nature of the labor, and the resuscitative measures adopted did not
prove successful.  On the fourth day the breasts  assumed their maternal
functions;  on the  seventh day they Avere full, tense, painful, and knotty,
with a slight inflammatory blush, though spirit lotion had been applied.
  I directed the areola, and a  circle extending half an inch beyond it, of
each breast, to be painted thickly  over Avith  the extract of belladonna,
reduced  to the consistence  of thick paste by the addition of the acacia
mixture.  As the late Mr. C. T. Haden recommended the use of colchicum
for the purpose of controlling arterial action in inflammation of the breast
and nipples, with the same intention I gave the following mixture:
  R Infusi  rosae comp. §vj.; magnesia? sulphatis § j.; vini colchici 3hj.; aquae
menthae piperita? 3xv.  M.  Fiat mistura cujus sumatur |j. 4ta quaque hora.
  The result Avas most satisfactory.   In thirty-six  hours after the applica-
tion of the  extract,  the mammas Avere cool, pale and flaccid; and the knots
softened and reduced in size.  I advised the repainting of the areolae ; and
in two days after—i. e. three and a half days from the first application—
they were so reduced in size that they were smaller than during the latter
period of pregnancy, and the knots could scarcely be felt.
                                                    Part xxxv., p. 234.
   Suppression of Milk.—If from  any  cause  the  lacteal  secretion  should
become suppressed, and it is desirable to again reneAV  it, it may be  accom-
plished by  the application of electricity.             Part xxxvi., p. 236.
  Abortive Treatment of Milk Abscess.—Dr. Goolden  has found this mode
of treatment eminently successful.— Case.—M. S----, confined of her first
child. According to  her reckoning and the appearance of the infant at its
birth, the labor Avas premature.  On the third day the breasts Avere swollen,
hard, tender, throbbing,  and  red ; the superficial veins enlarged,  with
feeling  of  great distention.   The nipples were retracted and cracked, and
the child was too feeble to suck, even if the  nipples had been more pro-
minent.  The milk partially oozed aAvay, and a little was draAvn by means
of a.breast pump, but not enough  to produce any sensible diminution of
their  bulk; besides which,  the abortive  efforts were attended with the
greatest suffering.  There Avas fever, anxiety of countenance, and depres-
sion of mind; as she had a  great  dread of a "  bad  breast."   This was
evidently one of those cases that must inevitably result in abscess, unless
something  more than the ordinary remedies Avere resorted  to.   I  gave
directions to paint the areolae and nipples  Avith extract of belladonna, and
to take a saline mixture with half-drachm doses   of colchicum  eirery six
hours.  Upon visiting her on the followdng day I Avas as much gratified as
surprised at  the result of the treatment.   The fever had  entirely disap-
peared ;  the  breasts Avere  quite soft; the milk had flowed  away in great
abundance into a bread and water poultice ; a cheerful expression of counte-
nance Avas  exchanged for the former one of anxiety  and dread;  and  all
apprehension of evil had disappeared.  I ordered the mixture to be omitted,
but to continue the local application.  The case required no further treat-
ment, and  she Avas " about" in the  course of a few days. 
LARYNGEAL AFFECTIONS.                    155
  In the cases related by Dr. Goolden, the belladonna, with the internal
administration of colchicum, appeared to  have had the effect  of  arresting
the secretion of the milk.   In the case above detailed it is seen that the
milk flowed aicay abundantly, and that the mother Avas enabled to con-
tinue lactation shortly after the application.
  The  long-recognized  power which this drug  is  known  to possess of
relaxing  muscular contraction, at once suggests the modus  operandi in
these cases.
  Doubtless, any of the active forms of belladonna would ansAver the pur-
pose equally well with the extract; such as a solution of its active principle,
atropine.
  The  latter is undoubtedly more elegant, and I dare say Avould be more
speedy in its effect;  but the extract, from its being a messy and unsightly
application,  is much more likely to be carefully washed  off, so  as not to be
injurious to  the infant lvhen replaced at the breast.   Part xxxvi., p. 237.
  Dispersion of the Milk.—Iodide of potassium given in doses of from six
to eight grains per diem, has the effect of suspending, and in less  doses, of
moderating, the secretion of milk.  This property  may be made  of the
greatest  use in  arresting impending  inflammation  and abscess;  the pain
and fever will often disappear next day.   After the  cure the milk returns
again two or three days after the suspension of the iodide.
  [Probably this treatment might be advantageously combined  Avith the
external application of belladonna, first recommended by Dr. Goolden, and
since found  so eminently successful by other practitioners.]
                                                  Part xxxviii., p. 221.
  Defective Lactation—Dietetic Treatment.—Experience proves that much
may be effected by proper diet; the  food should be " analogous."   First
among the grains are lentil poAvder,  or the so-called revalenta:  but pea-
soup and bean-soup have also a marked effect in improving the Aoav and
richness  of milk.  The lentil and  bean, however, are  preferable to peas,
when they are as easily procurable.   Shell-fish, as oysters, are peculiar in
containing much phosphorus.  If, on trial, they do not produce  urticaria
or roseola in the child, they Avill on the above account be advantageous, as
the phosphates are beneficial to both mother and child.   Part x\.,p. 310.

                              —•-•-•---


                 LARYNGEAL  AFFECTIONS.
  Transverse Divisions of the Larynx and Trachea.—In  cases of divi-
sions ot the  trachea, or larynx, Ave  Avould strongly recommend surgeons to
bear in  mind the advice given by Mr. Stanley, viz., not to be satisfied to
bring the outAvard parts together  by means of ligatures, etc., trusting af-
terward to position to complete the cure, but to introduce a ligature or
tAvo through the Avindpipe itself, or through the fibrous tissue connecting
the cartilages, so as to prevent the loAver portion retracting.  In a case of
cut throat, hoAvever, the surgeon must not apply his sutures immediately,
as he might very naturally feel inclined to do, but Avait a little to  see Avha
blood has escaped into the windpipe, and allow it to make its escape befoi
closing up the aperture.
  Rust, of Berlin, observes, that  "in wounds dividing  only partially \x 
156
LARYNGEAL AFFECTIONS.
trachea or larynx,  a  suitably inclined position  of the head and  neck is
generally all that is required tc effect a speedy union ;  but where  the lar-
ynx or trachea is completely cut across, it becomes  expedient to have re-
course to sutures. . The tendency of the loAver portion  to  sink down from
the upper is often so great, that Ave must not limit our sutures to  the cel-
lular tissue, but pass them through the substance of the trachea itself, and
even  through the cartilages of the larynx."  He  relates  a case  of cut
throat Avhich occurred in  Charite  Hospital  at Berlin,  Avhere the  thyroid
cartilage was divided, and adds, " that in this patient, the  tendency of the
lower eud of the divided larynx to sink down from the  upper, was  such as
to occasion the necessity of a suture through the substance of each  portion
of the cartilage (thyroid),  that sutuies passed simply through the soft tex
tures repeatedly gave Avay, and that the healing in this case Avas perfect.
  Mr. Stanley remarks that in  such cases avIkii a liquid  is SAvallowed, it
often passes down the trachea, and comes out at the Avound, giving rise to
a suspicion that the oesophagus is also Avounded,  but this is owing to a loss
of irritability of the glottis, which thus allows the liquid to pass.
                                                       Part x., p. 136.

   Coin removed from the Larynx by Inversion of the Body.—Dr. Dun-
can relates a case of this accident which occurred to a man who was amus-
ing himself Avith tossing up a shilling, and catching it in his mouth, Avhen
it slipped into the larynx.   At first, violent  coughing Avith great dyspnoea
wTere  produced, but these after some time subsided.  From the  favorable
result of Sir B. Brodie's case, it Avas determined to try inversion  of the
body, Avhich plan had also occurred to the  patient himself.  Instruments
were, hoAvever, kept ready in case the shilling should  change its position
so as to produce suffocation.  The mode in Avhich the experiment was per-
formed, though rough, Avas quite effectual.
  The man Avas placed with his shoulders against the raised end of a pretty
high sofa, and then being  seized by three of the most poAverful of those
present by the loins and thighs, he was rapidly inverted, so as to bring the
head into the dependent position, and,  after a shake or two, Dr. Simpson
at the same time moving the larynx rapidly from side to side, the  shilling
passed into the mouth and fell upon the floor.  Not the  slightest cough
or dyspnoea  was produced, and the patient immediately started up, de-
lighted Avith the result.  He was noAV perfectly free from uneasiness, and
there was a marked change in the character of the voice.  He had not the
slightest subsequent bad symptoms.                      Part xi., p. 173.

   Cynanche Laryngcea.—Dr.  Budd believes that this  disease is really
erysipelas, and that its not being recognized as such, is owing to its so fre-
quently proving  fatal, before it has had time to spread.   In support  ol
this, he relates in his  paper read to the Medico-Chirurgical Society, five
cases which have recently occurred in the London hospitals.
  These cases, the author observes, Avere clearly examples of the same dis-
ease ; but they did not all  begin exactly in the same manner.  In three, the
inflammation commenced in the fauces; in one, it commenced in the paro-
tid gland; and in one, the first appearance of it was an erysipelatous blush
at the angle  of the loAver jaAv.  In all the cases the inflammation soon
spread to the glottis, and  produced  there the same effects—namely, red-
ness and great thickness of the epiglottis, and of the  lips  of the glottis,
With effusion of sero purulent fluid in  the submucous cellular tissue—to 
LARYNGEAL AFFECTIONS.
157
Buch ?. degree as, in three of the cases, to produce  almost sudden closure
ot t.Vtf glottis, and consequent suffocation.
  The occasional connection of laryngitis with erysipelas Avas noticed by
Dr. Cheyne in  his article on laryngitis in the  " Cyclopaedia of Practical
Medicine:"
  The authorities the facts related by Mr. Ryland, and observes that they
prove conclusively that inflammation of the larynx, causing great swelling
of the lips of the glottis, and infiltration of the fluid in the  submucous cel-
lular tissue, and thus  leading  to  speedy suffocation, occasionally results
from the poison  of erysipelas.   He considers the following circumstances
favor the opinion he has expressed as to the nature of the disease.  That
the inflammation spreads in the same mode as in erysipelas of the skin,
presenting the deep redness and SAvelling, and infiltration of a serous or
sero-purulent fluid, Avhich  occur in that disease;  that it  is more fatal than
ordinary laryngitis ;  and that it occurs most frequently among the inmates
of hospitals in which erysipelas prevails,  and  among such of them as are
peculiarly liable  to erysipelas, viz., convalescents from continued fever or
eruptive fevers,  and those laboring under secondary syphilitic ulcers.
  Mr. Arnott, to sIioav the erysipelatous nature of the  disease under dis-
cussion, related the following cases : A gentleman was seized with a pain in
the back  of the throat, attended by difficulty  of  swallowing.  Nothing
could  be  seen.  Leeches  were applied,  and  blood  afterward taken from
the arm.  The blood was  buffed  and cupped.  He appeared better; but
:i few hours after Avas suddenly seized Avith dyspnoea and died.  The only
 disease found Avas inflammation of the glottis, one of the margins of which
 had sloughed.   Four  days after, his wife,  who had attended him, was
seized Avith an affection of the. throat;  the tonsils were  enlarged.  Ery-
sipelas of the head  and  neck shortly  afterward developed itself.   The
daughter, Avho came from  the country to see her mother, suffered from in-
flammation of the larynx  and  pharynx,  and aftenvard from erysipelas of
the head and face.  When there Avas infiltration of purulent matter, he be-
lieved that in these cases the operation Avas always fatal.  He did not
know what to do after the operation in these cases.        Part xv., p. 93.

  Syphilitic Laryngitis.—Dr. Watts relates the case of a man who, when
suffocating, with syphilitic inflammation  of the larynx,  was saved by tra-
cheotomy.
  Dr. W. saw him for the  first time Sept. 29th, after he had been given up
for death by three medical gentlemen; the patient was then  so breathless
as to be scarce able to make the  effort  to whisper  single words at  inter-
vals ;  his Aroice Avas nearly extinct, and the inspirations were  accompanied
Avith a loud hissing noise in the  larynx.  The friends suited he had not
slept for twelve  days, owing to the intensity of the orthopcena.  After a
careful examination of the chest and air passages, and having obtained a
perfect history of the circumstances, syphilitic  laryngitis was diagnosti-
cated; the iodides of mercury and potassium, with other appropriate treat-
ment  were prescribed, and the case was  viewed as being favorable  for the
performance of tracheotomy.  In consultation with Dr.  Dumville, the plan
of operation Avas agreed upon ;  but it was determined to wait until the last
extremity before having recourse to it, and in the meantime the patient
was carefully  watched.  In the evening of  Oct. 1st, the poAvers  of life
seemed fast failing, and it appearing  impossible for him  to  continue the 
158
LARYNGEAL AFFECTIONS.
 struggle for breath longor with  safety, the operation was  undertaken at
 his own instance, and most hapjily perfo: nc-i by Mr. Dumvillc.   The fit
 of spasmodic coughing usually attendant en ta? introduction of the tube
 having subsided, the man fell  into a sound  sleep even before the dressings
 were completed: so signal was the relief from suffering, so completely was
 he worn  out by anxiety and  fatigue, and  deprivation of rest.  The case
 progressed favorably; the patient continuing to take the medicines, was
 soon under mercurial influence, and gradually improved in health.   On the
 30th Oct., precisely thirty days after the operation, the use of the tube was
 finally dispensed Avith; the Avound closed up Avithin a Aveek, but required
 other seven days before the skin healed perfectly. The iodide of potassium
 was administered for a feAV months longer, to insure the thorough eradica-
 tion of the lues;  but from the period of the removal of the  tube he con-
 tinued steadily improving, until he regained more  perfect health than he
 had enjoyed for many years.
   Dr. Watts remarked, that notAvithstanding the case had been treated by
 others as asthma, the circumstance of the syphilitic constitution, the chro-
 nic cough Avithout pulmonary  disease, the apparent origin of the cough in
 the larynx, the periodical relapses of the laryngeal affection, and the pecu-
 liar  aching in _ the bones, appeared to him  as sufficiently indicative of sy-
 philitic laryngitis—an opinion  Avhich Avas further strengthened by the radi-
 cally curative effect of the remedies employed.  As promoting the suc-
 cess of the operation, he dAvelt on the importance  of the patient's  room
 being made very Avarm before operating, as also on the propriety of main-
 taining a high temperature afterward.  He had known death follow, as if
 by shock or spasm, the sudden inhalation of the chilly atmosphere  of the
 operating theatre in Avinter Avhen this precaution had been neglected.
                                                      Part xv., p. 201.

   Follicular Disease of the Throat and Larynx.—Dr. Green advocates
 the use of nitrate of silver as a  local application in chronic laryngitis, " cler-
 gyman's sore throat," and similar affections, some of which not unfrequent-
 ly simulate, or complicate phthisis.  The mucous membrane lining the fau-
 ces pharynx, and larynx, is abundantly studded with muciparous follicles.
 At the back of the  tongue they open into the foramen caecum and the len-
 ticular papillae ; in the uvula and  pharynx  they are large ; and the  tonsils
 seem to be  entirely composed of them;  in the oesophagus they are like
 Brunner's glands, and are imbedded in the submucous tissue.  In the up-
 per part of the larynx these follicles are numerous, and still  more so in the
 trachea : they secrete a fluid to lubricate the passages, which in the healthy
 state is bland transparent, and not abundant in  quantity, but is increased
 and vitiated by disease.
   Apply solution of  crystallized  nitrate  of silver, of from one to four
 scruples to the ounce of  distilled water.   Use  a piece of whalebone, ten
 inches  long and curved at the extremity, having a small round piece ot
 fine  sponge securely attached to it.  The  mouth being opened a ide and
the tongue depressed  by a spatula of a peculiar form, camr the sponge,
dipped in the solution, over the top of the epiglottis, and while the patient
breathes gently out press it downward  and forward through  the  aper-
ture of the glottis into the laryngeal cavity.  Apply this evarv other day
or oftener,  for two or three weeks, and then twice  a-week ft'' -e surface
 assumes a  healthy  appearance.   If there are extensive ul« -\ * is  on the 
                       LARYNGEAL AFFECTIONS.                   159

epiglottis, and about the month of the  larynx, apply for once  or twice a
solution of double the strength of that above mentioned   For a feAv days
before cauterizing the interior of the larynx, educate the  arts by applying
the solution to the more external parts.   Give iodide of potassium inter-
nally ; or sesqui-oxide of iron ;  with sedatives, such asbeladonna, conium,
hyoscyamus, morphia;  and expectorants.               Part xvi.,p. 119.
   Ulceration of the Epiglottis, and  Opening of the Larynx.—In a case
of ulceration  of the epiglottis, and opening of. the larynx in a  child, con-
sequent upon  SAvalloAving  sulphuric acid, Dr. Green  used the solution ot
crystallized nitrate of silver Avith the greatest success.   Part xvi., p. 126.
   Spasm of the Windpipe in  Infants.—During the paroxysm dash cold
water in the  face, and expose it to the fresh air.   Lance the gums if there
is the least fullness or tenderness ; and unload the bowels by a dose of cal-
omel, followed by  castor  oil, and  a  warm Avater injection.   Afterward
give small doses of calomel or grey powder, and the following mixture;
Fetid spirits of ammonia, half  a drachm ; dilute hydrocyanic acid, five mi-
nims ; tincture of henbane, seven minims ;  spirit of aniseed, one drachm ;
sirup of orange  peel, four  drachms; Avater an ounce and a half.   A tea-
spoonful twice or thrice daily.   And rub a little liniment upon the chest
and spine occasionally;  as a drachm of  tincture  of cantharides, a drachm
of laudanum, and an ounce of soap-liniment.  Or give assafoetida enemeta.
Depletion is rarely required.  Take the child into the country, and keep
it as quiet as  possible.                                 Part xvi., p. 131.
   Laryngismus Stridulus.—Inhalation of Ether recommended, by means
of a sponge  saturated  Avith ether and held to the nose and mouth  of the
patient  upon  the first indication of an accession of the spasm.
                                                     Part xvi., p. 132.
   Laryngitis—Acute.—Besides the ordinary treatment  by leeches and
tartar emetic, if there is cedema of the epiglottis (indicated by there being
difficulty in SAvallowing, and a sensation of a SAvelling in the throat, Avith-
out affection  of the tonsils) blow powdered alum into the  throat, through
a quill.                                               Part xxii., p. 11.
   Application of Nitrate  of Silver to the Fauces and Larynx.—[A vari-
ety of methods have been adopted to apply nitrate  of silver, either solid
or in solution to the fauces and larynx.  We haAre seen several methods
of applying the solution to  the larynx ; but we Avould warn the practitioner
to be very cautious how he adopts this method, for fear of suffocation.
There  is  no  doubt, hoAvever,  that if nitrate of silver could be  safely and
easily applied to the laryngeal and bronchial surfaces, it would have  a won-
derfully beneficial action, as it has upon all mucous surfaces.]
   Mr. Coxeter's  Laryngeal Shower  Syringe, is by far the  most  conve-
nient form in Avhich a syringe can be used for these applications to  the in-
terior of the throat and the posterior  nares.  It consists of a seamless
tube, composed of silver—not  unlike  that of a medium-sized catheter.
It is curved in a form suitable to its intended uses.  The distal extremity
is someAvhat flattened from side to side, and is perforated by fine openings,
which admit  of the emission of the contained fluid in the  form of a deli-
cate shower.   The proximal extremity is fitted Avith  an elastic suction-bot
tie, which, by its  own action, charges the instrument with the fluid, which
is then emitted by simply compressing the  bottle with the thumb.   Rings 
160                            LARYNX.
are attached for holding  the little instrument, and an ingenious arrange-
ment is made, by Avhich the quantity of fluid ejected can be accurately re-
gulated.  The inventor says that his shoAver syringe possesses the advan-
tage of applying gently, and Avithout  friction, to an irritable surfiice, the
remedial agent "intended to be employed.  It does this  more generally
and uniformly than the sponge, and is entirely free from the risk to which
the latter, in becoming detached from the Avhalebone, is liable.
                                                    Part xxvii., p. 74.
  Laryngotomy.—Place the patient on  his back, and completely expose
the crico-thyroid membrane by dissection before opening the larynx.  This
is necessary, as an artery (the inferior laryngeal) is often passing this space,
and requires, a  ligature.  Then make a vertical incision into the larynx,
through the crico-thyroid space, and insert a full sized trachea tube.   It is
sufficient,  in dyspnoea arising from  causes  in the larynx of the adult, to
make the  opening in the crico-thyroid space, but not so in the child.  In
the adult, any inflammatory effusion,  or thickening,  arising from acute
affections  of the larynx, takes place in the submucous tissue, and is more
local.  In the child, it t kes place more on the free surface of the mucous
membrane, and spreads doAvnward, thus becoming tracheal as  well as
laryngeal.  Laryngotomy, therefore, is not so applicable to the child as to
the adult.                                            Part xxx., p. 132.
                           LARYNX.
  Larnyx—Inflammation of.—In the first stage of an inflammatory attack
of the larynx  or trachea, when  the  mucous  membrane is  dry, an emetic
will restore the moisture.  Cauterization should be used locally at the same
time that the  emetic treatment is adopted internally.  In treating  these
inflammations  by the application of the  nitrate of silver, it  is important to
bear in mind that the more intense the degree of inflammation of the lining
of the larynx  is, the weaker ought to be the solution of the nitrate applied
to it.  The first effect  of the application is to coagulate the albuminous
film  upon the  surface  of the membrane Avhich has been  stripped of its
epithelium, and thus to cover and protect it. As the good effects of the
application are Avorn off in a feAv hours, the  touching  of the larynx must
be repeated frequently for some days, until all the symptoms of laryngitis
have completely disappeared; as in most severe cases,  especially in adults,
a chronic thickening is liable to  be left, it  is a good precaution to give a
little  mercury  toward the  end  of the  acute attack.   In  true  exudative
croup, Avhere the inflammation is  of a  much more  intense and fibrinous
character, and where it is almost of  a purely local  nature, seizing at once
on the  larynx or  trachea, the treatment by the application of caustic is
unsuitable,  the symptoms being increased rather  than diminished, by its
use.                                                  Part xxvi., p. 63.
  Topical Medication of the Larynx.—Instead of thrusting a piece  of
sponge into the larynx, in applying the  solution of nitrate of silver, Dr.
Cotton, by means of a pair of forceps made by Mr. Coxeter, squeezes the
sponge saturated Avith  the solution over the larynx, so that  it passes into
its interior.  This  plan is stated to be much less  irritating than the one
commonly employed.                                 part xxvi    y0< 
LEAD—LEECHES.
161
                               LEAD.
  Acetate of Lead.—[It is important that the prejudice of the poisonous
nature of the acetate of lead should be exploded, and its value as a medi
cament established.]
  Several interesting cases wherein acetate of lead has been administered
in large quantities without destroying life,  are recorded by Dr. Christison
and Professor Taylor.
  A woman Avas  admitted into Guy's  Hospital in May,  1846, having
SAvallowed an ounce and a half of sugar of lead dissolved in water, from
which  she recovered, and left the hospital in five days.
  Mr.  Gorringe reported  two cases in which two girls swallowed by mis-
take one ounce of the acetate, and another in which a girl swallowed one
drachm, and all recovered.
  Dr.  Hirding gives a case in Avhich a girl swallowed three drachms /  she,
too, recovered.
  Dr.  Iliff  records four  cases in Avhich  individuals swalloAved  each an
ounce / and Dr. Evans one, in which three drachms were swallowed, and
all in a very short  time recovered.   These cases, wdth the " observations
and experiments of Orfila, prove that the belief that sugar of lead is an
active  poison, is erroneous."
  Dr.  Sweeting suspects that where acetate  of lead, internally adminis-
tered,  has occasioned dangerous  symptoms, the preparation  has not been
free from oxidation—it is the oxide AAdiich is injurious.
  The same obtains in  painter's colic ;  these  people mix considerable
quantities of litharge  and red lead,  technically  called driers, with their
oils, and neglecting careful ablution before taking their meals, impercepti-
bly SAvalloAv a material of a very dangerous character.  Part xxiv.,p. 114.
   Use of Acetate of Lead.—The only point on which I presume to differ,
says Dr. Burridge, from,Mr. Sweeting, is  this—that  of combination.  In
accordance with the practice of Dr. Christison, and the rule laid dowrn by
the late Dr. A. T. Thomson, of University College, I ahvays give acetate
of lead in a fluid form ;  never Avithout acetic acid, and very rarely indeed
without Battley's liq. opii sedativ.                   Part xxiv., p.  116.
  Saturnine Poisoning.—Neither sulphuric acid nor sulphates can serve
as antidotes to sIoav poisoning by the salts  or  compounds of lead, the
sulphate  of  lead being  itself a sIoav but  sure poison, capable of killing
vigorous dogs in twenty or thirty days.               Part xxvii., p. 240.
                          LEECHES.
  How to make Leeches bite.—The leech which  it is intended to apply, is
thrown into a saucer containing fresh beer, and  is to be left there tiff it
begins to be quite lively.   When it has moved about in the vessel for a
few moments, it  is to be  quickly  taken  out and applied.  This method
will rarely disappoint the expectation, and even- dull leeches, and  those
which have been  used not long before, will do their duty.  It Avill be seen.
with astonishment hoAV quickly they bite.              Part viii., p. 157.
    vol.  n.—11 
162
LEECH  BITES.
   Leeches—Mode of applying.—Place the leeches on the skin and slightly
, exhaust the  air around them  by means of a cupping glass placed  over
 them, after the air is rarefied in it in the ordinary manner.
                                                    Part xxvi., jt>.«327.

   Leeches—Revival of—As soon as the leeches come off, they should be
 submerged in a mixture consisting -of one part of vinegar and eight  of
 water ; they  immediately begin to  disgorge, and  must  then  be pressed
 gently toward the mouth between the thumb and finger.  After disgorge-
 ment the leech must be washed twice in common  water, and then placed
 in an earthen vessel with plenty of Avater, and kept at a uniform tempera-
 ture.  The water must be  changed every morning, and the dead leeches
 cast out.  In four  or five days the leeches will bite and draw as much as
 before.                                           Part xxxiv., p. 283
                         LEECH BITES.
  Hemorrhage from Leech Bites—Modes of Arresting.—Wipe the orifice
with a bit of lint or fine linen, and Avhen  nearly dry, seize a small portion
of integument around the bite with the thumb and finger, and make mo-
derate pressure, until the hemorrhage is completely suppressed, Avhich will
be from five to fifteen minutes.
  Or, take a small pinch of doAvn from a beaver hat, and  pile it upon the
orifice ; then put over the down a piece of thin muslin, and  draAV it tightly.
If blood oozes through both,  dry it, until the hemorrhage ceases, and in a
short time the doAvn and muslin will  have become matted with coagulum.
All superfluous down may be cut off, and~dn two  days the orifice will have
healed, and the matted matter will fall off.
  Or, apply a piece of lint dipped in a strong solution of alum, or apply to
the place, tobacco, such as is used for smoking.          Part.xiv.,p. 194.

  Leech Bites—Bleeding from.—Roll a very small piece of lint into a hard
knot, smaller than a pea, and Aviping the  orifice clean, place this little pad
upon it, and draw a long strap of adhesive plaster over  it.   The elasticity
of the skin, pulling upon the plaster, supplies the requisite pressure.
                                                    Part xvii.,p. 291.
  To Arrest the  Bleeding from Leech Bites.—Dr. Tucker  states that he
has arrested bleeding from leech bites by dipping some of the flocculent
portion of lint in collodion, and pressing it on the orifice ; and then applying
oollodion freely over the whole surface with a camel-hair  pencil    Mr. E.
Wilson advises that the compress of lint should be covered by a little disc
of thin paper as soon as applied, so as to prevent it sticking to the finger
or the instrument (a pencil or pencil-case),  by which pressure is applied.
                                                     Part xix., p. 144.
  Hemorrhage from Leech Bites.—This may be  arrested by the applica-
tion of caustic. To apply this properly, crush a small piece of lunar caustic
to powder, heat the point of a silver probe  in a candle, and dip it into the
powder ; it thus becomes  crusted over with the nitrate, and forms a fine
button of caustic, which will easily reach  the bottom of any such wound.
                                                    Part xxii., p. 347. 
LEUCORRHOEA.
163
  Tincture of Mastic as a Hemostatic.—It is stated in " Schmidt's Jahr-
bucher," that Dr. Frankl  has found the tincture of mastic an excellent
hemostatic.   He employs it in epistaxis, and in troublesome bleeding from
leeck bites.  It is applied to the points whence the blood issues, by means
of a camel's-hair pencil.  Tei*zer, a  dentist of Vienna, is also reported to
have used it successfully in  hemorrhage following the extraction of teeth.
                                                  Part xxvii., p. 132.
  Styptics.—Vide "Matico,"  "Oil of Ergot of Rye," " Creasote," etc.
                         LEUCORRHCEA.
   Decoction of Elm Bark.—Four ounces of the fresh bark, bruised, and
 boiled in four pints of water, form a thick  decoction.  Dose,  four ounces
 three times a day; may also be used locally as a wash in almost every stage
 of cutaneous disease, and in that  disordered state of the functions of the
 skin induced by dram-drinking, attended with redness of the skin.
                                                        Part i., p. 61.
   Tincture of Muriate of Iron.—Recommended in leucorrhoea as follows:
   # Tinct. of muriate of iron, one drachm; tinct. of opium, half a drachm;
 infusion of Iceland moss, infusion of gentian, of each four ounces. M. Dose,
 an ounce every three or four hours.  A wash of sulphate of zinc may be
 used locally at the same time.                           Part hi., p. 30.
   Secale Cornutum.—Suggested in cases of leucorrhoea entirely devoid  of
 inflammation.                                          Part iv., p. 15.

   Ioduret  of Silver.—Suggested in cases  of leucorrhoea of long standing,
 in doses varying from  one-eighth of  a grain to one or two  grains, in the
 form of pills, two or three times a day.  Alum lotion, locally.
                                                       Part vii., p. 82.

   Creasote in Leucorrhoea.—Dr. Allnatt says: The folloAving is the formula
 I generally adopt for adults :
   R Creasote, minims xx.; solution of potash, 3ij.; white sugar, 3ij.
   Rub together in a mortar;  afterward add, by degrees, eight ounces of
 water.  Mix.  Make an injection, to be used three times a day.
   In obstinate cases of gleet, occurring in flabby leucophlegmatic males, I
 propose this remedy to the notice of the practitioner with great confidence.
                                                      Part vii., p. 86.
   Use of Astringents—Tannin.—Mr. Druit says:                \
  In obstinate leucorrhoea, I have used it as a vaginal suppository, ten grains
 being made into a mass Avith tragacanth, and introduced and allowed to
 dissolve. But in  this  disorder I believe alum and  the other  mineral as-
 tringents to be of more service; and that in many cases such treatment as
 will reduce a swelled  and congested uterus is of more consequence than
any mere local application.                             Part x., p. 139.

   Treatment of Leucorrhoea by Iodine.—M. Van Steenkiste has made use
of a dilute  tincture of iodine with  great  success  in cases  of obstinate
chronic leucorrhoea. 
164
LIGATURES.
   R Iodine, gram. iv.;  alcohol, gram. lx.;  solve ;  et aquro destil., gram-
mes cxxv.;  about 30 fluid grammes (or f.3xv.) are  to be thrown  into the
vagina as an injection, and  repeated every day, or  every other  day, ac-
cording to the excitement it  occasions.                   Part x.,p. 195.
   Leucorrhoea.—There are tAvo species of uterine  leucorrhoea; in one the
disease is in the cervix, and  the secretion is alkaline; and  in the other,
the secretion is acid, and the disease in the fundus.   Introduce the specu-
lum and  pass a  gum  tube containing a stilet armed with  litmus paper,
for about an inch into the cervix:  protrude the stilet and let it remain till
moistened.  Thus we find the  nature  of the secretion; if it is alkaline,
again introduce the tube without the stilet, and inject by means of a gum-
elastic bottle, a solution of sulphuric  acid,  half a  drachm of acid to an
ounce of ivater, or of acetate of lead of the same strength.  If the lips
of the os are abraded, touch  Avith arg. nit. before passing the instrument.
If the mucous glands of the  cervix are enlarged, pass the tube; and hav-
ing Aviped it clean from mucus, smear the end with ointment of arg. nit.,
gr. x.; to ung. cetac, 3j., and again pass it.  (Dr. Mitchell.)  Pt. xv., p. 320.
   New Remedy for Leucorrhoea.—Dr. Braman states that for nine years
he has been in the habit of using preparations of helonias dioeca (unicorn
plant) as a remedial agent.   " In  leucorrhoea," he  says,  " I consider it in-
valuable.   I use  it  Avith a  confidence I  attach  to no  other medicine.
Under its influence the patient,  whose life has been almost a  burden, soon
revives.   Her uncomfortable sensations vanish, and ultimately, an entire
recovery of health and strength is established."  It may be given in the
form of powder,  tincture, or sirup ; but the latter is the most eligible.
The doses Avhich  Dr. Braman recommends are of the poAvder, one  drachm
and  a half; of the tincture, one fluid  drachm; of the  sirup, three fluid
drachms.   These doses are to be taken thrice a day, half an hour before
the ordinary meals;  and according to the urgency of the case, the quan-
tity  administered may be increased,  if the patient bears  it well.  In
irritable stomachs, nausea is  sometimes produced; and when this occurs,
the dose must be diminished.                          Part xx., p. 229.
   Vide Selections from Favorite Prescriptions, Art. " Medicines."
   Iodide  of Potassium in  Leucorrhoea.—Dr. Payne recommends the
iodide of potassium as an injection in leucorrhoea.  It is to  be used (3iss. to
a pint of Avater) three or four times daily.            Part xxxvii., p. 211.
   Bichromate of Potash as  an Astringent.—To remove the fetor from
sloughing wounds, syphilitic sores, ulcers, etc., and  where an astringent is
useful, a lotion of bichromate of potash, five grains to the ounce, and in-
creased, is very serviceable.  In a case of chronic  leucorrhoea, where the
lips of the os uteri were swollen and spongy, it effected  a complete cure
after many other  remedies had wholly failed.        Part xxxvii. p. 268.
                        LIGATURES.
   Use of Ligatures  formed of Animal Substances.-The  substance
which Mr. Wragg prefers is  the fibrous tissue  of the deer, dried, then
twisted so as to form a small  round thread, smooth  and regular on the 
LIGAMENTS—LINIMENT.                    165
surface, non-elastic, sufficiently strong to resist the traction made on'it by
the surgeon in tying the knot.  The mode of preparing these  ligatures
appears to the author to be a matter of great importance, and one capa-
ble of insuring or compromising the success of the operation : These ten-
dinous slips ought to be dried sIoavIv, and not used until all the moisture
has disappeared; the author prefers those Avhich have been dried for some
years.  During the ten years he has employed "these ligatures, he  has
never used any others; and during this  period he has  tied arteries  in fin-
gers, hand, forearm, arm, leg, and thigh, and has never seen any  symp-
toms to shoAV that the absorption of  the knot had not taken place.   Some
cases, chosen  from a large number, will confirm the truth of these propo-
sitions: In 1836, Mr. Wragg  amputated the leg of a AAroman above sixty
years of age  for a malignant ulcer; the ligatures made of the fibrous
tissue of the  deer were cut  close to the  knot, and the wound brought
together;  the stump was healed at the  end of three Aveeks.  No part of
the ligature  could be  seen;  no abscess, no  ulceration, indicative  of the
threads having been on the tissues as foreign bodies.
  In the case of a young man, one of the cutaneous branches of the pos-
terior tibial artery Avas cut by a blow from a hatchet.   Mr. Wragg tied it
with one  of  these ligatures,  which  he  cut  close to  the knot; he then
brought the  wound together by four  points of the  interrupted  suture
made of a thread  of the  same substance.   Nothing further was seen of
the knot of the ligature; as to the threads used for the suture, they be-
came softened, and, from the time suppuration commenced, had a mace-
rated appearance, their volume diminished by degrees, so that at the  end
of a Gertain time he saw, by  the  effect  of a gradual  eating away,  a seg-
ment of the circumference of the thread disappear, and at last the knot
gave way just as if it had been divided by scissors.      Part xix., p. 141.
                       LIGAMENTS.
  Diagnosis of Inflamed Ligaments.—According to Prof. Cooper, if in-
flammation of ligament be primary, it may generally be diagnosed by the
slight degree of swelling which occurs at the joint, and by the absence
of acute pain Avhile the  patient is standing  on the diseased limb  in the
erect posture.   The least attempt at  motion is, however, productive of
severe  suffering, and  this constitutes an important distinction betAveen
disease of ligament and that of synovial membrane or cartilage; as in the
latter case, the  most painful position is when standing upright, with the
weight of the body pressing on the affected articulation.
                                                   Part xvii.yp. 130.
                        LINIMENT.
  Exanthemic Liniment.—The following liniment is particularly recom-
mended by Dr. Morris, Avhen desirous of keeping up a  mild rash  upon
the skin: R 01. crot.,  mxx.;  antim.  tart.,  9j.;  liq. potassae,  3j-5 aq.
purae, 3vij. M.,  while Dr. Hannay, of Glasgow, considers ipecacuanha one
of the most manageable  and efficient  applications.  His formula is pulv. 
166
LINT--LIP.
ipecac, ol. olivse, aa. 3ij.; adipis suill 3ss. M.   It  requires  to be rubbed
in for fifteen to  twenty minutes, and is, he thinks, peculiarly adapted to
cases of cerebral irritation in children, dependent on receded  eruption.
                                                     Part xn., p. 254.
                              LINT.
  Preparation of— With Nitric Acid—Dr. Rivallie lately communicated
to " L'Union  Medicale," his mode of cauterizing cancerous tumors with
solidified nitric acid.  He proceeds as folloAvs: Some lint is placed in an
earthen vessel, and a certain quantity of nitric acid, in  its highest degree
of concentration, is gradually dropped upon it.  A gelatinous paste is the
result, and to this, a shape in keeping Avith the tissues to be cauterized, is to
be given.  The caustic mass is  then seized  with long forceps, and placed
upon the part.  After a quarter of an hour, or twenty  minutes, it is care-
fully to be taken  off, and an eschar, four or five lines in thickness, is thus
obtained.  There are cases, however, Avhere the caustic may be left  for
twenty-four hours, when the surgeon wishes  to  destroy  a large encepha-
loid cancer.  The pain is trifling except  the skin intervene; and Avhen the
caustic is left a long time, there  is no pain after the  first three or four
hours.  With large  diseased masses the  cauterization  should be repeated
every day  after the eschar has  been carefully removed.  When the caustic
is applied  for a  few minutes  only, the part  should, on its removal, be
dressed with lint dipped in a solution of alum.           Part xxi., p. 24.
                                LIP.
   Case of Enlargement of the Labial Glands.—[This was a curious case
of enlargement of the upper lip.  The lip had been increasing in size for
tAvo  years; its progress had been unattended Avith pain, but he  had had
some irritation from exposure of the mucous membrane to the  air.  He
had no scrofulous or venereal taint.  Mr. Wilde says:]
  Upon examination, I found the loAver lip totally unaffected, as well aa
the extreme angles of the upper ; but all the rest of the red border of this
lip was immensely thickened, and so much enlarged that, AAdien the mouth
was closed, it formed a large, projecting,  red  mass, not unlike a pair of ripe
strawberries, the  division between  them being caused by the natural cen-
tral sulcus of the lip.  If these projections Avere allowed to remain un wiped
for some time, a number of globules of a clear fluid formed upon the sur-
face of. the mucous membrane.   The membrane itself Avas rather more vas-
cular than usual;  where the drops exuded, it was particularly smooth and
polished, but tOAvard  the edge of the lip  it had become thickened, covered
over with adhesive crusts, and cracked  in several places.  The external
surface of the lip Avas natural.
  As the  young man  Avas very anxious to be relieved of this deformity, I
removed it in the following  manner.  Assistants having commanded the
coronary  circulation,  by holding  the angles of the lip, as in the operation
for the  removal of cancer of this part, I made an incision, Avith a small,
sharp scalpel, through the mucous membrane, parallel with and about three- 
LIP.
167
eighths of an inch from the edge of the lip, and about tAvo inches and a
half in length.  Bv another incision, through the membrane, upon the den-
tal surface of the lip, Avhich was everted for the purpose, I completely  in-
cluded and dissected out the diseased mass, which, during the progress of
the operation, I found to consist of a congeries of small globular bodies,
nearly transparent, and about the size of advanced trout-spawn.  There
was scarcely any hemorrhage during the  operation, and any granules  of
the disease which  Ave re cut across, or adhered to the surface of the wound,
having been completely removed, the edges of the incision were accurately
adjusted, and sewed together  by a fine silk ligature, after the manner of
the continued suture.   Upon shutting the mouth, the deformity was found
to have been completely removed, and the edges of the lips met as before
the supervention  of the disease.  A feAv hours after, a smart hemorrhage
occurred from the surface of the wound, but it was checked by the use of
tincture of matico, and occasional pressure, which the patient was able to
offect for himself.                                     Par? xvi.,  p. 184.

  Hydatids  of the Lower Lip.—Dr. Heller, of Stuttgard, has seen five
cases  in which acephalocysts Avere developed in the loAver lip, and  always
on  its inside.  This affection appears first as a small and hard lump, Avhich
rapidly increases,  so that in one month it may attain the size of  a cherry;
it gives rise to pain, deformity, and difficulty in moving the lip.  The  hy-
datids are seated immediately  beneath the mucous  membrane, and  are
transparent.  If they can be  remo\Ted Avithout opening their ca\dty, they
are fonnd to be made up of a rounded vesicle, full  of fluid, transparent as
water, and Avith a diaphanous and tender Avail.  The only cure consists in
extirpating the cyst, which must be total, or it will reappear; hence nitrate
of silver may be  applied after the operation.
   In  a case which came under our own notice about six  months ago, in  a
youilg, delicate lady, seventeen years of age, the hydatid, situated on  the
internal part of the lower lip, had, in the space of  three months, acquired
the size of a small hazel-nut.  We touched it Avith 'tincture of iodine once,
twice, or thrice a-day,  as the  patient could bear it,  and in three weeks  the
transparent sac entirely disappeared, leaving a small ulcer Avith a hardened
base  ; to this we applied occasionally  nitrate of silver, which  healed the
wound.  Gentle external friction twice a-day, Avith a little iodine ointment,
eventually removed every vestige  of hardness.         Part xvi., p. 229.
    Malignant  Tumefaction  of the Under  Lip,  rapidly following  the
Appearance on its Surface of a Papula  near the  angle of the Mouth.—
("The following Avas communicated by Dr. Samuel B. Wells, of Middle-
burgh, N.  Y.)
   As some benefit might accrue from the communication of a feAv  cases of
an  anomalous character, which have occurred during a somewhat exten-
sive practice in the Valley of the  Schoharie, I herewith transmit a short
account of them which you are  at liberty to make public for the  use of the
profession.
  In  the summer of 1842 I was called to see a case of disease of the under
lip, then in charge of Dr. P. S.  Swart, in the village of Schoharie.  The
patient  was a man about 25 years of age, and had  enjoyed good health up
to  the time of the attack, although  his habits had been  somewhat intem-
perate.   Three days before  I saw him, a small pimple appeared  on  the
surface of the under lip, toward  the left  angle of the  mouth.  It com- 
168
LIP.
menced wdth swelling and redness, Avhich soon assumed a purple hue, and
increased rapidly.   At first there Avas not much constitutional disturbance,
very little pain, fever, or acceleration of  the pulse.  In less than thirty-six
hours the lip had attained four times its normal size, and had  assumed a
gangrenous aspect, the SAvelling extending downward as far as the clavi-
cle, involving the areolar tissue, together with the integuments of the parts
concerned, occasioning great  difficulty of respiration,  from pressure of
the larynx.   During the incipient  stage of  the disease, the patient had
been freely evacuated, and an antiphlogistic regimen adopted.  Externally,
discutients, such as solution of muriate of ammonia and acet. plumb., had
been applied. But as soon as the septic tendency of the disease became
manifest, cataplasms of yeast  and Peruvian bark Avere  substituted, and a
corresponding change Avas also made in the use of internal remedies—the
infusioij  of serpentaria,  quinine, Avine  and  ammonia being substituted.
Notwithstanding, the patient greAV worse every  moment—the  engorge-
ment of the  lip and the adjacent parts continued to increase until mortifi-
cation ensued, when, on the following day, he died.
  An interval of ten years elapsed, Avhen I was called to see a second case
of the kind: Mrs.  B----, a lady of robust  constitution, and who, up to
this time, had enjoyed excellent health.   She had been taken ill the preced-
ing day.  A  small  pimple occupied the surface of the loAver lip, as in the
foregoing case.  This Avas accompanied  with pain, redness  and  swelling.
There wras also considerable increased excitement of the system, together
with much cerebral disturbance.  This  patient  was bled  freely, and gen-
eral antiphlogistic measures  speedily  adopted.   NotAvithstanding, the
violence of the  symptoms continued unabated.  During the night, the lip
became greatly enlarged, and on the following day, gangrene and mortifi-
cation ensued, terminating fatally.
  The next  case, I Avitnessed in 1855.  This occurred in a middle-aged
lady, of good constitution and plethoric habit.  Five days  before I was
called, a small pimple made its appearance on the under lip, to Avhich she
called the  attention of her physician, who Avas then treating a case of fe-
ver in the family.   The nature of the disease was fully explained to her by
the doctor, who advised that  immediate measures be taken to  arrest it in
its present stage.
  Feeling but little inconvenience from its presence, nothing Avas done until
the following day, by which time the SAvelling had greatly increased, and
the lip had assumed a purple aspect.  The  parts having put  on a low grade
of inflammatory action, the patient was treated with active catharsis, and an
antiseptic cataplasm was applied to the lip.  These, together Avith such re-
medies as appeared adapted to the most prominent symptoms, were used.
Still, the disease continued to advance, as in  the foregoing cases.  The lip
having assumed a gangrenous appearance, its fatal tendency too soon be-
came alarmingly  evident.  Mortification ensuing, the patient  died three
days afterward.
  In the summer of 1856, a Miss G. consulted  me in relation  to a small
pimple which appeared the preceding day  on the surface of the under lip,
attended with redness  and swelling, but  unaccompanied Avith any other
disturbance  of the system Avhatever.  With a view of discussing it thus
early, I gave her an antimonial emetic, and in due  time followed with
twelve grains of submur. hyd., and in six hours thereafter wdth the black
dose.  These evacuated the system freely.  I applied,  locally, a solution 
LTTHECTAST.
169
 of acet. plumbi.  The following day there Avas no amendment, but, on the
 contrary, an increased tumefaction of the lip,  Avith a deep purple ap-
 pearance.
  Having failed in  arresting any one of these several cases Avith the ordi-
 nary remedies adapted to analogous  diseases, it occurred to me that if
 suppuration could  be established before the vital forces of the parts be-
 came exhausted, a  more favorable result might be  reasonably  expected.
 With  this in vieiv, I passed  an ordinary sized lancet from near the angle
 of the mouth, through the substance  of the lip, transversely to a corre-
 sponding point on the opposite side.  I then  introduced a small strip of
 muslin, about three lines in width, to the  extreme  end of the  puncture,
 and covered the parts Avith a cataplasm of yeast and Peruvian  bark.  A
 slight suppuration followed in thirty-six hours, and a speedy recovery took
 place in a feAv days.
  It Avould be superfluous to give the details of five other similar cases
 which have occurred in my practice since the above mentioned.  Suffice it
 to  say that the latter is an index of each one.  They severally exhibited
 the usual characteristics of the foregoing cases in their incipient stage, and
 were readily controlled and brought to a fiworable termination by adopt-
 ing this  plan  of treatment—free incision of the affected lip, introduction
 of  a tent, and the local application of a cataplasm of yeast and Peruvian
 bark to  the Avc*nd, with a  vieAV to the  establishing of suppuration—so
 successfully pursued in the case of Miss G.
   I practised  here twenty years before I saw a case  of this kind, and pre-
 sume there are many physicians Avith an extensive business Avho have never
 met with one.

                              -----»-*-»—


                          LITHECTASY.
  Lithectasy.—The removal  of stone from the bladder, by the  operation
 of lithectasy, as described  by Dr. Willis, has hitherto attracted too little
 notice.  The opinion seems to be gaining ground among our best surgeons,
 that the dangers of lithotomy consist  in the too free use of  the knife in
 the deep incisions, and that the most successful operators have been those
 who have made  free external, and very small internal incisions, trusting
 more to a certain degree of stretching, or dilatation, in order to enter the
 bladder, and thus preserve that organ as free  from injury as possible.  It
 is probably for the same  reason that  lithectasy may some day prove a
 more useful improvement than is  now generally acknoAvledged.  It is Avell
 known that Sir Astley Cooper, in the year 1819, performed this operation,
 at the suggestion of Drs.  Neil and James  Arnott.   It  consists  simply in
 opening the urethra  upon a  grooved staff, in  the mesial line, behind the
 bulb, to the extent of a few lines, and then making gradual dilatation by
 means of the fluid pressure dilator of  Dr. Arnott, " consisting of a cylin-
 drical tube of silk,  lined  Avith the thin gut of a small animal  to  make  it
 Avater-tight, and fixed upon a canula which  traverses its axis,  and having
 attached to its outer end a syringe guarded with a stop-cock,  by Avhich it
may be forcibly distended Avith Avater or mucilage."  This  instrument,
when empty, exceeds but little  in size the bulk of the canula or catheter
with Avhich it is connected, and is therefore easily  introduced along the 
170                          LITHECTASr.

groove of the staff into the bladder, and when there it can be gradually
distended to its utmost limits.   Mr. Elliot thinks it well, previously, to
accustom the urethra to the  presence of a foreign body, by the  use of
bougies, gradually increased in  size, so  as at the same time to produce a
certain degree of preparatory dilatation.  He also recommends  that the
external incision should be free, "since if the prostate were unfit to under-
go the process of dilatation, either  from great rigidity, as is frequently
found in old subjects, or from morbid irritability, the  operation could be
at once completed by lithotomy."   Mr. Elliot also suggests various im-
provements in the dilator, as, that it should be cylindrical and not taper-
ing toward each end, as it will  then preserve  its situation  more easily
when introduced," etc.
  He suggests that the dilatation should  be not only gradual, but at inter-
vals of a quarter of an hour  at  a  time, instead of being continued for
thirty or forty hours.  It seems surprising that these parts can be dilated
so completely, so easily, and so  safely, and yet  that surgeons  have not
tried the practice more generally. Mr. Elliot states, that although he con-
tinued the  dilatation for tAventy-five hours, he has no  doubt that a suffi-
cient degree of dilatation was accomplished in three hours, since no addi-
tional fluid was injected after that  period, and he could easily introduce
two fingers along with the  scoop into  the  bladder,  and  if  necessary
could have extracted a stone as large  as a hen's  egg, or four and a
half  inches in  circumference, the  size  of the  instrument.  Mr. Elliot
remarks, that his patient, from  beginning to end, Avas  never in danger,
that " the presence of the dilator effectually prevents any oozing, as well
as the injurious contact of the urine with the raw wound.  There was no
chance of shock, no  risk of peritonitis, infiltration of urine, inflammation
of the veins of the neck of  the bladder, or any of the grave sequelae that
too often supervene on the operation of lithotomy."      Part vii. p. 102.

   Calculi in the Female Bladder.—Experience  appears to shoAV, that the
removal of a calculus from the female bladder, after the neck of the latter
and the canal of the urethra have been  gradually  dilated by forceps con-
structed  for  the purpose, sponge tents  or otherwise, is a preferable  pro-
ceeding to its removal after the urethra has been incised.  It also demon-
strates, that  dilatation  can  be   carried on  to  an extent Avhich, in th6
absence of Avell-authenticated facts, Avould appear almost incredible.
  One of the most remarkable cases on record occurred in the practice of
Mr. Okes,  of Cambridge.   The patient was eleven years old.   Sponge
tents, gradually increased in size, with  string attached, were introduced
into  the urethra, opium, preceded by purging, being administered.  The
sponge was used morning  and evening, for  three successive days.  The
urethra was  sufficiently dilated on  the  third day to allow of the calcu-
lus being withdrawn. _ It is  stated,  that  the stone measured in circumfer-
ence,  at its major axis, 8f inches;  in its minor, 3\ inches.   The calculus
was seized  m its long axis, and therefore the urethra must have  been dis-
tended by  the calculus and  the  thickness of the forceps to a circle of at
least 3f.    Incontinence of urine lasted only three days
  This plan of treatment by dilatation is in imitation of that made use of
m the natural efforts to get; rid of a calculus from  the female bladder, the
stone itself acting as the dilating power; and numerous remarkable in-
stances are on  record of  calculi thus voided, without any subsequent 
LITHOLIBT.                          171
incontinence of urine.  In far the greater number of cases, however, in
which the  calculi  have been- large, incontinence of urine, which Avas a
marked  antecedent symptom, has persisted; this, probably, arising from
ulceration at the neck of the bladder, in consequence of the pressure of
the foreign body. Thus, there is in the London Hospital Museum a calcu-
lus which Avas removed from a Avoman by the  late Mr. Headington.  Its
anterior extremity Avas found sticking in the urethra, and the entire stone
was removed easily by traction of the tAvo index fingers.  It measured 3 J
inches long, 2 inches broad, l£ inch thick, 7f inches round  its larger, and
5£ inches in  its smaller circumference.   Incontinence of urine lasted till
death.   The fact of incapability of retaining  the  urine usually folloAving
the natural method of expulsion,  when the calculus has been large, sug-
gests the propriety of operating Avithout  any unnecessary delay, in order
to avoid this inconvenient and distressing sequence.   Part xxvi., p. 249.
                             ---•-♦-•—


                          LITHOLIBY.
  Litholiby.—Dr. Denamiel designates by this term an operation consist-
ing in the crushing of the stone, as it lies in the trigon vesicae, behind the
prostate, betAveen an instrument introduced by the  urethra into the blad-
der, and the fore and middle finger of the left hand, introduced per anum.
He affirms that some calculi are so  friable as to  break under the least
pressure; that the trigon vesicae, where  free calculi generally lie, is acces-
sible to the finger introduced into the rectum; and that a sound passed
into the bladder may serve as the point dPappui.   He also states that the
action of alkaline fluids upon the mucus, which forms the common cement
of the elements of calculi, leads  to the disintegration of the mass, what-
ever may be the chemical composition of the layers  which compose it.
  The distance from the  integument  to the neck of the bladder is com-
monly 2\ inches; it varies  between 1 inch  and 4 inches.  The  prostate
gland and the trigon vesicae are  separated  from  the rectum by only a
very thin layer of areolar tissue, in Avhich fat  is never deposited ; conse-
quently, any hard body may be easily felt and compressed.
  The patient, having the bladder moderately distended, is put into the
horizontal position, upon a properly constructed bed; the  thighs separated
and raised ; and feet resting upon chairs.  The left fore and middle fingers
of the operator are then introduced into the rectum, and the stone is felt.
A curved sound, grooved upon its  convexity, as far as its vesical extrem-
ity, that it may the more readily hold the  stone, is next passed into the
bladder.  Then  pressure is made, until the calculus gives Avay.   In many
cases, a very slight amount  will suffice.  Should  any  difficulty arise, the
pressure may  be directed alternately tOAvard the right  or  the left, that
every part of the surface of the stone may be acted  upon.  In cases Avhere
the calculi are hard,  several sittings are required, and the use of alkaline
fluids becomes needed, to favor their disintegration.  A quantity of warm
water should be injected into the bladder after each operation, that the
smaller fragments may be immediately washed away.
                                                   Part xxviii., p. 208. 
172
LITHOTOMY.
                          LITHOTOMY
   Treatment  after Lithotomy—-These  remarks Avere called forth by a
case on which Mr. Sherwin operated, a child of nine years, the day folloAv-
ing a journey of seventy miles; and although the operation was satisfac-
torily  performed,  the case soon  assumed  a  dangerous  aspect.   On the
second day, Mr. Sherwin says :
   I noAV felt convinced that I should lose him;  as, from the very onset of
the attack the vital powers seemed unable to sustain  any  depleting mea-
sures, and though having most of  the  characteristics of  peritonitis, the
symptoms  precluded the antiphlogistic treatment.   On  referring the
same evening to Sir B. Brodie's published "Lectures," I felt impressed
with the fidelity of his  description  of the  untoward symptoms  following
lithotomy.   I caught at a suggestion he  offers in a similar case,  Avhich  he
rescued by laying "open the rectum Avith the wound, so as to give exit to
a quantity of sanies :
   11th, 1 a m.—Found  matters looking still worse ; the boy had passed a
wretched night, rolling from  side  to side  in great pain ;  the belly hard
and  tympanitic; pulse feeble  and fluttering, and  hardly to be  felt  or
counted, with more frequent  intermissions; countenance of dusky leaden
hue ; occasional sighs and hiccoughs ; tongue  quite brown and dry.   I
now determined to open the Avound, Avhich was externally united: this
AAras  done with the handle of a scalpel, and  having pushed up my finger to
explore the  parts, I gave exit  to  about tAvo or three ounces of  a  pink
colored sanies, having a fetid  and ammoniacal odor.
   I broke up the entire wound in the  peritoneum, and had  the patient
raised out of the holloAv of his bed into a more  depending position ;  gave
a little brandy and Avater Avith a teaspoonful of castor oil. 11 a.m.—Much
improved  in every respect;  countenance  calm ; had  slept a little, and
parted Avith a good deal of flatus; the pulse settled to  100. 9 p.m.—Has
slept  Avell;  looks  happy; pulse  slower;  tongue moist;  has asked for
tea, and bread and butter.   From this time the boy did Avell; and  he
returned to his home  quite free from ailment in about three weeks after.
   Remarks.—The urine ivas alkaline, with  considerable deposit of lime
and mucus; this (which ought  to have  been done before)  Avas afterward
corrected by mineral  acids, Avith decoct,  pareirse bravae, and quinine.   If
instead of giving a free  vent  to  the sanies, I had treated the  case as one
of pure peritonitis, there can  be no doubt but that he AA'ould have sunk in
a feAv hours.  Yet I committed an error  in  the first instance by operating
so soon after a long journey.  I relied too confidently on the youthfulness
of the patient; time ought to have been  alloAved for the bladder and con-
stitution to become tranquil before he incurred the additional risk of a for-
midable operation.   Again, his bed was  an inconvenient one; it alloAved
his pelvis  to sink  into  a holloAv, which, A\dth  my neglecting  to leave a
canula in the wound, allowed some of the urine to lodge between the rec-
tum and bladder ; a circumstance that has proved, probably,  a  more fre-
quent source of mischief after lithotomy than is generally suspected.
                                                     Part  viii., p. 94.
  Lateral Operation  of Lithotomy.—Dr.  Keith thinks  that in the first
incision, many good operators commit an error in going too near the sym-
physis pubis, the consequence of Avhich  may be, that  when the stone is 
LITHOTOMY.
173
 grasped in the forceps, it is  driven out of  the  hold of the operator by
 coming against the arch of the  pubes, and  he cannot, as he ought,  draAV
 downward, because the incision is not Ioav enough.  With this difficulty
 in view, most surgeons noAV make the first incision as far as is safe from
 the symphysis pubis ; and Dr. Keith seems to extend this incision  quite
 as far as he is Avarranted past the side of the rectum.
   But the most important incision is the deep one ; and in using his  pecu-
 liar instrument, Dr. Keith Avas influenced by the fact, that the  success of
 all the most fortunate lithotomists has depended upon the narrow limit to
 which they restricted  themselves, in dividing the neck  of the bladder.
 His instrument is " a gorget neither blunt nor sharp—an edge on it that
 behoved  to cut through a substance so solid as a prostate gland, yet so
 blunt that such a tough elastic membrane as the bladder would stretch
 upon its edge."  When the perineum is very shalloAV, this gorget Avill not
 be required, the bladder may be entered and the  prostate notched by a
 knife, long in the handle and  short in the blade, Avith  its cutting  edge
 limited to an inch and a quarter from the point; but in most cases it wdll
 be necessary to slit  the neck of  the  bladder and  prostatic urethra ob-
 liquely downAvard and outward to about half an inch, and then Dr.  Keith
 brings his gorget into use to finish the operation.  This instrument has its
 left edge quite rounded, the  other ground  to an edge, and then blunted
 with a file ; the point  Avell rounded into a blunt bottom—a copy, in fact,
 of"' Cheselden's Conductor."  Dr. Keith says that by these means he in-
 sures a positive entrance into the bladder, "  obviating the chance of merely
 dilating the  sphincter  vesical, as Cheselden and  Martineau are  alleged to
 have often only done ; and avoiding the cutting of parts that never should
 be cut."                                               Part  ix., p. 134.
   Lithotomy.—Dr. Warren, of Boston, has practised the bilateral opera-
 tion of lithotomy, and strongly recommends it, saying that  he  would feel
 disposed to employ it  in most cases where lithotomy is required, in prefer-
 ence to the lateral operation.   In  his opinion, its simplicity, the compara-
 tively small pain from the incision, the facility of seizing and removing the
 stone, the very slight  loss of blood, and the absence of any severe conse-
 cutive symptoms, all concur in producing a  favorable impression with  re-
 gard to this mode of operating.  The chief  objection to this mode, arising
 from the great danger of wounding the rectum,  he fully acknowledges,
, but thinks it will be found even less than in the lateral operation, if the
 staff, with the urethra and  prostate gland be drawn toward the  symphysis
 pubis, at the same time draAving out the rectum  in the direction of the
 sacrum, with the left hand.                             Part xi., p. 138.

   Remarks on Lithotomy.—[Much difficulty is sometimes experienced by
 the surgeon in  seizing a calculus with the forceps, after the bladder has
 been opened.   In two cases where this occurred at Guy's Hospital, under
 Mr. Key  from the  stone slipping up further into  the fundus on every at-
 tempt to seize it, it  was remedied by making considerable pressure  exter-
 nally on the fundus of the bladder; when in each case it immediately
 slipped betAveen the blades of the forceps, and was extracted.]
   The two cases alluded to presented difficulties of a  similar kind, the
 6tone in each being lodged high up in  the fundus of the bladdei-, so as to
 elude the grasp of the forceps, until it Avas dislodged by pressure made on
 the lower part of the abdomen.  The cases  elicited from Mr. Key, the fol- 
174
LITHOTOMY.
lowing clinical remarks on the principle of obviating this not unfrequent
occurrence in the operation of lithotomy.   A calculus usually lies free in
the bladder as long as the mucous coat of the  organ preserves its healthy
condition.   The oxalate, urate, and even the phosphatic stones, are found
in the base of the  bladder, until the surface of the membrane becomes
villous from inflammation, and its secretion becomes alkaline and viscous.
The bladder, inflamed and irritated by  the stone, contracts upon it Avith
more  force, and secretes an abundance of alkaline mucus, the phosphatic
salts of Avhich crystallize on the surface of the stone, and make it adhere
often  with considerable tenacity to the surface  of the organ.
  The part of the bladder usually occupied by a calculus under these cir-
cumstances is the fundus, Avhich retains the stone with tenacity, Avhile the
loAver part of the  organ receives the urine as it passes from the ureters;
and in sounding such a bladder, the calculus is felt either on the  concave
surface of  the instrument, or by withdrawing it tOAvard the pubes—a cir-
cumstance that always portends some difficulty in seizing it after the blad-
der is opened.
  It has happened more than once that a patient has been removed  from
the operating table Avith the stone remaining in the bladder, after long and
continued efforts made in  vain  to seize it; and the failure has arisen, not
from  the extraordinary size of the calculus, but from its peculiar position.
The forceps, at first, though opened to their full extent, obtain but a slight
hold  of the stone, the extremity of it only is  seized, and it soon  escapes
from  the grasp of the operator.  Repeated attempts are made to gain a
firmer hold of it, and at each attempt the stone is pushed further from the
opening, until the forceps are obliged to be buried nearly to the handles
before the stone can be felt.   It is in the retreat of the stone before the
forceps that the difficulty of seizing it lies.  The stone, instead of retreat-
ing in a direct line from the opening into the bladder, ascends behind the
pubes, where  the forceps  cannot, without assistance, reach it, much less
grasp it.
  It  is more than probable that in many  of the cases recorded of insuper-
able  difficulty in extracting calculi of ordinary size  by lithotomy, the ope-
rator has not  sufficiently borne in mind  the impossibility of  directing the
blades of the forceps to the altered position of the  stone, which,  from the
pressure of the forceps in the unsuccessful attempts to seize  it, retires, not
backAA-ard, but upward, so that it becomes placed in a line  little less than
perpendicular in relation  to the external incision.  In such a situation,
even in very young  children, it becomes difficult to seize  it; and in the
adult, especially when the prostate gland is enlarged, impossible to  reach
it.  The advantage of pressure made above the pubes was forcibly shown
in these cases.                                         part xii-? ^ 208.

   Lithotomy.—-There are four steps (says B. B. Cooper) in the operation,
as  I perform it, viz.: open the perineum, open the pelvis, open the bladder,
 and take out the stone.  Well, the first thing  you  do when the patient is
 laid on the table, is to sound hhn, and be sure that  you  feel the stone be-
 fore  you operate.  Having ascertained the position of the stone, he is then
 to  be tied up  in the usual  manner; and it is as well  to  tell  the patient to
 practise the position, in order that he may become  somewhat accustomed
 to  one so unnatural; then  pass the straight staff, and give it to an assistant
 to  hold.  Then, havmg examined the perineum, and ascertained the point 
LITHOTOMY.
175
of junction of the raphe of the perineum with that of tho  scrotum, place
the tip of the fore-finger of your left hand upon it, and commence yOur in- .
cision about one finger's-breadth to the left of it, carrying your knife down-
ward and outward to a point midway betAveen the margin of the anus and
left tuberosity of the ischium.  By this incision you lay open the perineum;
next pass your finger  into the Avound, and feel for the staff' in  the mem-
branous portion of the urethra, and keeping the bulb out of the way, place
the point of the knife in the groove of the staff, and make your second in-
cision through the deep perineal  fascia, in the  same direction, and to the
same extent, as the first.   You have noAV completed the second  step, and
opened the pelvis : I know my anatomical friends Avill cavil at this, and say
that I have not opened the pelvis ;  but  there is only a slight fascia inter-
vening.
  Next commence your third step in the same place in which you did the
Becond, by again placing the point of the knife in the groove of  the staff;
and, taking the handle of the latter in your left hand, from the assistant
who has been holding it, depress it, till it is nearly parallel with the handle
of the knife.  Then push the knife along the  groove in the staff, through
the prostate, into the bladder, which you will know to have entered, by the
resistance offered to  its passage ceasing.   This  is a difficult  part of the
operation ; for if you let the knife slip out of the groove, between the blad-
der and rectum, much mischief must accrue.  You should have the groove
of the staff turned a little to the  left, in  order that your incision through
the prostate may correspond Avith the other incision.  'Next pass your left
fore-finger into the bladder, and the staff being wdthdrawn, feel for the
 stone.  In order that you may not make a larger incision through the
 prostate  gland than is necessary, your  lithotomy knife should  be of the
 6ame breadth as your  fore-finger, so that it may make an opening just big
 enough to admit it; and trust to enlarging the opening of the prostate by
lacerating it with your finger : lacerating is an  ugly word, gentlemen, but
it is a safe one.  You  have noAV finished the third step, Adz.: opened the
bladder.  All  that you  have hitherto done is what  every good  surgeon
ought to do without difficulty; but the rest is beyond his control.  I mean
the fourth step—removing the stone.   I have  seen the very best ltihoto-
mists fail in seizing it, and the patient has been  removed to bed with the
stone still in his bladder.   When you have your  finger on the  stone, and
you introduce the lithotomy forceps along it into the bladder, with the
blades  of course  shut, keep them  so, until  you have felt the stone with
them.   Then open them, and, seizing the stone, gently and gradually with-
draw it.  You should hold  the  forceps Avith their flat surfaces looking
 upward and downward, in order that you may be able to open them suffi-
ciently, and also to protect the soft parts from injury in the abstracting of
 the stone.                  *
   They should also be of good length, so that the hinge may be in the
perineum; then you will be able to open the handles.     Part xii., p. 209.

   Use of the Canula after Lithotomy.—The use of the canula after the
operation of lithotomy, though practised by some, is by too many surgeons
altogether neglected and despised.  We say too many, because  we believe
that a neglect  of  this  simple precaution is, from  infiltration of urine, not
unfrequently the cause of death.
   The principal objection to the use of the canula is the fear of its causing 
176
LITHOTOMY.
inflammation of the  lining membrane of the bladder, but  this has been
found by experience to be futile.   And surely, if authority or precedent
have any weight, its use  by Dionis, Le  Dran, Ambrose Pare, and in our
own times by Sir B. Brodie  and Mr. Liston, are enough to sanction its
employment.
  According to Dr. O'Ferrall, there is neither pain  nor irritation, nor con-
stitutional disturbance occasioned by the insertion of a properly made tube
after the operation of lithotomy; and  many sources  of pam and danger
are avoided by its use.   1st. The scalding pain, inseparable  from the pas-
sage of urine through  a fresh Avound, is prevented.   2d. That insidious,
but too surely destructive accident, infiltration of  urine into the cellular
tissue is rendered nearly impossible.  3d. If hemorrhage  should occur, it
may be, as is well known, generally arrested by its  aid.   4th. The peri-
tonitis and the  diffuse  inflammation, phlebitic or cellular, Avhich might be
supposed to spring from the alternate expansion and  contraction of parts,
neAvly subjected to operation, is, as far  as the repose of the pelvic viscera
is capable of effecting that desirable object, averted.     Part xii., jt?. 210.

  Lithotomy in the Female.—Mrs.----, aged forty-five,  was admitted
upon the 10th of June, on account of stone in the bladder, from Avhich she
had suffered the usual symptoms for  ten months.  On the  12th, after
dilating the urethra  by the  successive introduction of bougies, gradually
increased in size, I  passed  my  finger into the bladder, and divided the
ring at its orifice  outward and downward, by means  of a straight bis-
toury.   This incision  Avas  of very small  extent,  hardly  exceeding the
breadth of the  blade, Avhich Avas rather narroAV.  The  textures then rea-
dily yielded, so as to alloAV me,  Avithout  the use of violence, to introduce
the forceps, and extract  a stone about  the  size of a chestnut.  Not the
slightest inconvenience followed the operation.  The patient regained the
power of retaining urine in the  course  of eight days, and returned home
quite well on the 23 d.
  Lithotomy in the female,  continues Professor Syme, affords an instruc-
tive illustration of the principle  on which this operation may be performed
wdth safety on the male.   However much the  facility and  rapidity of the
operation may be promoted by cutting instead  of tearing the textures thus
far, it does not  appear that the choice of these means materially affects the
patient's  chance of recovery, provided the opening from the skin to the
prostate be made sufficiently free.  But in both sexes there is still an
obstacle remaining which admits of ready removal by incision, and cannot
be overcome by tearing Avithout  almost certain death.  This is the sensitive
ring which surrounds the neck of the bladder, at the base of the prostate
in the male, and at the corresponding part in the female.
  In dilating the urethra, to accomplish any of  the purposes which require
its capacity to be temporarily increased, I find no means so convenient as
the introduction of bougies.                            Part xii., p. 212.
  Lithotomy with Albuminous  Urine.—Mr. Phillips describes a case of
lithotomy, performed upon a patient whose urine was so highly albuminous,
that, on the application of heat,  nearly one-fourth of the fluid in the tub*
became solid ; there  Avas  also a  slight excess  of lithate of ammonia pre-
sent.  When the patient  came  under Mr. PhiUips's care,  he Avas  much
afflicted with the ordinary symptoms  of stone; the bladder Avas very irri-
table ;  he was fifty-six years of age.  A consultation Avas held on the case, 
LITHOTOMY.
177
and it was decided that the presence of the albumen was probably caused
by the irritation excited in the kidney by the presence of the stone in the
bladder, and an operation Avas decided  upon.  Before  the operation, the
albumen slightly decreased in quantity.
   [In six Aveeks after the operation, this patient was  discharged cured;
the urine was quite free from albumen.   Mr. Phillips observes :
   This point is one of great interest in practice, and it has been  laid down
by an eminent authority, that under such circumstances it is imprudent to
operate at all.  Whatever may be the value of that rule in other cases, I
am by no means  satisfied of the propriety of  its  application in cases of
stone in the bladder; and if  it had been  acted upon in the present case,
the patient would  still be  suffering from  his disease.  The question is un-
doubtedly a iTery delicate one;  does  the albumen result  from irritation
Avithin the bladder extending to the kidney, or is the irritation confined to
the kidney itself?—in the one case removable by operation, in the other
beyond its reach:  I knoAV no test by Avhich we can distinguish betAveen
them, but the present case  is a proof that such a distinction does  really
exist, though we are at present unable to detect it.     Part xiii., p. 273.

   Operation.—Mr. Liston observes the following rules :  1. Use the sim-
plest instruments.   2. Interfere as  little as possible with the ileo-vesical
fascia.   3. KnoAV well the exact position of the stone, for the use of the
forceps is the most annnoying part of the operation.  4. Dilate internally,
if necessary, for a large stone ; or make a bilateral incision, but it is very
seldom necessary.  5. Introduce a gum-elastic tube through  the track of
the wound into the bladder, to secure the flow of urine from it, and keep
it there, in children  20 hours, in adults 40 or 50.        Part xiv., p. 207.
   General Treatment of Lithotomy Patients.—The general treatment of
lithotomy patients at St. Thomas's Hospital, is the folloAving :  Before the
operation he is kept in a  quiet ward  for ten days or a fortnight, his diet
attended to,  and  his boAvels  regulated ;  the day before the operation (for
which,  if possible, temperate Aveather is chosen) he has  low-diet, and  a
dose  of castor-oil; and on the morning an enema of gruel, wdth or  with-
out castor-oil.  After the operation he is put to bed Avith  his legs straight
and close together, and a napkin put on in the same Avay as a child's nap-
kin ; this is changed throughout the treatment, when it becomes Avet.   In
the evening or next morning a piece of lint is.pushed up the wound by  the
finger, and changed Avhenever the patient wets;  and when all  the  urine
comes per urethram, the wound is dressed Avith Avax and oil spread on  the
lint, and introduced  as before.   If the  urine  does not Aoav  through  the
Avound at first, the finger is introduced to remove any obstruction ; and if
the discharge stop from SAvelling of the Avound, no lint  is introduced, but
a bread poultice applied.  Cold is not applied, and an opiate rarely given.
For the first week or ten days the belly is fomented with chamomile.   The
diet  is  at first farinaceous, and is gradually improved  ; and castor-oil is
given on the  third day.                               Part xvi., p. 206.

  Hint on Sounding.—When you sound for stone, use rather a short and
straight  instrument at first.  Introduoe it very slowly  and cautiously, so
that the  point of the instrument sinks into the post-prostatic fossa, in which
the stone is generally situated.  If you do so, you "will generally strike the
stone  at  once ; but if you sweep a sound, with a  good full ourve, into the
    VOL. n.—12 
178
LITHOTOMY.
bladder rapidly, you carry your instrument over the stone, and you may
turn the point of it all round the bladder in vain.       Part xix., p. 171.
  Incontinence of Urine after Lithotomy.—When incontinence of urine
follows  lithotomy, give the extract  of nux vomica, beginning with  an
eighth of a grain thrice a  day, and gradually increasing the dose.
                                                     Part xix., p. 172.
  Diet after Lithotomy.—According to Bransby Cooper, patients should
not be  kept on spare  diet after the  operation of lithotomy, nor, indeed,
after any severe ordeal of the kind.   It should always be remembered that
you  cannot diminish constitutional power Avithout increasing irritability:
and  that, consequently, support is generally requisite, and should be  early
prescribed.                                           Part xix., p. 173.
  Extraction  of large Calculus—Bilateral Operation with the double
Lithotome of Dupuytren.—Prof. May gives the following: G. II., aged
18, entered the Washington Infirmary for stone  in the bladder.  On sound-
ing him a feAy days after his entrance, a calculus Avas at once detected, and
from several  subsequent examinations, I believed the stone  to be so large
that I did not deem his case a favorable one for lithotrity.  I therefore de-
cided to cut him, and, on  the 15th of April, performed the bilateral section
before the medical class in the following way:
  The patient having been etherized and placed in the usual  position, a
deeply-grooved staff was  introduced  into the bladder, and pressed firmly
against the perineum,  as near as possible in the median line.  A  crescentic
incision' Avas then made  over the staff, which, commencing on the  right
side at  a point equi-distant from the anus and the tuberosity of the ischium,
was terminated at a similar point on the opposite side, the centre of the curve
being three-fourths of an inch aboAre the anus.  The incision was, by a few
strokes of the scalpel, deepened, the fascia and perineal muscles divided,
and the membraneous portion of the urethra exposed, which was then
opened upon the groove of the  staff longitudinally, and to a sufficient de-
gree to admit the beak of the double lithotome of" Dupuytren,  which be-
ing fairly placed in the groove, Avas  introduced  upon it into the bladder.
The stone being felt Avith  the end of the lithotome, the staff was  extracted,
and the instrument being reversed, the blades  were sprung to  No. 18 on
the graduated scale, and it was wdthdrawn  from the bladder, thus dividing
the  prostate equally, on both sides nine lines.
  The  calculus was then readily seized Avith the forceps, but, finding that
from its size it would not  pass through the incision that had been made in
the prostate, the forceps were extracted, the lithotome again introduced,
and the gland further divided by  the blades being sprung  to theh?  maxi-
mum point of twenty-one lines.  The stone was  then seized with curved
forceps, and extracted entire Avith not more than the usual force required
in the extraction of a  calculus of medium size by the lateral operation.
  The following were  its dimensions : Longest diameter, two inches within  •
a fraction;  shortest  diameter, one and five-eighths of an inch; circum-
ference, five  and five-eighths inches.  It was  hard, being a triple  phos-
phate, and round.  The patient recovered from the operation in about the
usual time, and being sufficiently strong to travel, left for his home in Vir-
ginia in about two months after the operation was performed.
  The  measurement  of the several diameters of the prostate, from the
urethra as the starting-point, to the periphery of the gland, is as follows \ 
LITHOTOMY.                           179
and gives the average size of the gland in a healthy state in the adult.  In
old men and children there is, of course, considerable variation from it.
The anterior face of the gland is considered.  Transverse  diameter, nine
lines; oblique diameter, ten to  eleven lines;  inferior vertical diameter,
se\Ten lines ; superior vertical diameter, three lines.  The oblique diameter,
the greatest, is the one divided in the lateral  operation.  This is eleven
lines, or one line less than inch.  Add to this the dimensions of the urethra,
about four lines, and this section  will give us but fifteen lines.  Now, it is
very certain that a calculus of over sixteen  lines in its shortest  diameter
could scarcely be extracted through this opening without either tearing or
incising beyond  the limits of the gland, for  although something must be
alloAved for the stretching and yielding of the parts, yet this is fully coun-
terbalanced by the increased volume which the  blades of the forceps Avould
add  in  grasping  the stone.   The surgeon, therefore,-is obliged  either to
tear the parts by main force, or to incise them freely beyond the prostate.
   Noav, in the bilateral division of the gland in which both the oblique di-
ameters are incised, Ave have, allowing four lines for the urethra, a  section
of tAventy-six lines ; and if to this Ave alloAV for  the stretching of the curve,
approaching as it does  toAvard a straight line  during the passage of the
calculus, it is evident that it Avill  permit, Avithout great difficulty, the pas-
sage of a stone of tAvo inches  in its short diameter, leaving, at  the same
time, intact the  parts beyond  the gland.  None of the methods of peri-
neal lithotomy, can, therefore, in its free and  safe incision, be compared
with the bilateral operation, permitting, as it does, the passage of a calcu-
lus of two  inches  in diameter and six inches in  circumference, Avithout
causing any laceration.
   In speaking of this  operation, Velpeau  remarks that " a calculus of
twenty to  twenty-four lines in thickness, and  from five to six inches in
circumference, might, strictly speaking, pass through the opening Avithout
causing any laceration."
   If, says Prof. May, the stone be larger than  this, it had better either be
broken, if possible, through the Avound, or  extracted  by the high opera-
tion.   There  are surgeons Avho  prefer performing the bilateral  section
Avith a common scalpel, for the purpose of simplifying the  operation, and
from the belief also that the  incision  through the gland does not corre-
spond  to the expansion given  to  the blades of the lithotome, from the
yielding of the latter on account of their length and slenderness.  I do not
think the last objection t r> oe correct.  If the instrument is made properly,
and the blades are well and  firmly articulated  and sharp, I have not been
able to discover any such defect.  The operation can, no doubt, be very
well performed Avith the common scalpel or bistoury, and if the lithotome
of Dupuytren «lid not possess positive advantages  over it,  it ought to be
©referred, upon the  ground of being the more simple instrument.  But the
lithotome, as Velpeau remarks, renders the parts more tense as it divides
them, gives greater regularity to the wound, terminates the operation
with a single cut, and especially makes " an actual curved, instead  of a
simple V incision, which latter is the only  one Avhich pan reasonably be
expected, if we use  the bistoury or other lithotomes."  It is  an instrument,
moreover, that can  be  safely used at all ages, as the blades can be  sprung
by the graduated scale on the handle from four to ten and a half lines on
each side.  I first used the double lithotome in 1842, and then on a child
of three and a half years.  The  blades were set  to four  lines each, thus 
180
LITHOTOMY.
making an incision of eight lines through the prostate, and through tins,
with a pair of ordinary polypus forceps, I extracted a calculus  one incb
in its long, and five-eighths of an inch in its short diameter (about as large
as a common  sized almond in the shell) Avithout  the  Avound being even
stretched by its passage.  The child did not lose over §j. of blood, and the
recovery was very rapid, the Avound being nearly  closed in two Aveeks
after the  operation was performed ; a fact Avhich.goes  far to  disprove the
assertion made by some, that cicatrization is much slower after the bila-
teral than the lateral section.
   There  are, moreover, other reasons, besides those already mentioned,
which, it appears to me, render this operation safer in many respects than
the lateral method, and Avhich I, therefore, think should cause it  to be
adopted, not only specially, for the removal of small calculi,  but also as a
general method.
   In the first place, there are  fewer vessels divided by it, and the bulb of
the urethra is not touched, for the incision is made between the anus and
the bulb, and the latter Avith  its transverse artery can be always avoided.
In the lateral operation, from the position and extent of the incision, I do
not  see  how the  bulb  and artery can well  escape,  notwithstanding  the
directions in the books.  Without attaching to their  division great im-
portance, it is yet  undoubtedly preferable to avoid  them when it can be
done.  If the double lithotome  is used, the pudic artery  cannot by any
possibility, except  anomalous distribution, be reached. Even  the super-
ficial artery, Avhen in its usual position, is not usually divided; so that the
operator  is incomparably less incommoded  by hemorrhage, as the poste-
rior branches of the transverse, and the anterior twigs of the hemorrhoidal
artery are really the only arteries that are usually divided.  Again, as the
lithotome cuts outward and backward, there is less danger to the rectum.
Indeed, I do not see how the  intestine can be injured,  unless it should be
greatly distended from neglect, prior to the operation;  and lastly, the
ejaculatory ducts and vesicuhe seminales are not  exposed to risk, for it
will be recollected that  the  membranous portion of the urethra is first
opened, and then the blades of the lithotome are sprung.  Their obliquity
outward, from this point, is such that  the ducts cannot be injured, while,
the blades not passing  the limits of the prostate, the vesicuke cannot he
reached.                                             j>art XXY[^ ^ 246.

   Causes of Death from Lithotomy.—The accidents  which are  of the
most formidable nature after  this operation  are—hemorrhage, infiltration
of urine into the cellular tissue with suppuration and abscess of this struc-
ture,  mflammation of  the  bladder, peritonitis, purulent  infection, and
secondary disease of kidneys.   Dangerous hemorrhage is stated to be of
uncommon occurrence.  Mr. Listen stated that he had lost but one patient
from bleeding out of 100 operations.
 _ Hemorrhage, properly so called, may arise from division of the superfi-
cial artery of the perineum, the transverse  artery, or the artery of  the
bulb, and the internal pudic itself.  In  some cases the accident arises from
the surgeon's making his incisions in an irregular manner ; but the most
frequent  cause is some irregularity in the origin, course, or relations of the
numerous blood-vessels  distributed to  the perineum.  The operator may,
m making his incisions,  err in  three ways ; he may commence his incision
too high, or  he may incline it too much  laterally toward the tuberosity 
LITHOTOMY.
181
 of the ischium.   Each  error may bring its  peculiar consequences  after
 it.
   When the incision is commenced very high up, the point of the knife is
 apt to fall on the bulbous portion of the urethra, or divide to one side of
 it the artery of the bulb.
   By prolonging the incision  too far downward, that is to say, carrying
 it much beyond the level of the tuber ischii, the superficial branches which
 the internal pudic sends  to  the  margin of the anus are  almost sure to be
 divided; but here again the superficial situation of the A'essels, which are
 not usually large, enables the operator to secure them without difficulty.
   The trunk of the pudic artery itself may be  divided when the incision is
 lateralized too much,  and its lower angle made to terminate very close to
 the ramus of the ischium. This  accident has happened in the hands of the
 very best surgeons:
   M. Blandin, and many other anatomists, think that it is impossible for it
 to occur, unless there be  some irregularity  which disturbs the normal
 relation of parts at the floor of the pelvis.   Finally, the  superficial artery
 of the perineum may  be implicated, because, in some subjects, it is near to
 the median line; but the artery can be taken up wdthout difficulty in this
 situation. Primary hemorrhage may occur during the external or internal
 incisions.  In the latter case, the danger is proportionate to the extent of
 the incision through the prostate ; in the former case, to  the amount of its
 deviation from the median line.
   Venous hemorrhage is another accident of lithotomy which occasionally
 occurs.  A serious form occurs from division of the venous plexus about
 the neck of the bladder and prostate.  In aged patients, and after long
 continued irritation of the urinary organs, these veins are apt to become
 abnormally developed, even  to a varicose  state.   Besides  this, they  are
 enveloped in prolongations of the deep pelvic fascia, and thus prevented
 from retracting or becoming  quickly closed after  division.   From  these
 causes, troublesome A-cnous  hemorrhage may come  on in old patients sub-
 mitted to the operation.  Sir  B.  Brodie lost a patient Avithin a feAv hours
 from this cause, having been foiled in all  his efforts to restrain the bleed-
 ing.  It may take place in  adults, or eAren in  children, under peculiar  cir-
 cumstances.  M, Robert Avitnessed  two examples  at  the  Hotel Dieu of
 Paris.  In one  case, that of a young man, the venous plexus continued to
 pour forth blood until death ensued.   No artery  had been wounded.  The
 Becond case Avas that of a child  addicted to masturbation.   The enlarged
 veins furnished a copious bleeding, Avhich became suddenly fatal after an
 act of that vice.  These are altogether exceptional cases, for we may  lay
 it doAvn as a rule that the danger of venous hemorrhage is  in direct pro-
 portion to the age of the  patient.
  The period at Avhich secondary hemorrhage sets in is very uncertain.
 You  should make if  an  invariable rule to examine the patient's  linen
 every day for  any traces of  blood, more especially if the  pulse become
 feeble and the face  pale.   Secondary hemorrhage, however, usually com-
mences about the fifth or sixth  day—sometimes  earlier, on  the  third or
fourth—sometimes later, on  the eighth or tenth day.
  Infiltration of urine into the cellular tissue  is one of the most frequent
causes of death.  It may take place under tAvo  different circumstances.   It
may occur Avhene\rer  the internal incision is carried beyond the limits of
the prostate, or Avhen the neck of the bladder and prostate  are injured 
182
LITHOTOMY,
and lacerated during the efforts made to extract a large calculus. In botn
these cases, the fibrous capsule of the prostate is divided or lacerated; the
urine becomes infiltrated  into the subjacent cellular tissue, inflammation
sets in, and, according to its seat  or extent, excites  peritonitis  or givea
rise to slouo-hing and gangrene of the soft parts Avithin the petvis; _
  Infiltration, again, may occur, not from a too  free internal incision  hut
because the external one has not  been made on the same plane as the in-
ternal ; because it has been too small, or the soft parts which constituted
walls have been lacerated and rendered irregular  during the extraction
of the stone; anything, in a word,  Avhich impedes the  free discharge of
urine through the external wound, may become an  occasional cause ot this
infiltration, which takes place in the perineum, and not in the sub-perito-
neal cellular tissue  as  in  the former species.  Simple inflammation of the
pelvic cellular tissue, not caused by urinous infiltration, is a very rare acci-
dent.
  The symptoms  of urinary  infiltration are extremely various, for the
effects of the accident are modified  by several circumstances.  In some
cases, the symptoms set in a feAv hours after the operation, and terminate
fatally in a few hours more, or within a day or tAvo  ; in other cases, the
progress of the disease is slower, and. the patient does not sink until after
a considerable period.
   Tbe sub-peritoneal is, as might naturally be  expected, the most rapid
 and dangerous. The patient complains of pain about the neck of the blad-
 der,  and  from the very outset has a peculiarly unfavorable and anxious
 expression of countenance; the pulse is small, weak, and rapid; the tongue
 soon gets dry;  and  the  lower  part of the abdomen tumid and painful;
 often there is vomiting; prostration noAV rapidly ensues; there is low
 delirium, and the patient dies within forty-eight hours.
   In other cases the typhoid symptoms and prostration  are not so great;
 the fever at first is of a more irritative character, and is occasionally inter-
 rupted by rigors;  still, as  the  urine  continues to work its Avay between
 the layers of the fascia, and the inflammation ascends  along the sides of
 the rectum, more unfavorable symptoms do not fail to present themselves.
   Purulent infection is  not  often  a  cause of death in  English surgery.
 Inflammation of the bladder is  somewhat common; but we  should esti-
 mate the inflammation caused by the  stone, and that also, of the operation.
 In alluding to the last cause of death  after lithotomy, Mr. Gay, in his con-
 cluding remarks, says, that calculus vesica? can never  long exist without
 producing deterioration of the  system  and  latent disease of the kidneys,
 and with such cases as these, he observes, lithotritists are very careful not
 to meddle.                                          part xxvii., p. 150.
   Lithotomy—NewMethod: {Recto-Urethral.)—This  operation maybe
  described briefly as follows: The rectum is  cut into from the median line
  of the perineum, and thus freely dividing the commissure of the sphincter
  ani.  From this  dissect upAvard in  the median line to the membranous
  urethra, which is slit up as far as the  edge of the prostate, the knife being
  guided by a previously  introduced staff.  The prostatic urethra is then
  dilated until of sufficient size to allow of the introduction of the forceps
  and the extraction of the  stone.  The bladder and the prostate are there-
  fore not wounded.                                 j>art xxw\\\^ ^ 205.

    Lithotomy.—If  a  patient be relieved by  making Avater,  says Prof 
LITHOTOMY.                           lo3
Syme, the case is probably one of urinary irritation,   If the pain occurs
during micturition  only, there is probably stricture, but if the pain be
slight before micturition, increases during the process, and becomes severe
for a short time afterward, we ha\re probably a case of stone.   The success
of lithotom}' depends in a great measure on the manner in which the pros-
tate is divided.  There is one part which cannot bear injury, this is at the
base of the gland Avhere it joins the base of the bladder;  it is a dense tex-
ture, very tough and unyielding, forming a sort of ring around the urethra,
endowed Avith  an extraordinary degree of sensibility.    Noav, if this tex-
ture be torn, the patient will die, or  if injured, the danger Avill be in pro-
portion.   The different success of different surgeons  depends upon this
ring being divided  sufficiently by some and not  by others:  therefore, if
on introducing your finger to dilate the deep part of the incision, you feel
you  have not cut enough, pass  a straight probe-pointed  bistoury along
your finger, and, by a gentle sawing motion, carry the incision  on to the
extent you find necessary, in order to enable you to dilate Avith facility.
                                                    Part xxxi, p. 295.

   Prevention of Hemorrhage after  LitJwtomy.—There are many objec-
tions to plugging the Avound.  It  prevents the  flow of urine, which creates
much irritation, and on its removal fresh bleeding is often excited.   To
obviate this, attach to the common tube  a  conical bag of oiled silk, about
an inch and a half from its inner extremity, pass the tube into the neck of
the bladder, and then fill  the oil-silk bag Avith sponge.  The wround may
in this Avay be most effectually plugged, and the escape of urine is secured
by means of the tube.                                Part  xxxL, p. 298.

   Median  Operation of Lithotomy.—In reference to the comparative
mortality of the lateral and  median operations of lithotomy, Dr.  King
having considered  shock, hemorrhage, and infiltration  of urine, which are
less  liable to occur  in the latter  than in the former operation—and  puru-
lent deposits and peritonitis Avhich are accidents occasionally attendant on
all operations, observes that the  remaining source of danger, viz., inflam-
mation of the neck  of the bladder, is  the most frequent cause of death after
lithotomy, and we  have to  consider whether it  is more  likely to occur
when the prostate  is partly divided and  partly lacerated, or when it is
simply dilated.  The prostate Avhen  once cut  into very readily tears, and
the  inflammation  excited by the urine getting into  these fissures  pro-
duces more fatal results in lithotomy than all the other sourpes of danger
put  together.  But if the prostate be not incised at all, this condition of
things is entirely altered.   In the old Marian operation,  the prostate was
actually torn asunder, by instruments, and there  is no wonder that death
so often resulted.
   Mr. Allarton's proposal is of a very different nature.  He recommends
that the finger should be introduced, in the first place, and  dilatation
effected  by  careful pressure—that  long-bladed  forceps should  next be
passed into the bladder, and, the stone having been seized, should be care-
fully and steadily AvithdraAvn—the length of the blades causing the instru-
ment, Avith  the stone in its  grasp, to act as  a Avedge, and  thus assist in
the proces of dilatation.  Even  should the structure of the prostate tear
under this gradual  pressure,  it is of little moment so  long as the mucous
membrane remains entire, the urine being thus prevented from having 
184
LITIIOTKITS ,
access to  the  lacerated portions, which access, and not the mere fact of
laceration of the prostate, constitutes the grand danger in lithotomy.
                                                   Part xxxv., p. 118.

  Rectangular Catheter-Staff for Lithotomy.—Mr.  Hutchinson recom-
mends the use of an instrument combining the advantages of both a grooved
staff and a catheter.  It is rectangular in form, and the groove commences
only from the angle, being broader  at that point to allow its being more
readily found, and  the angle  being very prominent in the permaeum is
more readily reached by the knife.   There are also other important ad-
vantages : from the straight direction  Avhich the knife  runs it does not
readily leave the groove—from the groove only commencing at the angle,
the urethra  cannot be opened too far forward, or the artery of the bulb
wounded.   From its being a catheter as Avell as a staff, the surgeon may
be quite certain it is in the" bladder before commencing the operation, and
the bladder  can be injected Avithout any change of instruments.   There is
no difficulty whatever in its introduction.
        *******
  One of the great advantages of this over the curved form of staff is, that
the rectum is quite secure from being Avounded if the finger be kept in the
rectum whilst making the incisions.                 Part xxxv., p. 120.
                          LITHOTRITY.
  Sir B. Brodie adverts to the inconveniences or dangers of lithotrity, as
follows:
  1. Hemorrhage.  This may arise from the forcible passage of the litho-
trity forceps through the neck of the bladder.  Sir Benjamin has knoAvn it
discolor the urine for two or three days.  But it has never interfered with
the operation.
  2. Rigors may folloAV lithotrity.  The rigor is usually produced by the
stretching of the  urethra by the withdrawal of the forceps: or it may be
occasioned by a fragment of* calculus sticking in the urethra.  A dose of
opium may prevent the rigor altogether, or  defer it till  the  next day.
Rigors do not appear to interfere materially  with the patient's recovery.
  3. Sir Benjamin refers to tAvo cases in which fragments of calculus im-
pacted in the urethra gave rise to urinous abscess in the perineum.   One
patient died two months after with symptoms of diseased kidney.  The
other patient got well.
  4. Sometimes the patient suffers from  pain in the  Avhole canal of tho
urethra, from the simultaneous escape of many fragments.  Sometimes he
labors under  great irritation  of  the  bladder, apparently  from a fragment
lodged near its neck.  He may have complete retention, but Sir Benjamin
has never seen it last for any time.
  The patient should partake plentifully of diluting drinks.   If  fragments
lodge, a middle-sized catheter may be introduced into the bladdei" when
they may be either dislodged and come away, or pushed back and after-
ward crushed.  Sir Benjamin has removed fragments from the anterior
part of the urethra by long,  slender forceps.  It might  be necessary to
make an incision in the penis  or the perinseum.  Sir Benjamin howevei 
LrTHOTKITY.
185
believes that if perfect repose is enjoined, after the operation, the passage
■of fragments will seldom occasion any serious inconvenience.
  5. Inflammation of the mucous membrane of the bladder may occur.  It
generally subsides spontaneously in two  or  three days, or continues till a
fragment is either discharged from the  urethra, or pushed back into the
bladder by the catheter.  In one instance, Sir  Benjamin saw this inflam-
mation prove fatal.   The stone had been large—perhaps the patient had
not been kept quiet.
  On the whole Sir Benjamin is of opinion that lithotrity has great advan-
tages over lithotomy. He touches on the  cases to Avhich it is not applicable.
   1. In boys, under the age of  puberty, lithotomy  is too  successful to
be abandoned.  The urethra is not wide enough to be favorable to litho-
trity.
   2. Lithotomy is attended  wdth little danger  in  the female, while her
short and Avide  urethra admits too readily  of the  escape of the injected
Avater by the side of the lithotrity forceps.
   3. Large  stones are not well adapted for lithotomy, but they are still
worse adapted for lithotrity. Sir Benjamin  inquires whether it Avould not
be well to crush first and cut afterward.   •.
   4. Lithotomy is not well adapted for cases of enlargement of the pros-
tate gland, where the patient cannot empty  the  bladder, unless the calcu-
lus is small;  then  the fragments  may  be  Avashed  out  of the bladder
through a large catheter.  When the tumor of  the prostate projects into
the bladder, it is difficult to elevate the handle of the instrument suffi-
ciently to catch the stone readily.
   5.  Lithotomy is very fatal where the kidney is  diseased, especially Sir
B. Brodie  supposes from the loss of blood that it entails.  Crushing he
thinks safer.   But  any shock  to the system must be hazardous, and  it
must, usually, be more advisable  to palliate.
   Sir Benjamin sums up what  he has to say in favor of lithotrity in these
Avords:
   " With the exception of such cases as those which have been enumerated,
there are few to which this  method of treatment  may not be advantage-
ously applied.  It may be said that the exceptions are  numerous ; but they
are the result chiefly of delay.  If a patient  seeks the  assistance of a com-
petent  surgeon Avithin six or even twelve months  after a calculus has
descended from the kidney into the bladder, the urine having remained acid,
it will rarely happen that he may not obtain a cure by a single operation,
and with so small an amount of danger that it need scarcely enter into his
calculations.  As time advances the facility  Avith Avhich he can be relieved
diminishes, and after the lapse of  tAvo or three years, especially if the urine
has become alkaline, it is probable that the calculus  will have attained such
a size as to render the old operation preferable, and that the access of dis-
ease in the bladder  or kidneys may render  any operation  hazardous.   It
would be absurd to say, and it would be unreasonable  of human-kind to
expect, that an operation that has for its object to relieve them of a disease
so terrible as stone in the bladder, can be always free from inconvenience,
and difficulty,  and danger.    Nevertheless, from what experience  I have
had, I am satisfied that the operation of lithotrity,  if had recourse  to only
in proper cases, is not only much more  successful than that of lithotomy,
but that it is liable to feAver objections  than almost any other of the prin-
cipal operations of surgery."                           Part vi., p. 106. 
186
LITHOTRITY.
    Lithotrity—-The  first case of lithotrity  performed  in Ireland, was by
  Sir Philip Crampton, in 1834, in the Meath County  Hospital.  The opera-
  tion was  only repeated once, and  in less  than a Aveek's time the  Avhole of
  the detritus had come aAvay.  Sir  Philip  asks  Avhat is  the problem Avhich
  lithotritv has to solve ?  According to Civiale it is as follows :
    1st. The reducing of calculi Avithin the bladder  into fragments suffi-
'  ciently small to be discharged or  removed through the natural  passage.
  2dly. The effecting this by such means as shall excite no dangerous irrita-
  tion in the urinary organs.  3dly. The  freeing the bladder or urethra
  from the  fragments Avhich these organs may not have the pOAyer  to expel.
    The best instrument for performing the operation of lithotrity,  is Baron
  Heurteloup's or Weiss's curved percuteur.  The late Mr. Oldham improved
  this instrument by carrying out a  suggestion by Sir Philip Crampton, by
  which fragments of the calculi  are prevented from accumulating  betAveen
  its jaws.  The invention of the screw is  due  to Mr. L'Estrange of Dublin.
• Sir Philip Avould prepare the patient for the operation by enjoining a light
  diet, abstinence from fermented liquors, clear out the boAvels, and order the
  hip-bath : if the urine be acid, give alkalies combined with uva ursi or Pe-
  ruvian bark ; if alkaline, give the mineral  acids; and if mucous  deposits,
  infusion of Pareira brava ; enjoin absolute rest, and use occasionally an an-
  odyne enema.  The urethra is to be gradually dilated, if necessary; when
  preternatural contraction of its orifice exists, divide it.  Introduce the ca-
  theter  frequently, as it allays the irritability of the bladder and urethra.
  The objects of the  operation are to reduce calculi  within the bladder to
  such a size that the portions may be removed or discharged through the
  natural passages,  to effect this by such means as shall excite no dangerous
  irritation in the urinary  organs,  and to  free the bladder from the small
  fragments Avhich remain.   Great care should be taken that the  case be a
  suitable  one for the operation, as in some cases cystotomy must be pre-
  ferred.   Lithotrity may be performed where the bladder is perfectly healthy
  and the  stone is small; and it is  decidedly advantageous  where there is
  phthisis or albuminuria.   It is a great and valuable  addition to chirurgical
  therapeia, but cannot  be  considered as  a substitute for cystotomy, since
  there are numerous cases  in which the last operation will prove the safest
  and most effectual.
    Cystotomy, for example, is preferable in boys before the age of puberty ;
  it is so simple and the urethra is so small as not to  admit of the lithotrite.
  Cystotomy is also preferable in the female ; also where the calculus has at-
  tained a  very .large size;  also where  the  prostate gland is enlarged, unless
  the calculus be of very small size.                     Part xiii., p. 266.

    Lithotrity.—According to Mr. Listen, this operation is  applicable, 1st,
  to patients above puberty, if the stone is not large, say i to \ inch in di-
  ameter, or as large as a chestnut; 2nd, when the bladder and  urethra are
  tolerably healthy, as shoAvn by retaining  the urine for  hours, and being
  able to pass it in  a good stream, and Avhen the bladder will admit of injec-
  tion and careful exploration.                            Part xiv., p. 207.
    Treatment after the operation of Lithotrity.—d>.  Adams, of the Lon-
  don Hospital,  says: In regard to* the getting  rid  of the  contents of the
  bladder,  I am strongly of opinion that the less interference there is on the
  part of the surgeon the better.   Let the patient drink freely of barley-wa-
  ter, and give him an alkaline mixture wdth tincture of hyoscyamus, and you 
LITHOTRrrY.
187
will find the bladder relieve itself much better than you can relieve it by
the aid of any instruments, hoAvever ingeniously contrived.  I am averse
to the  exhibition of opium after the operation, unless the patient should
have a shivering fit, and then it may be desirable to employ it; opium has
the effect  occasionally of inducing the  retention of urine, and  therefore I
would not use it unnecessarily : a dose  of  castor-oil may also be given the
morning after the operation, and the hip-bath is to  be employed night and
morning.                                            Part xix., p. 171.

  Lithotrity and Lithotomy.—In the course of his remarks on the Patho-
logy and Surgery of urinary  concretions, Mr. B. B. Cooper  says : The
choice between lithotrity and lithotomy is  often one requiring considerable
judgment on the part of the  surgeon; and this is a question  in Avhich a
knowledge of the chemical  nature of the stone must always be of  great
service : not that the chemical composition of the stone has anything to do
with either of these operations directly ; but the physical" character of the
different kinds of stones  A-aries as much  as their composition, and  that
character can be judged of pretty correctly as soon  as the composition  of
the calculus is knoAvn.  Uric  acid, for instance, often occurs in a form in
wdiich it easily breaks into pieces  under a crushing  force ; and the  crys-
tallized variety of the triple phosphate also crumbles away completely un-
der  pressure.  By  means of the  lithotrite it is easy to  comminute  such
stones as these ; but there are others Avhich yield  wdth great difficulty  to
the action of that instrument.  The oxalate of lime calculus is of this na-
ture ; the tuberculated  portions break off  readily enough, but the mass of
the  calculus is crushed  Avith  great difficulty ; and when it is  broken, the
fragments are so sharp that they are likely to produce extreme irritation
in the bladder, and then a secondary action may be established, in wdiich
these fragments  become  the  nuclei of  other calculi, or at least cause the
deposition of fresh quantities of earthy matter from the urine.  Whatever
may be the nature of the stone, I  think it is ahvays inadvisable to employ
the crushing process if there be  evidence of a tendency to the deposition
of the earthy phosphates.   Of course this  must be  judged of by the urine ;
and unless the tendency can be removed, it seems to me that the operation
of lithotomy should be preferred ; for I believe that the incision through
the prostate gland causes less irritation  than the use of the lithotrite, and
the consequent  presence  of the calulous  fragments.  The  adi'antage of
lithotomy is, that the  chief source of irritation is  removed at once"; and
although there may remain the constitutional tendency to deposition from
the urine, there would  be no nuclei  to  promote that  tendency, and  it
would be therefore the  more  likely to  be counteracted by therapeutical
agents.
  Whenever, also, from the diathesis of the patient, the state of the urine,
and the examination by the sound, the stone isbelieAred to be of that  kind
which is crushed wdth  difficulty,  the operation of lithotomy is certainly
indicated.
  With regard to the constitutional condition of the patient, the same con-
siderations would weigh Avith the surgeon in lithotomy as in lithotrity ; and
one of the chief points  would be, to overcome, before the operation Avas
performed, the constitutional tendency, if any  still continued to exist, to
further  deposition.  Generally speaking, the physical character of the stone
bears little immediate relation to the  operation of lithotomy; but I may 
188
LrTHOTEITY.
 say that the kind of stone most suitable to lithotrity is perhaps that most
 difficult to deal with in lithotomy.  The more friable a stone, and the less
 the  cohesion of its particles, the better suited it  is to the lithotrite; but
 such a stone Avould be more likely to increase the difficulty of the opera-
 tion in lithotoim', as it would probably  crumble and break away when
 seized by the forceps, and so lead to the necessity of some modification of
 the  operation, in order to  get rid of the  Avhole of the fragments.  The
 hardness  of the  stone can be no  objection in lithotomy, unless it be too
 large to be removed Avhole,  in which case great irritation may be produced
 in the efforts of the surgeon to break it Avhile in  the bladder.  I believe
 that the operations of lithotrity and lithotomy may, in a certain manner,
 be very advantageously combined.   For instance, it  sometimes happens
 that a stone is so large, that, although ti may be removed Avithout pre\ ions
 crushing,  it requires a very  extensive incision through the  prostate.  In
 such a case, I think that  a  strong kind of lithotrite may be  introduced
 through the wound, and the stone easily broken doAvn, Avithout producing
 so much irritation as Avould arise from the extension of the wound by the
 forcible extraction of a large stone.                     Part xx.,p. 158.
   Lithotrity.—Mr. C. HaAvkins says: No  attempt to extract any portion
 of stone through the urethra should be made Avith  the lithotrite ; the op-
 erator should be  content Avith crushing the stone in the bladder.  If a por-
 tion of the stone should become  impacted in the urethra, it is much safer
 to cut doAvn upon it and remove it, than lacerate the urethra by efforts at
 extraction.                                          Part xxiii., p. 200.
   Lithotrity.—After the  operation of lithotrity, it sometimes happens that
 a fragment of the stone becomes impacted in the membraneous part of the
 urethra.  To  ascertain the nature  and seat  of the fragment  pass a soft
 bougie doAvn the urethra;  the fragment seldoms  fails to leave a mark  on
 the bougie, AAdiereas a metal sound would pass over  it and communicate no
 impression.  Where impaction is to be apprehended, the patient should
 not be alloAved to make Avater Avhile on  his knefis, but must endeavor to do
'so while on his back.  Immediately after the operation several injections
 of warm water should be thrown into the bladder by means  of" a large ca-
 theter, Avith large eyes, for  the purpose of removdng as much of the detri-
 tus  as possible.   If a fragment should be  impacted, and if it should be
 near the neck of the bladder, it may be gently pushed back, but in all cases,
 if there is any resistance,  injections of warm Avater should be used through
 the catheter.  If it is  impossible by  these  means to push back the  frag-
 ment, there is only the choice betAveen extraction and crushing, and when-
 ever the former can be effected Avithout much difficulty it is to be preferred.
                                                    Part xxvi.,  p. 230.
   Lithotrity.—In the choice  of subjects  for this  operation, take care, if
 possible, 1st, to let the age be between  thirty and sixty, Avith neither the
 irritability of youth, nor the debility of old age.  2d. The urethra should
 be large enough to admit  instruments of considerable size.  3d. The blad-
 der should be healthy, and capable of holding six  or eight ounces of fluid.
 4th. The  kidneys should  also  be healthy.  5th. The calculus should be
 loose in the cavity of the  bladder.  6th. The  diameter of the stone oug'it
 not to exceed an inch and a quarter, as near as can be calculated.   Whe e
 the above kind of case occurs, lithotrity and not lithotomy ought to ba
 performed. 
LITHOTBITY.                          189
   Simple enlargement of the prostate need not prevent the operation, but
 where there is inflammation or suppuration it is inapplicable, and lithotomy
 should be performed.   Lithotrity should never be adopted,  unless the
 bladder be free from inflammation, and one great means of knowing this is
 to ascertain the quantity of water Avhich the  bladder can hold.  A blad-
 der violently inflamed, is like a stomach inflamed, neither can contain much
 without parting Avith it.  If  the bladder can  hold eight or ten ounces
 (other circumstances  being fiworable), lithotrity wdll  generally succeed;
 but  if it Avill  contain only three or four  ounces,  this operation is not
 proper.  As soon as the surgeon has filled the bladder, he should suddenly
 change the position of the  patient backward, so as to throAv the stone into
 the back of the bladder.  The manipulations can be carried on better in this
 place than nearer the prostate and the anterior part of the bladder,  Avhich
 is ahA'ays more irritable and sensitive than the back part. Part xxx., p. 163.
   Lithotrity.—[In a .case of  lithotrity on a  rather  old  patient, at St.
 BartholomeAv's  Hospital,]  Mr. Skey,  after carefully injecting  the bladder
 with warm Avater, was observed to break the  stone once, and then order
 the man to bed.  Mr. Skey then explained to his  class that  this is a rule he
 adopts at the advice  of Sir B. Brodie, never  at the first  sitting to break
 the  stone more than once, so  that the  bladder may thus become accus-
 tomed as Avell to the instruments as the altered state of the stone.
                                                    Part xxxx.,p. 122.
   Lithotritic Instruments in Cases  of Enlarged Prostate.—Supposing
 you have to perform lithotrity in a case of enlarged prostate,  you must, in
 order to success, take into account the alterations which have taken place
 in consequence of the  prostatic disease.  The tA\ro principal  are:  first,
 elongation of the passage by an inch  or more; second, formation of a sort
 of a pouch  beneath  the neck of the bladder, in AArhich pouch the stone
 usually lies; to OA'ercome the first, you require to have your instruments
 several inches longer than  usual; you Avill best overcome the  second by re
 versing the beak of the  instrument when introduced into  the bladder, or
 by tilting the pelvis of the patient backAvaid,  to  execute which proceeding
 quickly, every lithotrity couch should be provided with some mechanical
 contrivance.                                       Part xxxAdi., p. 161.
   Lithotrity.—According  to Mr. F. C. Skey, cases  should be  rejected if
 there  be—1. Manifest disease of the kidney.   2. The urethra so con-
 tracted as not to admit Avith  facility a  lithotrite of ample size.  3. The
 bladder so intolerant as to be  incapable of retaining its urinous contents
 for three or four hours;  and, on the other hand,  a bladder  of Ioav nervous
 susceptibility.  4. Much enlargement of the  prostate gland.  Moreover
 in performing the operation, the  folloAving cautions should be  observed:
 The  quantity of Avater injected should not exceed four or five ounces.   No
 attempt should be made to open the instrument till it has been pushed
 thoroughly home into the bladder. In the act  of separating the blades,
'pass the lower blade doAvnAvard  toward the bottom of the bladder, that
 the upper blade  may not be painfully pressed against the neck.  The in-
 strument  should retain the mesial line throughout the entire  operation,
 there being  neither necessity for, nor advantage in, directing the instru-
 ment to the right or left.   At  the first  operation do as little as possible,
 breaking the stone only once.   No advantage is gained by an abstemious
 diet-                                                  Part x)., p. 123. 
190
LOBELIA INFLATA—LOCK-JAW.
                    LOBELIA  INPLATA.
      Uses of Lobelia Inflata.—In pertussis, combining the  tinct. lobel., of
   which  Professor Eberle  speaks so  highly,  with the  acid  hydrocyan.,
   extolled  by Thompson  and Roe, wdth equal  propriety might I vaunt the
   recipe as a specific, as they do  theirs, although such a thing as a specific
   probably does not exist, except it be sulphur for psora.  In asthma, espe-
   cially of a spasmodic kind, the most marked benefits result from the use
   of this pi mt singly, or combined as above—the existing disturbance of the
   nervous fibre of the bronchial surface, or the spasms  of the mucous mem-
   brane of the bronchia are speedily allayed, and, by a short course, a cure,
   or a suspension of some length at least, is the sequence of its administra-
   tion.  For  an adult, R Tinct. lobel. inflat., 3j-;  acid hydrocyan., gtt. i-ii
   Ter quatuo^ve die.  But if the  paroxysm be  severe, the tincture may be
   given in much larger doses, and  repeated at short intervals, till entire re-
   lief is obtained.  By this combination, I have  enabled  several inveterate
   cases of asthma (which had been repeatedly prescribed for by various
   physicians, quacks, and old women) to pass for several months with a com-
   plete suspension of all their sufferings.
     In diphtheritic  laryngo-tracheitis,  continues  Dr.  Livezey,  where the
   excitation of  emesis cannot  be readily  accomplished,  Avhich  frequently
   arises from the nature of the  disease as Avell as  the difficulty and unplea-
   santness of medicineto infants, this difficulty may be obviated by enemata,
   containing a portion of the tinct. lobel. or pulverized plant, which at once
   relaxes the system, removes the tension of the chest, changes the seat of
   excitement to  a distant part, and emesis readily  ensues ; the bowels in the
   meanwhile  are emptied  of their contents, and  recovery from every dis-
   tressing symptom immediately follows.
     In all cases of coughs, especially Avhen inflammatory  symptoms mani-
   fest themselves, as in catarrhal affections in children as Avell as in adults, I
   consider the tincture of this plant (or infusion, when the stimulus imparted
   by the alcohol might be objectionable) far preferable to ipecacuanha or the
f  tartrate of antimony and potassa, being more decisive in its  effects than
   the former, and a better and safer nauseant  than the latter, without that
   fear of irritating the  gastro-enteric mucous membrane, the pathological
   condition of avInch has been too much overlooked  by earlier Avriters, but
   which is now claiming deserved attention.
     In febrile disorders, incident  to  every section of country, more or less,
   in summer and autumn, when it  is desirable (as in fact it is always so) to
   lessen vascular action, and as  a febrifuge, the " nitrous poAvders " sink into
   utter insignificance in comparison with this plant, Avhich is not liable to the
   same pbjection as the tartarized  antimony used  in combination with calo-
   mel and the nitrate of potassa by many of the older practitioners, which
   too frequently increases that tenderness and erethism already existing in
   the mucous membrane of the  stomach and intestines.   Part xvi  p  134.
                           LOCK-JAW.
  acupuncture in Protracted Lock-jaw.-{The patient, 25 years of age,
unmarried, had for years  been subject to attacks of  suppurating sore 
LOCK-JAW.
191
throat, in Avhich the jaw often became nearly immovable for two or three
days before the discharge of the matter.   In 1826 she had a severe attack,
from which resulted complete lock-jaw, accompanied Avith hysterical symp-
toms, which attack yielded after six weeks of treatment  so far that she
could put a teaspoon into'her  mouth.  After nearly a year the jaAV  again
became completely fixed, without accompanying sore throat, and the same
treatment, Avith galvanism, was tried without effect.  Although unequivo-
cally connected Avith hysteria, there wras reason to  think, from the inflam
inatory symptoms wdth which the disease set in, that the affection' was not
purely spasmodic, but was kept up by rigidity of the muscles closing the
jaw, produced by  inflammation, in  consequence of which  the antagonist
muscles had become inadequate to the effort of opening the mouth, under
the mere influence  of volition.]
  It Avas this view  of the case wdiich made Dr. Seller consider it more rea-
sonable in making trial of the  needles, to  insert them  into  the muscles
which open the jaw, in the expectation of exciting these to  such a contrac-
tion as might overcome the rigidity of their antagonists.
  On each of the tAvo following days, tAAro needles were inserted, one on
each side of the mesial line, betAveen  the chin and the hyoid bone, the
effect being short convulsive efforts, the teeth began to grate on  each
other, and the jaw was drawn from side to side, not by  single alternate
contractions, but by several convulsive movements  on  one side, followed
by  a nearly equal number toward the other side, interrupted occasionally
by  a momentary opening of the mouth to the extent of about two fingers'
breadth.
  The convulsion continued after the needles were Avithdrawm, ceased and
became renewed again after a feAv minutes, and returned spontaneously in
the evening on both  occasions.   Some increase of voluntary poAver over
the jaw foUoAved both appfications of the remedy.  After each trial of the
acupuncture, some improvement Avas observable;  but as the spontaneous
convulsion Avas almost always folloAved by a  slight loss  of motion, the
progress made was but sIoav.
  The needles wrere usually inserted to the depth of half an inch, and some-
times to the depth  of an inch.
  [The acupuncture,  together with the leeches, was use'd for ten days, by
which time the patient could open the mouth two fingers' breadth, and chew
Boft substances.  She then went into the country for five weeks, by wdiich
she derived great benefit, but being exposed to cold and wet on her return,
had another  severe attack, the consequence of which was the loss of much
of the voluntary power over  the muscles of the jaw.  The needles Avere
again resorted to Aidththe same effects as before, but the pain produced by
the convulsions were  greater, and lasted longer, Avhile the spontaneous
convulsion recurred several times in the  evenings, after each of the first
trials.  As leeching did not succeed in mitigating the convulsion, the tem-
poral artery was opened with  the desired result, and with the effect at the
same time,  of restoring, to a considerable extent, the sight of the  right
eye, which she almost lost wdth the first attack of lock-jaw.   A second de-
traction of blood from the same vessel diminished the force of the convul-
sion so much as to permit the acupuncture to be used twice a day.   Nine
days after the reneAval of the operation, the jaiv had recovered its natural
extent of motion.   The aphonia, ivhich had come on at the same  time as
the  affection of the eye, w^as  completely cured by a smart  shock of elec- 
192
1.01N8.
tricity.   So great was the effect produced by the recovery of her voice,
and complete  power over the jaiv, that from a mere spectre, she reas-
sumed her natural robust, ruddy appearance.]
   Vide " Tetanus."                                    Part xi., p  189.
                            LOINS.
  Pain of the Loins.—Br. Oke says: Pain of the  loins may be derived
from the muscles, from the hver, from the duodenum, from  the kidneys,
from the colon, from the uterus, from the  aorta, from the spine, or from
matter collected on the psoas muscle independent of spinal disease.   In
order to  arrive at its true cause, we must endeavor to ascertain what func-
tion is principally involved which will at once lead us to it.
  If  the pain be rheumatic, it will be increased by pressure, and by the
slightest action of the muscles affected.   There will probably be also
rheumatism in other parts of the body, the system will not  evince much
disorder, the urine Avill be high colored, and deposit a lateritious sediment.
  If derived from the hepatic function, the pain will shoot upAvard along
the splanchnic nerves  to the scapulae ; the alvine evacuations Avillbe either
deficient in, or exuberant with, bile ;  or show a morbid quality of that
secretion ; the urine wdll have a bilous tinge ; there may be congestion of
the hemorrhoidal veins ;  and the spirits will be  depressed.
  If from the duodenal function, three or four hours  after the meal the
pain will be aggravated, shooting  through toward the right side of the
abdomen, and remaining till the food has passed inte the jejunum.   Dys-
peptic symptoms will  prevail, and there will frequently be painful pustules
breaking out about the face.  I havs  lately met with a case in which the
boils were extremely annoying.
  If from the kidneys, the pain  will shoot down the course of  the sper-
matic nerves toward the round ligament  in the female, and  tOAvard the
testis in the male, Avhich will often  be retracted by the action of  the sper-
matic nerves upon the cremaster  muscle.   There  A\dll be more or less
irritation  communicated to  the mucous  membrane of the bladder.  The
urine  also will be diagnostic in this  instance; it may  deposit mucusr calcu-
lous matter, blood, pus, or albumen, according  to the nature of the case;
or it may be otherwise morbid in its constitution.
  If from the uterus, the pain of the back will arise either from disordered
function or disease of that organ.   In the former case the pain will be of a
neuralgic character, will return in forcing paroxysms  extending around the
hips and hypogastric region, Avill be attended with hysteria, and often with
increased quantity of the menstrual discharge.   In the latter case the pains
will be constant and severe, extending along the anterior crural nerve half
Avay down the thighs.   There will be a  thin, offensive discharge from the
vagina.  The countenance will be wan and  sallow, exhibiting the  wear and
tear of organic lesion.
  If from the colon, there wiU be  constipation, and inflation in the course
of the bowel, or the faecal discharges will  be of small diameter, or  there
Avill be soreness of the intestine under pressure, especially at its ascending
or descending portions, accompanied by  mucus, or shreds of lymph in the
form  of boiled vermicelli, amongst the excretions. 
LUMBAGO.
193
  If from arterial dilatation, an abnormal pulsation of the vessel involved
—the aorta, for instance—may possibly be detected by auscultation in the
incipient  stage  of the disease, if such were  suspected;  but in a  large
majority of cases  such a cause may reasonably escape the attention of the
ablest surgeon, from there being no tangible symptom that  might lead him
to suspect it; and even after the dilatation has considerably advanced, it
may be sufficiently large to press upon and disturb the spermatic nerves,
but not large enough  to project and pulsate externally, and this may, at
this stage, be confounded with disease of the renal function.  A few  years
ago I met with a  case of this kind in a man of middle age.   The  pain had
been constant and wrearing, shooting from the loins doAvn the course of the
spermatic nerves,  and for a considerable time Avas reasonably attributed to
the renal function, especially as there had been constant disturbance of this
function.  At  length  the  aneurismal sac began to approach the surface,
and then, of course, the cause became apparent.
   If from  disease of the spinal column, the  pain will be aggravated by
percussing the spinous  processes at this part of the spine,  or by  suddenly
striking the toes  against  an  uneven surface.  There wdll be involuntary
action of the muscles, especially of the flexors of the legs, diminished tem-
perature, abnormal feelings, and more or less loss of  power of the lower
limbs.   Should there be at the same time any unnatural projection of the
spinous processes, the disease Avill be confirmed.
   If from a collection of matter upon the psoas muscle, unconnected with
spinal disease, the pain will be continued, dull, and deep-seated, extending
from the loins down the psoas, or  in whatever direction the matter may
have taken its course.   The  pain will be  aggravated by flexing  the thigh
toAvard the abdomen, and there Avill be difficulty in  walking; moreover,
there will be marks of a strumous habit, and more or less symptoms of hectic
fever.  Should any fluctuating tumor present at the groin, or at any other
point wftere the matter may find its Avay out of the body, it vrill be conclu-
sive as to the nature of the case.                         Part ix.,p. 50.

                              ---»»*
                           LUMBAGO.
  Nature and Treatment.—Lumbago is a very characteristic form of mus-
cular rheumatism.  It .occupies the loins, and is often aggravated  to tor-
ture by an unguarded movement implicating the muscles of the part; but
if the patient remain perfectly quiet, he is comparatively  free from suffer-
ing.  When very severe, he may be obliged to remain in bed, and very
often is confined to the sofa.  Even when he is  able  to Avalk about, he
often does so in a semi-bent position, being unable to raise his body into A
complete erect posture for some time after he has risen ; nay, in some cases
he cannot straighten himself at all.
  Purgatives are very frequently of great service in the different forms of
muscular rheumatism, more particularly in lumbago, and as a general rule
ought to precede the use of other remedies.  The best plan, where there
is nothing to contra-indicate  its adoption, is  to give from three  to four
grains  of calomel at night, followed by a black dose next morning, and to
repeat  this once or twice during the first week ; after which it  is sufficient
    VOL. ii.—13 
194
MALARIA.
to regulate the action of the bowels, and to give rather a brisk purgative
about once a week.                                      Part v.,  p. 11.
  Treatment of Lumbago.—Dr. Macleod advises a brisk calomel  purge
once or twice a week, and considers half a drachm to two drachms of the
compound tincture of guaiacum three times a day, Avith £r grain ol  opium
at night, the best plan.                                Fart vm->  P- 25-
  Lumbago, Sciatica, Paralysis from Arsenic, etc.,  vide " Firing."
                         MALARIA.
   The active Principle of Malaria.—Dr. Gardner, Professor of Chemis-
try in Hampden Sidney College, submits the following propositions :
   1st.  Sulphureted hydrogen gas exists in the stagnant waters and atmos-
phere of certain marshes.
   2d. The character  of malarious  regions is similar to that of those in
which sulphureted hydrogen is generated.
   3d. Certain agents have been supposed to give activity to the  exhala-
tions arising from marshes,, called malaria.
   4th.  The properties of malaria are fully reeognized by the profession.
   5th.  Sulphureted hydrogen is the active  agent in the production of
those forms of malarious fever met with on the sea coast, and the diseases
belonging to the same class found inland.
   He shows from  carefully instituted  experiments, that sulphureted hy-
drogen gas exists in the stagnant Avaters and atmosphere of certain marshes
where  malarious diseases are prevalent, and that certain agents give ac-
tivity to the exhalations arising from these marshes.  On account of the
difficulty of procuring a sufficient quantity of atmospheric air to detect the
presence of the gas, he prepared pure surfaces of silver and brought them
into contact  wdth the air and Avater in the suspected regions.   Silver is
one of the most delicate tests  for sulphur, and is not so liable to be attacked
by the agents which act upon lead, copper, etc., and so delicate a test of
sulphur is metallic silver, that it will detect it  in  a solution containing one
part in three millions of water ; and as a means of determining the amount
of sulphureted  hydrogen in mineral waters, it  is perhaps one of the best
tests which we possess.
  Dr. Gardner having prepared his  silver plates  (polished coins), exposed
them to the  action of the  air and water of marshes in different localities.
The polished coins were first perforated in a marked place so as to be re-
cognized, next cleaned and dried, then  carefully  weighed,  furnished with
strings, and lastly, suspended in  the places fixed upon.  Thirty different
coins Avere thus suspended  in different places ;  some were soon stained, and
others, as in the Buffalo River, were not  affected for Some time.   Ulti-
mately, hoAvever, most  of them Avere  more or  less  stained; and it was
found that the shallow waters of marshes contained the most, and rivers
the least  amount of gas, the coins  suspended in the latter  sometmes re-
quiring a month, and those suspended in the  air even more time for dis-
coloration,  while those  suspended over the stagnant marshes, would be
affected in a week or even less.
  Sulphureted  hydrogen has been discovered on the most deadly coasts.
» 
MANGANESE.
195
It is produced in marshes where sulphates exist either in the vegetable
matter, water, or soil.   The destruction of the sources of the gas, by the
exclusion of the sea, has annihilated  the fatal malaria of some of the Ita-
lian marshes and given health to the  pestiferous town of Viareggio.
  The agents which decompose sulphureted hydrogen are also inimical to
malaria.  Fire is of this number, for by means of it the gas is converted,
in the open air, into sulphurous acid  and wrater.  Chlorine destroys both
malaria and sulphureted  hydrogen,  the latter by combining Avith its  hy-
drogen and precipitating the inert element sulphur.  The value of chlorine
has been proved both in the American and British squadrons.
  The existence of trees, by decomposing the organic compound,  and ap-
propriating its water, is  calculated to destroy malaria.
  Its Aveight, and the readiness ivith Avhich Avater may be  separated from
it, preclude its rising to  any altitude in the atmosphere.
  It is produced in the autumnal months: because, then,  the amount of
moisture, the coolness of the nights over the temperature of the days, and
the fresh deposition of leaves, furnish the most abundant materials for the
formation of the organic compound.
  The poisonous effects of sulphureted hydrogen are too well  known to
require comment.  There  is no agent, which marshes evolve, that is so de-
structive to life.  Messrs. Thenard and Dupuytren killed birds in an atmos-
phere containing l-1500th  part of the gas.   Nysten found that  it  Avas ab-
sorbed at once by the blood.  Tavo or three cubic inches caused immedi-
ate death Avhen  injected into a vein, the cavity of the chest, or the cellu-
lar tissue of a dog.   The same authority, Avith Lebkuchner, and Chausier,
found that it was absorbed through the healthy skin, and produced danger-
ous effects.  The gas is  a narcotic poison, prostrating the nervous  system,
and destroying muscular  energy.  In small quantities it produces colic,
and internal congestion.
  Liebig states, that sulphureted hydrogen produces immediate decompo-
sition of the blood.                                     Part viii., p. 5.
  Malaria.—For producing malaria it appears to  be necessary that a sur-
face should be flooded and  soaked with water and then dried.  The quicker
the drying process, the  more virulent is the poison that is evolved.   For
this reason Dr. A. T. Thompson recommended that the floor of a sick room
should only be swept, never Avashed.  An invalid might as Avell sleep in a
swamp as in a  room the floor of  Avhich is frequently  washed.  Dr. Alison
has observed the more frequent  occurrence of croup on Saturday night,
the only day of the week  on Avhich the loAver  classes of Edinburgh Avash
their houses.                                       Part xxxiv., p.  18.

                             —»-♦-•—


                         MANGANESE.
  Pharmaceutical Preparations  of Manganese— Oxide of Manganese.—
This is a very good  preparation,  especially when obtained by the humid
method ; it should therefore be made only when it is Avanted for use.
The best mode of prescribing it is to add to an ounce of simple sirup, half
a drachm or a drachm of the hydrated oxide, with some oily emulsion, to
prevent the contact of the  air.
  Carbonate of Manganese is  best prepared by  dissolving  seventeen 
196
MANGANESE.
ounces of pure crystallized sulphate of manganese, and nineteen ounces of
carbonate of soda, in a sufficient  quantity of water.  Double decomposi-
tion takes place ;  one  ounce of sirup is added to every seventeen ounces
of the liquid, and the precipitate is alloAved to settle in a well-stopped bot-
tle.  The supernatant fluid is then decanted off; the precipitate is washed
with sugared water,  and  alloAved to drain on a cloth saturated Avith sim-
ple sirup;  it is then expressed,  mixed Avith ten  ounces  of honey, and
rapidly evaporated  (the  access of air being prevented) to a proper  con-
sistence for making pills.  The dose  is from four  to ten pills, each foin
grains, every day in chlorotic cases, Avhere  iron has not succeeded.   The
hyperoxidation of the carbonate of manganese may be prevented by
adding freshly prepared vegetable charcoal to the pills.
  Neutral Malate of Manganese.—This is  procured by treating carbo-
nate of manganese Avith malic acid.   It is an eligible preparation, as the
base of the salt is in  the form of protoxide, and the  acid is easily digested.
The dose is from  two to four grains, in pifls.
  The preparations of manganese have this immense advantage over those
of iron, that they  can be combined with vegetable  tonics and astringents,
namely, tannin, and the substances Avhich contain it, as gall-nuts,  rhatany,
catechu,  dragon's blood, kino, monesia, canella, and cinchona.  These can
all  be combined  with malate of manganese.   Sirup of malate  of man-
ganese consists of simple  sirup, §xvj.; malate of manganese, §j.; essence of
lemon, 3ij.: an ounce of sirup contains 29 grains of malate of manganese.
Pills of malate of manganese.—Malate of manganese, gr. xv.; powder of
cinchona, gr.  xv.;  honey,  a sufficient quantity to make  twenty  pills.
Lozenges of malate of manganese.—Malate of manganese, gj.; suo-ar,  §xj.;
mucilage of tragacanth, a sufficient quantity. To be formed into lozenges,
each 12 grains in  weight; each of which contains a  grain of the salt.
   Tartrate of Manganese is prepared in the same  Avay as the malate, tar-
taric acid being used. It may be  substituted for  the  malate in all the
above mentioned formulae;  and is  used to  prepare the following highly
tonic sirup.  Sirup of tolu, gxvij.; extract  of rhatany, 3iiss.; tartrate of
manganese, 3iiss.   Dose, from four to five spoonfuls daily.
  Phosphate of Manganese is best prepared by  dropping a solution of
phosphate of soda into a  solution  of sulphate of manganese.  The preoipi-
tate is collected after  filtration, dried, and preserved in  well-stopped bot-
tles.
  This preparation may be employed, like  the phosphate of iron, in can-
cerous affections.   Pills of phosphate of manganese.—Phosphate of man-
ganese, 5iss.; powder of cinchona, 3ss.; sirup of catechu, a sufficient quan-
tity.  To be divided into four grain pills.   Sirup of phosphate of man-
ganese.—Phosphate  of manganese 3ss.; sirup of tolu, gin., 3iij. • sirup of
cinchona, §v.; essence of lemon, 3iss.; powder of tragacanth, gr  x.   This
preparation must  be made quickly, and preserved in a well stopped bottle.
Lozenges of phosphate  of manganese.—Phosphate of manganese, §i.:
sugar, gxij.   Mix and divide in  twelve grain lozenges, each  containing
one grain of the phosphate.
                                  A    -----  _ may more conveniently
be prepared extemporaneously, by mixing together an ounce of iodide ol
potassium, and  the  same quantity of sulphate of manganese, perfectly 
MANGANESE.
197
dried, and in the state of poAvder.  It is then made into a pill-mass with
honey, and divided into pills, each containing four grains of the iodide;
Avhich should be kept in a well-stopped bottle.   The dose is at first one
pill daily, gradually increased  every three days, to six pills; the medicine
is then omitted for eight days, after which it is resumed again.   Sirup of
iodide of manganese is prepared  by adding concentrated hydriodic acid
to a drachm of perfectly pure hydrated  carbonate of manganese, until it
be entirely dissolved ;  then mixing Avith the solution 17 oz. of a sirup of
guaiacum and sarsaparilla.  Dose, from two to six spoonfuls daily.
  In  cases where iron  has not  succeeded, it is desirable not to make a
 sudden transition to manganese,  but to combine the two remedies as in
the following formula.  Pure crystallized sulphate of iron,  gxiij. ; pure sul-
phate of manganese, giiiss.; pure carbonate of soda, gxviiss.;  honey, |x.;
sirup as much  as may be sufficient  to  make a mass  to be divided into
four-grain pills.  Dose from two to  ten pills daily.   The insoluble pre-
parations of manganese should be first used, as  the carbonate, phosphate
and oxide: then  the  more  soluble   preparations, the  tartrate, malate,
 etc., may be employed.  The use of this medicine should not be perse-
 vered in so long  as that  of iron, as its preparations are more rapidly
 assimilated.  Manganese is not,  like iron, found  in the excrements of per-
 sons Avho take it—at least it is in very small quantity.
   In the depraved state of the blood which succeeds  intermittent fevers,
 manganese is useful;  it is the most certain  remedy for  preventing a re-
 turn of the attacks.  Leucophlegmasia and engorged spleen, of long dura-
 tion,  are rapidly reduced by  the  use of iodide  of manganese Avith sirup
 of cinchona.   The  preparations  of  manganese should  also be used in
 urethro-vaginal catarrh in chlorotic patients, and in chronic blennorrhcea,
 especially in individuals Aveakened ■ and rendered anaemic by  excess.  The
 salts of manganese  Avith which  Ave are acquainted, are powerfully astrin-
 gent, and may be used as external applications, in all cases where other
 astringents  are not indicated.    In  this respect they possess no  other
 peculiarity.                                           Part xx., p. 295.

   Use  of Manganese as an Adjuvant to Iron.—It  is  especially in dis-
 eases of the blood that ferro-manganic medicines  are 'useful.   They have
 a special action on the vascular  apparatus, on the formation of the blood,
 and on the circulating fluid itself.  They do not  act  merely as tonics or
 astringents; but are regenerators of the  blood.  They have succeeded
 admirably in anaemia followdng hemorrhage, operations, polypi, metrorrha-
 gia, etc.; also  in the  chlorosis  attending puberty, which is  a more com-
 mon disease than  is  generally supposed, and occurs even in  males.  M.
 Petrequin has also frequently found the combinations of iron  with manga-
 nese of benefit in the diseases of Avomen at  the critical  period.  He has
 often seen, in these subjects, metrorrhagia, accompanied with an aspect
 of the surface Avhich Avould lead  to  the suspicion  of organic uterine dis-
 ease ; the hemorrhage, however, was but a complication,  and  the patients,
 apparently in a hopeless state, have recovered under the use of ferro-man-
•ganic preparations, conjoined Avith tonics and ergotine.
   In  amenorrhcea  and dysmenorrhcea,  the patients  often  imagine that
 they require to be bled; but  care must generally be  taken not to comply
 with this request.
   These medicines  are no less efficacious  in the treatment of ancemia 
198
MANGANESE.
 resulting from  prolonged  intermittent fevers,  prolonged  suppuration,
 strumous, syphilitic, or cancerous affections, phthisis, etc.   I ills and the
 sirup of the iodide of manganese and iron are preferable in these cases.
   In the functional affections of the heart connected \yith chlorosis and
 anaemia, and which must not be  mistaken for organic disease, a combina-
 tion of iron and manganese with digitalis and  other  moderators of the
 heart's action is advantageous.   The  same remark applies to the func-
 tional disorders of the lungs, attending the same constitutional states. ^
   Disordered states of the nervous system are intimately connected with
 those of the blood.  M. Petrequin has found that the ferro-manganic pre-
 parations succeed well in these, even though uncomplicated with  chlorosis.
   He has also seen benefit from the use of iron wdth manganese in many
 cases of dyspepsia, gastralgia, and gastro-enteralgia.
   In nervous affections connected with exhaustion from venereal ex-
 cesses, onanism, rapid growth, etc.,  as well as  in leucorrhoea,  diabetes,
 etc., M. Petrequin has a high opinion of these medicines.
   It has  been observed that manganese not only preserves wrater, hut
 purifies that which has undergone change (Martin-Lauzer).
   M. Petrequin  commences by giving the powder of iron and manganese,
 wdth some vinous drink; he then administers two  pills daily, one before
 breakfast and one before  dinner, replacing them soon by the  lozenges.
 The sirups and chocolate complete  the treatment.  He  gives the medi-
 cines at meal-time. The sirup he gives  before  breakfast, in  doses of a
 teaspoonful;  and he  finds  it  useful  to administer directly after it some
 infusion of centaury, or of  chamomile flowers and orange.
   Large doses are unnecessary and useless.
   Preparations  of  Manganese and  Don.—M.  Burin-Dubuisson, of
 Lyons, who  prepared most  of the ferro-manganic combinations used by
 M. Petrequin, has published  an  interesting  brochure, from which the fol-
 loAving formulae are extracted :
   Powder for Effervescing Solution  of Manganese and Iron.—Take of
 coarsely powdered bicarbonate of soda, 20 parts; tartaric acid, 25 parts;
 powdered sugar, 53 parts; finely powdered sulphate of iron, 1\ parts;
 finely powdered sulphate of manganese,  £ part: mix carefully, and keep
 in well-stopped bottles.  A teaspoonful i% mixed with each glass of wine
 and water drank during meal time.
 _  Pills of Carbonate of Iron and Manganese.—Take  of pure crystal-
 lized sulphate of iron, 15 parts;  pure crystallized sulphate of manganese,
 25  parts; crystallized carbonate of soda,  120 parts; honey, 60 parts;
 water,  sufficient quantity.   Pills  of 20  centigrammes (3 grains) are made;
 they keep easily, without becoming oxidized, in well-closed vessels.  From
two to four are given  daily.
  Ferro-Manganic Chocolate— One part of carbonate  of iron and man-
 ganese is first mixed with four of sugar, and divided into large lozenges;
 of these 100 parts (grammes)  are mixed with 500  of chocolate  paste, in
the preparation of which 100 parts of sugar have been left out.   This will
make 800 lozenges, each of which contains about 3  centigrammes (nearly
half a grain) of carbonate of iron and manganese.   The chocolate decom-
poses the hydrated carbonate of manganese and iron of the saccharate into
hydrated sesqui-oxide of iron and manganese ; there is no metallic taste.
  Sirup of Lactate of Iron and Manganese.—Take of lactate of iron
and manganese, 4 parts; powdered sugar,  16  parts; rub together, aud 
MANIA.
199
 add of distilled water, 200 parts; dissolve rapidly, and pour into a matrass
 over a water-bath, containing 384 parts of broken sugar;  filter the solu-
 tion.  This sirup contains about 15  parts  of lactate of iron and 5 of lac-
 tate of manganese in 3,0£0 parts.  One or two spoonfuls are taken daily.
   Lozenges of "lactate of iron  and manganese are  made  by adding 20
 parts  of the  lactate to 400 of fine  sugar, with a sufficient quantity of
 water.  The mass will make 840 lozenges; of Avhich six or eight are  taken
 daily.
   Pills of Iodide of Iron and Manganese.—M. Buriu-Dubuisson forms a
 sohition  of iodide of iron  and  manganese, in the proportion of one part
• by weight to two  of water:  the proportion of the salts is about three of
 iodide of iron  to one of iodide of  manganese.  Six parts of this are
 mixed with 294  of simple sirup; of this, M. Petrequin gives one or two
 spoonfuls daily.                   *
   Pills of Iodide  of Iron and  Manganese.—Take of the  officinal  solu-
 tion  prepared by M. Burin-Dubuisson,  16 parts (grammes) ;  honey,  5
 parts; some absorbent powder, 9±  parts.  Divide into  100 pills.  The
 honey and the solution are first mixed, and evaporated at  first rapidly,
 then more sloAvly, to 10  parts.   Then add  the powder, and divide the
 mass into four parts, Avhich must be rolled  in poAvder of iron  reduced by
 hydrogen; each of these must  then  be divided on an iron plate into 25
 pills, and again rolled in the iron powder.   Finally, they are covered ivith
 a layer of tolu, according to M.  Blancard's process.
   All these preparations must be made very carefully.   M. Burin-Dubuis-
 son has  ascertained  that  the commercial  salts of manganese frequently
 contain  copper,  and even  arsenic; he hence insists on the necessity of
 calcining the sulphate of manganese  twice, or more frequently, at a dark
 red heat, and of" carefully testing the solution.         Part xxvii,,p. 331.

                              ---•-•-•---


                            MANIA.
   Antimony in Mania.—Dr. Sutherland states that  the  employment ot
 antimony in the treatment  of mania is of the highest value.   A fourth of
 a grain of the potassio-tartrate may be given every fourth hour, or at the
 commencement of the paroxysms of furor.   It is poAverful as a means of
 controlling the action of the heart and arteries.  In many eases in which
 it has been given, it has acted like  a  charm in  instantly subduing the ex-
 citement  and violence of the  patient;  and in some  cases an  alteration in
 the symptoms for the better has  been traced  from the commencement of
 its administration.                                     Part viii., p. 13.
   Digitalis in Mania and Epilepsy.— Vide "Epilepsy."
   Musk in Certain Cases of Delirium, Mania, etc.— Vide  " Delirium."
   Treatment  of Mania  and Nervous  Excitement.—[Dr.  J. Williams
strongly  recommends the use of  narcotics and other remedies calculated
to produce sleep, not only in order to  put  off, but  even to cure an attack
of mania. He observes that.]
   Some  of the mildest cases ivdiich  occur, Avhere there is  preternatural
excitement with  vigilantia, are those of persons  having over-fatigued the
menial powers by continued application, more especially if confined to 
200
MANIA.
one subject;  and the ill effects seem to be produced  more  frequently in
those whose hopes and fears are in addition adding to the excitement, as
is often noticed in junior barristers and students at our universities.
  Now, in such instances, if a young man  apply«early, the case is usually
cured very rapidly, sometimes  even  Avithin tAventy-four  hours; if passed
over for a feAv days, recovery is retarded, and if totally neglected, phreni-
tis or mania  by no  means unfrequently ensues.   In  such cases there is
a great action, which is but too frequently  mistaken for poAver; the pulse
is  quick,  perhaps 100, 120, or even  more, tongue  Avhite,  face flushed,
throbbing  and heat of the temples, rolling, sparkling, and injected  eye,
rapidity of speech,  and everything showing great excitement; noAV this
description is not sufficient to guide  us as  to the treatment, for all these
symptoms may depend  on excessive nervous irritation, but more attention
must be given to the pulse; if the pulse, in addition to being  quick, is
also full, hard, and bounding, and if  the skin is dry and hot, then the ab-
straction of blood, both general and local, will usually be necessary, and
often within an hour or two after depletion, the  skin  becomes moist, and
the patient falls asleep.  But Avhat I am the more anxious to  particularize,
is the opposite condition, where bleeding is unnecessary and  unsafe. Sup-
posing the pulse to  be quick, soft, and fluttering, weak or intermittent, the
skin  moist and clammy, and yet the  excitement just  as decided  as in the
other case, to bleed here  is most improper, and. many cases  of insanity
have arisen  from such practice.  The judicious administration of a nar-
cotic will frequently act as a charm,  and we have often found the follow-
ing prescription very useful:
  R  Tr.  hyoscyami, ntxxx.; tr. humuli, 3ij.;  camphorae, gr. v. ad x. aut
xv.; sir. auranti, 3ij-;  mist, camphorae, 3vj.'; M. et fiat haustus, h.  s. s.
  This has often caused calm and  refreshing  sleep; and the patient, who
has  previously passed  tAvo or three nights wdth great  restlessness and
watching, feels himself invigorated.
  A very efficient way of relieving  head symptoms, when dependent on
visceral congestion, more especially of the  liver, is applying leeches to the
rectum, and if considered necessary, subsequently placing the patient in a
warm  bath;  a  large quantity  of blood may be  lost in  this Avay without
producing much prostration.  Many cases  of insanity arise from extreme
irritability dependent on prostrated  power ; and to support this power by
good nutritious food, and  sometimes even with  brandy and wine, at  the
same time soothing the system by procuring refreshing sleep  at night by
morphia, will speedily evidence the advantages of such treatment
  The great  error originally was, allowing the power to sink; it is of the
greatest importance that these powers  should be supported—the nervous
excitation must be calmed.  In these cases, mistakes  are but too  fre-
quently made;  irritation is confounded with inflammation
  Purgatives may  procure sleep, by  diminishing vascular action, where
bleeding is.inadmissible   Narcotics,  when given in  insanity to procure
sleep, should be admmistered in full  doses
  Combining opium with camphor or  henbane, or digitalis, will  often be
very judicious.   With tartar emetic, calomel and opium in large doses will
Often calm the system when there is  great restlessness and fevlr, especially
if the  head be kept cool.   Opium  should never be omitted where insanity
has succeeded constant intoxication; and in those cases wherfthe count!
nance is exsanguined, with cold, clammy skin, it is especially indicated"and 
MANIA.                            201
is no less useful in that anaemial state of the brain where there is great ex-
haustion, in Avhatever way produced.
  Where there is constant vomiting, opium may be administered in an
effervescing draught.
  The infusion of opium with a bitter, as recommended by Dr. Paris, Avill
secure  the narcotic principle without interfering Avith the intestinal secre-
tions.
  It is  impossible to limit the extent to which opium may be required;
but in stating that a full dose is necessary, from tAvo to five grains may be
considered a large dose for most constitutions ; where habit has impaired
its effect, one, and even two drachms of solid opium ha\Te been taken in a
very limited period.   Pinel knew  120 grains of opium given in  one dose
to a patient suffering with cancer of the uterus ; and  I have seen a Avine-
glassful of laudanum taken at a  draught, and this has been repeated three
times daily for months—such cases, however, necessarily form the  excep-
tion.
  When opium has disagreed with a patient, a strong cup of coffee will
often remove the unpleasant effects.
  Administering an opiate in the form of enema renders it much milder,
and at the same time  secures its sedative and narcotic influence, without
producing that headache, sickness, and dryness of the  fauces, so often com-
plained of when opium is taken by the mouth.
   If narcotism be highly desirable, and  neither of these modes seem prac-
ticable, rubbing the abdomen wdth laudanum and oil Avill sometimes be
found effectual.  These narcotic frictions over the head wdll be often found
useful: even brushing the hair with a common hair brush for half an hour,
will frequently tranquillize a  nervous and irritable patient.  In some cases
it may be necessary to rub the scalp with liniments, or ointments, contain-
ing morphia, belladonna, veratria, or aconitine.
   Antiperiodics.—Insanity is  someAvhat periodical: and it should be
remembered, that,  when it is intermittent, it is not inflammatory, and in
such cases arsenic, tr. ferri sesquichloridi, the preparations  of  zinc, and
copper, Avith tonics, may  be often usefully prescribed.   Arsenic can be
strongly recommended in  these cases, and has been given with the greatest
advantage;  it appears to alter the sensibility and irritability of the brain.
 Quinine is  sometimes given wdth the same  intention; thus,  a case of in-
somnolence, was cured by giving gr. vj. of quinine at bed-time.
   The douche, the author most properly remarks, should never be resorted
to, except Avhen imperatively necessary; and the application of the ice-cap
will generally be found far more efficacious.
   Our object is to  keep the head cool—and not to make it suddenly cold.
                                                       Part xiii., p. 35.

   Periodic  Mania.—Large doses of  tincture of henbane (one or two
drachms), preceded by an active  purge, sometimes affords singular relief
in cases of periodic mania.  Vide Art.  " Testes."    Part xviii., p. 214.
   Cerebral Excitement—Mania.—In cases of violent cerebral excitement,
delirium tremens,  and mania, e\rerything points to the  necessity of  some
 sure, speedy,: and active mode of  allaying excitement and procuring sleep
—yet  the stomach is often highly irritable, or in such a state that it wdll
not absorb  medicines, or the patient evein refuses to SAvallow at all.  Of all
 cases, says  Mr. C.  Hunter, perhaps this is the one in which the value of 
202
MARASMUS.
the hypodermic injection of morphia is most clearly seen.  Inject one-third
to half a grain of acetate  of morphia beneath the subcutaneous cellular
tissue of any part of the  body, and  in a few minutes sleep will  be pro-
cured.                                                 Part xl., p. 279.
                            MARASMUS.
   Inspissated Ox-Gall—[Dr. Clay has also found that the inspissated gall
 has a remarkable tendency to counteract the constipating effects of opium,
 which drug not only checks  the secretion of bile, but almost all the other
 secretions of the body.  The administration of gall, therefore, if this fact
 be further corroborated, wdll be a valuable addition to our list of remedies
 when Ave are Avishful to give opium but dread its constipating .effects.  In
 the case alluded to by Dr. Clay, the patient was taking  large doses of the
 pil. scillae  comp.  c. opio  at bed-time, for  a  constantly  irritating,  dry,
 asthmatic cough: eight grains of the  inspissated  gall were  also given
 every night, Avhich completely counteracted those constipating effects of
 the opium which had previously existed.   Dr. Clay further states that,]
   In all cases of marasmus, AAdiether of children or in the atrophy of adults,
 I have in ox-gall a Aaluable  remedy.   In acidity of the stomach,  etc., of
 children, it is  of most decided,  effectual,  and  immediate  relief.   The
 curdled vomitings,  green motions, abdominal gripings, and restlessness
 immediately disappear, and a better state of general health is substituted ;
 in all such cases there was a decided action on the kidneys, increasing the
 secretion.   On looking at its effects upon children as just stated, particu-
 larly lvhilst at  the breast, living almost entirely on milk, the result is not
 different to what Ave might suppose when considering the experiments of
 Bagliva, LeAvis, etc.  " That it prevents milk from  turning sour, and dis-
 solves it when in a  state of coagulation ;" an antacid  preparation  is in-
 dicated, which is one of the peculiar properties of this remedy.  To  show
. its direct effect upon hardene(]faeces,  a child of sixteen  months old passed
 a very hard motion with very great difficulty, not having had one for three
 days.   I poured a  solution of ox-gall over it in a  vessel, immediately its
 chalky appearance was changed to a  more healthy bilious color, and re-
 duced to a pulpy mass in half an hour; from this fact, I will suppose a
 case (one  AAdiich  has frequently occurred in my practice), an  adult  with
 hardened  faeces  in the rectum, almost,  if not quite impossible, to  pass
 without assistance ;  under such circumstances,  what could afford a better
 prospect of relief than two or three ounces of recent gall diluted wdth as
 much water, used  as  an injection.   It  is needless to observe  I would
 pledge myself as to the  result, viz., an immediate softening of the  mass
 facilitating its propulsion.
   The preparation I have been in the  habit of giving, is simply the recent
 gall of the ox  slowly evaporated  to  the consistence of  an extract, and
 afterAvard made into pills.
   I prefer the simple extract made into pills' without  any addition; and
 i£ the gall be recent, it has very little smell, but an intensely bitter  taste.
 The gall-bladder of a moderate sized ox will afford as much extract as will
 make one hundred four gram pills, and is an article both cheap and easy to
 procure-                                                 Part vl, p. 68. 
MATIC0.
203
  Iodide of Potassium.—Recommended in certain cases of, by Lisfranc.
Vide " Iodic Preparations."
  Mal-assimilation  in Children.—Mr.  Henry,  surgeon  to Middlesex
Hospital, observes:
  Sometimes a pallid  cachectic emaciated child will in a few days gam
some pounds in weight, after the operation of a brisk  cathartic.   What
explanation can be offered of this fact ?  If the intestines of such children
be examined, the mucous absorbent surface -\vill be found to be covered
by a thick tenacious mucus, completely preventing assimilation  of the
chyle.  A brisk cathartic,  especially calomel, which may  be combined
with rhubarb and scammony, will wash this aAvay, and  the lacteals thus
be left free to  absorb the chyle, with which, for  the first time they come
in contact.                                         Part xxxix.,p. 264
                           M ATICO.
   Remarks on Matico.—When  applied  externally, Dr.  Jeffreys recom-
 mends the inner side of the leaf as most  powerful.  " To leech-bites, and
 bleeding from cuts  or other recent  Avounds, the inner  side of the leaf
 should be pressed upon the bleeding part for a few minutes,  Avhen  it will
 be found to possess not only an adhesive, but also a healing quality, not
 easily  separated by Avashing the hands  or other  ordinary  means."  In
 bleeding from the nose, the powdered herb used as snuff has been found
 a very convenient mode of applying it.  We subjoin the formulae for pre-
 paring an infusion, a decoction, and a tincture :
    Infusion of Matico.—Take  of matico-leaves, one  ounce.  Boiling
       water, one pint.  Macerate for  two hours, or until cold.  Dose—
       tAvo tablespoonfuls for an adult, twice or three times daily, or oftener,
       if the case is a severe one or the symptoms urgent.
    Decoction of Matico.—Take of matico-leaves, one ounce ;  Avater, one
       pint.  Boil for ten  or fifteen minutes, and strain.   Dose, the  same
       as that of the infusion.
    Tincture of Matico.—Take  of matico-leaves,  three  ounces ; Proof
       spirit  of Avine, one pint.  Digest  for fourteen days, in the  usual
       Avay, and filter for use.  Dose—from thirty to sixty drops in Avater.
   [By  the term inner surface, Dr. Jeffreys means the under and reticulated
surface of the leaf.]                                     Part x , p. lo5.
   Use  of Matico.—Dr. Ruschenberger says:   In enlarging a  burroAving
bubo, I divided the arteria ad cutem abdominis, which bled freely. I directed
that an attempt should be made to arrest the hemorrhage by lint and press-
ure.  After a trial of ten minutes, which totally failed, I directed moistened
matico leaves to be applied.   The assistant reported in a few minutes that
the matico exerted no influence, and proposed  to secure the bleeding ves-
sel by ligature.  I now visited the patient, who had lost six or eight ounces
of blood, and Avas still  bleeding.  After coarsely powdering some matico
leaves in the palm of my hand, I formed  the mass into a  paste AAdth cold
water; I then removed the clot, through wdiich the arterial blood formed
a passage of the size of a croAV-quill: the blood floAved per saltern, forming
a jet of at least three-fourths of an inch  high.   The  paste  Avas applied 
204                      MEASLES—MEDICINES.
lightly with the fingers, and filled the wound.  The surrounding skm was
immediately sponged clean ;  the hemorrhage ceased instantly, and  not a
single drop of blood flowed afterward.   No pressure was used, or dress-
ing applied.  In the first application the entire matico leaf had been simply
dipped in water and then applied.   It failed, as already stated.
  I exhibited  drachm  doses of finely poAvdered  matico in a case of pro-
fuse menorrhagia, repeated every two hours.   The flow ceased after the
third dose.  The powder was simply mixed in about tAvo ounces of wa-
ter.  The patient experienced no unpleasant effects from its use.
                                                    Part xvi., p. 319.
                            MEASLES.
  Iodide  of Potassium.—M. Ricord observes:  The iodide^ of potassium
possesses  the remarkable property of causing determination of diseased
action to the skin.  In cases of what may be termed " suppressed measles"
and " scarlatina" it  will frequently induce a healthful  reaction under the
most desperate circumstances.  One or two grains, according to the age
of the  patient, under tAvelve years, may be dissolved  in a quantity of su-
gared water, and  administered, repeatedly, as an ordinary drink, the whole
quantity being given in twenty-four hours, for  three or  four days.  In
measles, a small plaster to the chest assists the peculiar action of the iodine.
In scarlatina, the  compound tincture of iodine, diluted with three or four
parts of Avater, may be frequently applied, by means of a camel-hair brush,
to the front and sides of the throat and neck.   Milk is injurious during the
first two or three days, in cases either of measles or scarlatina. •
                                                       Part vii., p. 43.
  Turpentine in Collapse of.—In a case of collapse coming on in a boy three
and a half years old, during an attack of measles, forty minims of turpen-
tine, combined with two drachms  of ipecacuanha wine, proved a most val-
uable diffusible stimulant.                            Part xxvi., p. 325.
   Charcoal in Epidemics of Measles.—Dr. Wilson observes that through-
out the course of the epidemic (measles)  he has never observed diarrhoea
to be beneficially  critical, but otherwise, and has hence never hesitated to
check it, for Avhich purpose he has found no remedy so efficient as  the or-
dinary wood charcoal in powder, and when assiduously and promptly exhi-
bited, it has never failed, within his knoAvledge, to have a promptly benefi-
cial effect.                                           part xxxv.,;?. 26.
                           MEDICINES.
  Liquor Hydriodatis Arsenici et Hydrargyri.—Of this liquor hydrioda-
tis arseniciet hydrargyri, each drachm  measure consists of—water, one
drachm; protoxide of arsenic, one-eighth  of a  grain;  protoxide of mer-
cury,  one-fourth  of a grain : and  iodine (converted into hydriodic acid)
four-fifths of a grain.   The color of the solution is yellow, with a pale
tinge of green;, its taste is  slightly styptic.  It cannot be properly con-
joined  with tincture of opium, or with sulphate, muriate, or acetate of
morphia; for all these  produce immediate and  copious precipitates in it.
Hence, if opiates  are to be  used during the exhibition of this  arsenico- 
MEDICINES.
205
mercurial compound, they must be taken at different  periods of the day.
Tincture of ginger produces no bad effect.
  The following formula is proper:
    Liquoris hydriodatis arsenici et hydrargyri, 3ij.;  aquae destillatae,
      giiiss.; syrupi zingiberis, §ss.  Misce.  Divide  in haustus qua-
      tuor.  Sumatur unus mane nocteque.
 Thus, one-sixteenth of a grain of protoxide  mercury would be taken in each
dose, along Avith tAvo-fifths of a grain of iodine, which, being in the state of
combined  hydriodic acid, will be much  diminished in energy of medical
effect.  This is no doubt the proper dose to begin the exhibition of arse-
nic with, but it will  soon be necessary to increase it.   The  division into
draughts is here necessary;  first, to insure aocuracy in the dose, so essential
in the case of this active medicine; and, next, to prevent injury to the  in-
gredients by the use of a metallic  spoon as a measure—the  general Avay in
which, unfortunately, the dose of a medicine  is determined. Part iv., p. 67.
  New Classification of Medicines.—M. Mialhe, states that his researches
have led him to conclude that the greater number of substances intro-
duced into the economy act chemically either mediately or immediately  on
the serum of the blood, some  coagulating and others fluidifying its albu-
men.  In  the class  of coagulants are ranged all tonic, astringent, and
styptic agents, as most of the mineral acids, a great many of the metallic
salts, tannin, creasote, ergot of rye, etc.  The class of fluidificants comprises
all true  diuretics, with many alteratives and general  excitants, including
most of the vegetable acids, ammonia and its salts, the iodides, sulphurets,
and alkaline chlorides, etc.  But some medicines, which at first act as coag-
ulants, aftenvard become fluidifiant; this is the  case with bichloride of mer-
cury.  Others, which  have not  any perceptible  action on  the  albumen
when first introduced into the circulation,  become afterward coagulant in
a high degree.  Of this class is ergot of rye. This substance, accordingto
Mialhe, having after a time effected a thickening of the albumen, ultimately
produces  a  firm coagulation, " or  rather a process of organization more
than simple coagulation."  By this action  Mialhe explains all the knoAvn
effects of the ergot; and he supposes the agaric used for stopping bleeding,
the champignon, etc., to exert a similar coagulant agency. Part viii., p.  15.
  Action of different Medicines on the Mental Faculties.—All stimulants
and exciting medicines  increase  the quantity of blood that  is sent to the
brain.  If this quantity exceeds  a certain amount, then most of the facul-
ties of tiie mind become over-excited.   Nevertheless, the degrees of this
action is observed to vary a good deal in different cerebral organizations;
and it is also found that certain stimulants  exercise a  peculiar and charac-
teristic influence upon special or  individual  faculties.   Thus  ammonia and
its preparations, as well as  musk, castor, wine, and ether, unquestionably
enliven the imaginative  powers,  and thus serve  to render the mind more
fertile and creative.  The empyreumatic oils are apt to induce a tendency
to melancholy, and mental hallucinations. Phosphorus acts on the instinct
of propagation, and  increases  sexual  desire; hence, it  has often been
recommended in cases of impotence.   Iodine  seems  to have a somewhat
analogous influence ; but then it often  diminishes, at the same time,  the
energy of the intellectual powers.  Cantharides, it is well knoAvn, are a
direct stimulant of the sexual organs; while camphor tends to moderate
and lull the irritability of these parts. 
206
MEDICINES.
   Of the metals, arsenic has a tendency to induce lowness and depression
 of the spirits; while the preparations of gold  serve to elevate and excite
 them.  Mercury is exceeding apt to bring on a morbid sensibility, and an
 inaptitude for all active occupation.
  ' Of narcotics, opium is found to augment the erotic propensities, as well
 as the general powers of the intellect, but more especially the imagination.
 Those Avho take it in excess, are, it is well knoAvn, liable to priapism.   In
 smaller doses, it enlivens  the ideas and  induces various hallucinations, so
 that  it may be truly said that, during  the  stupor which it induces, the
 mind continues to  be aAvake while the body is asleep.   In  some  persons,
 opium excites inordinate  loquacity ;  Dr. Gregory says, that this  effect is
 observed more especially after the use of muriate of morphia.  He noticed
 this effect  in numerous patients, and he then tried the experiment  on him-
 self A\dth a similar result.  He felt, he  tells us, while under its operation,
 an invincible desire to speak, and possessed, moreover, an unusual fluency
 of language.  Hence  he recommends it to those who may be called upon
 to address any public assembly,  and who have not. sufficient confidence in
 their own  unassisted powers.
   Other narcotics are observed to act very differently on the brain and its
 faculties from opium.  Belladonna usually impairs the  intellectual  ener-
 gies ; hyoscyamus renders the person violent, impetuous, and ill-mannered.
 Conium  dulls and  deadens the  intellect;  and digitalis  is decidedly anti-
 aphrodisiac.  Hemp will often induce an  inextinguishable gaiety of spirits;
 it enters into the composition of the  intoxicating drink which the  Indians
 call bauss.  The use of the Amanita Muscaria is said to have inspired the
 Scandinavian warriors with a wild and ferocious courage.  Tobacco  acts
 in a very  similar manner with  opium, even in those  persons Avho  are
 accustomed to its use; almost all  smokers assert  that  it stimulates  the
 powers of the imagination.                               Part ix.,p. 82.
   Pleasant substitute for Epsom Salts as a Purgative.—M. Garot recom-
 mends the  following formula for  the preparation of tasteless purgative salts
 (citrate magnesia)—Carbonate of magnesia 15 parts ; citric acid 21 to 22 ;
 aromatic sirup  60 : water .300.   The citric acid is separately dissolved and
 added to the carbonate of magnesia diffused in Avater.   As thus prepared
 it is not effervescing;  but it is easily rendered  so  by adding only  half the
 quantity of acid,  and  reserving  the addition of the  other half, until the
 dose is taken.   The above proportions in grains would constitute a dose.
   Dr. Pereira long since suggested the use of citrate of magnesia in nearly
 similar proportions.   He found  that one scruple of crystallized citric acid
 saturated about fourteen grains of light or heavy  carbonate of magnesia.
                                                      Part xvi., p.  296.
  How to mask the bitter taste of Epsom Salts.—Mr. Combes has found
 that coffee  possesses the poAver of covering the nauseous taste of sulphate
 of magnesia ; we are told that—
  The folloAving is his formula for an ordinary dose of about an ounce of
the salt.  Sulphate of magnesia 30 parts ; ground coffee  10 ; Avater 700 or
 800.  Boil  them briskly together for tAvo minutes in an untinned vessel.
Remove from the fire, and having allowed the mixture to infuse for a few
minutes, strain it.   Sugar it and drink it hot or cold, according to taste.
To insure the  effect, the coffee  must be boiled Avith  the salt as directed
 above; adding the latter to  it afterward or to an infusion does not suffice. 
MEDICINES.
207
If the quantity of the sulphate be much increased, and it is desired noi
yet to add more coffee than the aboAe, that Avill suffice if, while the fluid
is boiling, a grain or two of tannin be added.           Part xvi., p. 296.
  How to  make Senna pleasant to the Taste.—The " Bulletin de Thera
peutique "  signalizes another use of coffee in disguising the taste of purga
tives for children ; MM, Guersant and Blache frequently employing it foi
this  purpose.   A  Aveak decotion of coffee is made,  to wdiich some milk
and  sugar are added, care having been  taken while  boiling the coffee, to
put in a few follicles of senna.   If it is ghren to the  children with a little
bread, they will generally  take it with  avidity.  This medicine  generally
acts freely upon children, and  thus administered does not induce the vio-
lent griping it sometimes  does in the adult.   (As a matter of taste, we
think the senna tea and prunes of our grandmothers is a more  delicious
preparation).                                         Part xvi., p. 297.
  Formula for  Frank's  Solution  of  Copaiba.—Balsam of   copaiba
two parts, liquor of potassa (P. L.) three parts, water seven parts; boil it.
for tAvo or  three minutes, put it in a separator, and alloAv it  to stand
for  five or six days, then draw it off from  the bottom, avoiding  the
upper stratum of oil.  To the clear liquid add one part, of SAveet spirits of
nitre, perfectly free from  acid, to which a few drops of liquor of potassa
has  been added, until it slightly browns turmeric paper; should it  turn
foul or milky a very little liquor of potassa will usually brighten it; if not,
place it in  a clean separator, for a few days, and draw it off from the bot-
tom as before, wdien it will be  perfectly brilliant without filtering.
                                                     Part xvi., p. 297.
   Medicines—To disguise the taste of.—We should prepare the mouth
before instead of after swalloAving nauseous medicines, in order that their
taste may not be perceived ; aromatic  substances chewed just before, as
orange or lemon peel, etc., effectually prevent castor  oil being tasted.
                                                    Part xxiv.,p. 349.
   Cod Liver. Oil—Mode of taking.—Let it be taken in a simple weak in-
fusion of-quassia. This would seem  the  more valuable as it is in itself a
mild and agreeable tonic  bitter, assisting in improving the tone of the
general system.                                     Part xxvi., p. 327.
  Administration of Phosphorus.—It has  long  been a desideratum in
medicine, says Dr. Glover, to find some safe  mode of administering phos-
phorus.  I have given  phosphorus lately in  the following ways; first, in
the form of a solution in chloroform ; secondly, in cod liver oil.   Chloro-
form dissolves about one-fourth of its weight of phosphorus ; and  the  solu-
tion is not inflammable.   I have given four or five minims of this  solution,
shaken up with a drachm of ether, in a wdneglassful  of port wine, twice a
day, with great benefit in rallying the forces of the patient, as I fancied
at least, in  cases of typhoid fever.  The solution in the oil is made by
cutting the phosphorus  into chips,' and  putting it into a bottle of the oil,
in the proportion of half a  grain to the ounce, then immersmg the bottle
in hot Avater, and with a little shaking,  solution is easily effected.   I think
I have seen this beneficial in strumous cases.          Part xxvii., p. 246.
   Wine—Medicinal Use of.—As a diuretic, Moselle may be as  useful as
gin or Avhisky.  It contains an  excess of salts, and may prove as energetic
as. and less heating than, the essential oil in gin or whisky. 
208
MEDICINES.
  In diabetes, use the claret wines, Avhich are free from sugar, and contain
much tannic acid.
  In dyspepsia and gout, use the Avine most  free from ultimate acidity
and least stimulating.  The best is the least acid claret wine ;  next, strong
or perfectly dry champagne.   Good  Mansanilla will  ansAver  the  purpose,
and' is much cheaper than  Amontillado  sherry.   But,  after all, weak
brandy and Avater, or some pure spirit and Avater, is most free  from acid
and. sugar,  and  answers best in dyspepsia.              Part xxx., p. 298.
  Phosphate of Lime.—Dr. Kuchenmeister  recommends the following
formula in  cases in which phosphate of lime is indicated: Calcis phosphat.,
3ij.; calcis carbon., 3j.; sacch. lactis, 3hj.  M. 5ss. bisterve in die.  In-
stead of the  milk  sugar, lactate of iron  may be substituted, if iron  be
required.   The  especial use  of the  carbonate of lime appears to be that
carbonic acid is liberated by the acid of the stomach, and  dissolves the
phosphate.  Lactic acid also  is formed from the sugar, or is  set free from
the lactate of iron, and dissolves the phosphate.  The most ready Avay  of
absorption  is, hoAvever, Avhen the phosphate is given Avith food, especially
with milk, Avith which it forms a soluble combination.  Part xxxi., p. 234.
  Employment of the Chlorate of Potash as a  Topical Application.—
The  chlorate Avas used in solution in  the proportion of frOm one drachm
and a half  to three drachms to one pint of water.  He (Mr. Moore) had
found it very useful in cases of indolent ulcer  and phagedena, in cleansing
cancerous sores, and as an application  to  the mucous membrane of the
nose, mouth, and tongue in cases of ozena and secondary ulceration.  The
author suggested that the beneficial  effects of the  application were proba-
bly due to its setting free oxygen, and proposed its use in some  forms of
dysentery, Avith affections of the loAver boAvel.
  Dr. Mayo said he believed Mr. Stanley used the same remedy (scruple
doses every four hours) for phagedenic syphilitic ulceration.
  Mr. C. Hawkins  generally combined it in  such cases with tincture of
myrrh.   The remedy aa as very useful in cases of  cancer, in removing the
odor, independently of its effect upon  the  sore itself.   Scruple  doses he
thought scarcely sufficient to administer internally.    Part'xxxi.,p. 310.
  Selections from Favorite Prescriptions.—Dr. Horace Green gives the
folloAving prescriptions, many of which are the result of years of collect-
ing from the most  experienced and  practical men who have visited the
hospitals of NeAV York:
  Narcotics and Sedatives.—The narcotic principle in medicine differs
from that of the sedative in this, that its primary action is in some degree
stimulant, whilst the sedative principle tends  directly to depress the vital
poAvers without inducing any previous excitement.   The ultimate action
of both narcotics and sedatives is to diminish the sensibility of the ner-
vous system, thereby allaying pain and promoting sleep.
  Among  the   direct sedatives  hydrocyanic acid  is  one  of the most
prompt and efficient.  Administered in appropriate doses, it tends direct-
ly to loAver the sensibility of the nervous system, to  diminish the fre-
quency of the pulse, and  to induce a sensation of quiet and  calmness
throughout the Avhole system.  Alone, or in conjunction Avith other reme-
dies, prussic acid constitutes one of our most valuable therapeutic agents.
  The following combinations Avith this remedy have been  proved to be
of great service in the treatment of disease: 
MEDICINES.
209
 ^ R Acidi  hydrocyanici, medicinalis,  gtt. lx.;  morphias sulph., gr.  iij.;
tinct. sar.guinariae, vini ipecacuanhse, aa. f. gss.; sir. pruni virginianse, vel
misturae amygdalae, f. §v.  M. fiat  mistura cujus  sumat  cochlearium  par-
vum bis terve in dje.
  We have found the above a most valuable  remedy in  the treatment of
chronic bronchial disease; in allaying the cough present in  tuberculosis,
and in all pulmonary catarrhal diseases,  unattended Avith fever.  As the
acid is apt to floa'. on the top of the liquid, the phial should be shaken on
the administration of each dose.
  R Acidi hydrocyanici, gtt. xl.; vini antimonii, f. gss.; syrupi  tolutan.,
f. |iss.; mucil.  acaciae,  f. gij.  M.  fiat  mistura, capiat cochl. parvum ter
quaterve die.
  This may be  used in the same cases as  the former, Avhen the  cough is
troublesome, and is attended Avith some degree of fever.
  As a remedy in the  treatment of hooping-cough,- hydrocyanic  acid sur-
passes in efficiency every other knoAvm general remedy.  We have  em-
ployed  it for many years in this  disease, and can fully substantiate the
declaration of  Dr.  Hamilton Roe, that " Hydrocyanic acid of Scheele's
strength will, if exhibited as soon  as the  whoop is  heard, effect  a cure in
almost  every case  of simple hooping-cough."  If the disease  has been
going on for many weeks,  its effects are not so immediately  felt, but
nevertheless  it  will cure in most instances.
  The following formula Ave are accustomed to employ:
  R Acidi hydrocyanici, medicinalis, gtt.  xxv.; vini ipecacuanhas, f.  3ij.:
syr. tolutan., f. §j.; aquae destiUatae, f. §iij.   Fiat mistura, cujus  sumatur
cochl. parv. quarta quaque hora.
  It is important that its use be entered upon as soon as the presence of
the  characteristic whoop determines  the nature of the disease.  If the
breathing is  oppressed, or the symptoms present indicate the existence of
bronchial inflammation, the administration of the sedative should be pre-
ceded by the exhibition of an emetic, and perhaps by the application of a
few leeches to  the chest.
  If administered  too  freely, the acid Avill produce a greatly depressing
effect on the vital powers.   Should much  debility, therefore, occur during
its  employment, the  remedy should be omitted, and mild  tonics, Avith  a
more stimulating expectorant, be  exhibited  for a few days, when the use
of the hydrocyanic acid may be renewed.
  " The dose of hydrocyanic acid  for an infant," says Dr. Roe, " is about
three-quarters of a minim of Scheele's  strength, gradually increased  to  a
minim, Avhich may be given every  fourth hour; for a child of three years
of age, about one minim, gradually increased, if necessary, to a minim and
a half every  fourth hour; for children  of ten or tAvelve years  of age,  a
minim and a  half, increased to tA\ro  minims, every fourth  hour.  It is safer
to give this medicine  in  small doses  at very short  intervals, than to run
any risk  of producing too great  depression by a  large  dose.   The fre-
quency of its exhibition  must depend upon  the strength of the patient
and the severity of the attack.  The dose should  be  repeated when the
effects begin  to subside, which in mild cases generally happens in three or
four hours ; but when much fever is present, its influence is felt but a very
short time;  under  such circumstances, a larger quantity may be given
and at shorter  intervals, without any apprehension of danger, so long as
the fever lasts."
  vol.  11.—14 
210
MEDICINES.
  R Acidi hydrocyanici, medicinalis, f. 3j.;  liquor potassa?, f. |ss.; infos.
calumbae, f. §ij.; misturae amygdal.,  f. §iv.  Misce.  capiat  cochl. minim.
ter  die.
  In cases of long-continued chronic bronchitis, the physician occasionally
finds this disease complicated Avith a peculiar irritable condition of the
gastric mucous membrane, manifested by tenderness  of the epigastrium, a
red tongue, frequent headache, and a feverish condition of the  system.
In such cases where the inflammation has extended  to the  mucous mem-
brane  of the  stomach, producing  this not  uncommon form of broncho-
gastritis, the exhibition of the above combination Avith the hydrocyanic
acid, the alkali, and the bitter vegetable infusion, will exert  a prompt and
a decidedly happy influence on this diseased action.
  Combined with  the  extract  of belladonna,  hydrocyanic  acid has also
been found very useful in the treatment of gastralgia and in " irritable
gastric dyspepsia."
  The folloAving mixture prepared, and a teaspoonful of the medicine ad-
ministered three or four times daily in these affections, will, by acting on
the nerves of the stomach, greatly' diminish their irritability.
  R Extract  belladonnas, gr. x.; acidi hydrocyanici, medicinalis, gtt. lx.;
tinct. calumbae, sir. simp., aa. f. 5§j.; aquas destillatas,  f.  §ij.  Misce.
  The above  combination has likewise been  employed with great benefit
in the treatment of spasmodic asthma.
  These, then, are some of the useful combinations of one of our  most
important therapeutic agents; and we can assure the practical physician
that not only in these affections, to Avhich allusions have been made, but in
the treatment of many other diseases, he will find these remedies invalu-
able aids in controlling  diseased action.
  The anhydrous, or pure hydrocyanic acid, which consists of one equiv.
of cyanogen, and one equiv.  of hydrogen, is of a nature so exceedingly
poisonous, that it cannot be employed with safety in  medicine.  The medi-
cinal acid, which is the preparation that  should always be directed to be
used in our prescriptions, contains only 2.5 per cent.  (United States Phar-
macopoeia) of the  pure  acid.  That of the Apothecaries' Hall, London,
contains 3.2 per cent.;  whilst the medicinal acid of the French Apothe-
caries is nearly equal to that of the United States Pharmacopoeia—namely
2.4  per cent, of the pure acid of Gay Lussac.
  As the strength of the different medicinal acids cannot be depended on
as being always of the same uniform power, it has been proposed that the
cyanide of potassium be substituted in medicine for  the hydrocyanic acid.
  R Cyanidi potassii, gr. xxij.; alcohol, officinalis, f. 3xj.  Misce.
  This preparation  of  cyanogen, which possesses  the same medicinal
qualities, and is of the same strength with the hydrocyanic acid, is greatly
preferred by  many practitioners as a therapeutic agent, inasmuch as it can
be depended on as being always of a uniform strength.  It may  be used
in the same doses and under  the  same circumstances in Avhich the hydro-
cyanic acid is administered.
  As palliatives in the  treatment of all  forms of neuralgia, the narcotics
and sedatives are very generally resorted to by practitioners, especially
during the paroxysms  of the disease.   When  appropriately combined,
their efficacy in these affections is more prompt and  decided than when
separately administered.
  R Extracti hyoscyami, 3ss.;  morphiae  sulphatis, gr. iij.;  strycnniae, 
MEDICINES.
211
gr.  ij.;  capsici pub;'., 3ss.;  zinci sulphatis, gr. xv.  M.   Fiat  massa, in
pilulae xxx. dividenda; capiat unam, ter quaterve in die.
  In neuralgia, unattended by organic lesions, the above pills, exhibited
every sixth or fourth  hour, according *to  circumstances, will be found to
be an excellent remedy.  They have proved especially serviceable in that
form of neuralgia in  which the division  of the fifth  pair of nerves is so
frequently involved.   Not only in facial neuralgia, but in  all cases where
the disease has been caused by malaria, this combination may be adminis-
tered with confidence that the result wdll be favorable.  The valerianate
of iron  conjoined with the extract of hyoscyamus is an excellent anti-
spasmodic and tonic, and may be employed Avith great advantage for the
treatment of chorea and all the neuralgic affections of anazmic and de-
bilitated females.
  R. Extracti hyoscyami, 3ss.; ferri valerianatis, 3j-   Fiat  massa,  et in
pilulas triginta dividendas: quarum date unam ter in die.
  The valerianate of iron and the valerianate of zinc are two highly valuable
remedies, and were the therapeutic powers of these medicines  better un-
derstood by the profession, they would be  much more extensively employed
than they now are for the treatment of disease.  The  valerianate of zinc,
Dr. Neligan says, " is one of the most  valuable modern  additions to the
Materia Medica."
  R. Extracti hyoscyami, Biss.; zinci valerianatis, 9j.   Fiant pilulas xxx.
Capiat unam bis terve in die.
  The above pill is a valuable remedy in the treatment of facial neuralgia,
and, indeed, is equally serviceable in all the nervous and neuralgic  affec-
tions for which the valerianate of iron has been advised.
  R. Extracti belladonnas, gr. viij.; camphori pulv., 3j-; quiniae disulphatis,
By.  Misce; Fiant pilulas triginti.
  These pills are very effective in the treatment of dysmenorrhea.   One
pill may be exhibited every hour or two hours till the pain ceases.   In fe-
males of a nervous temperament, When painful menstruation  occurs, inde-
pendent of organic lesions, these pills, administered as above directed, sel-
dom fail of affording relief.  In those cases of dysmenorrhoea where a tonic
is not  particularly indicated, the  folloAving are more appropriate,  and
are equally efficacious.
  R. Extracti belladonnas, gr. viij.; ipecacuanhas pulv., gr. x.; zinci sulpha-
tis, 3ss.   Misce;  Fiant pilulae xxx., quarum capiat unam quaque tiora, do-
nee leniatur dolor.
  The following pills are highly recommended by an intelligent and experi
enced practitioner in the treatment  of leucorrhoea occurring in anasmic and
nervous females:
  R. Extracti hyoscyami, 5j.;  argenti nitratis, gr. x.; cantharidis  pulv.,
gr.  xij.; quiniae disulphatis, Bij.  Fiant pilulas xl.  Sumat unam mane et
nocte.
  The same physician advises the subjoined formula as a combination that
may be  employed with great advantage as a diuretic and alterative  in the
treatment of cellidar dropsy.
  R. Extracti conii, 3j.;  cantharidis pul.,  9y.; hydrarg. submur.,  3ss.;
ipecacuanhas  pulv., Bj.  Misce; Fiat massa;  in pilulas xl. dividenda, cu-
jus capiat unam ter  quaterve in die.
  A combination of the extract of belladonna wdth quinine  has been em-
ployed  very efficaciously in the treatment of gastralgia. 
212                           MEDICINES.

  R  Extracti belladonnas, Bss.; quinias disulphatis, 3j.  M. Fiant pilulas
xxx.  Sumat unam ter in die.
  In that variety of gastralgia which is not unfrequently occurring in the
course of chronic gastritis, we have derived the greatest benefit from the
employment of the folloAving pills.
  R  Extracti  hyoscyami, 3j.; argenti nitratis, gr. x.; bismuthi subnitra-
tis, 3iss.  Fiant pilulas xl.: quarum sumatur una mane ac nocte.
  The nitrate of silver combined  wdth some one of the sedative extracts
may be employed advantageously in the treatment of almost all chronic
gastric affections.  In cases of obstinate, chronic gastritis, or long continued
dyspepsia, we have found the folloAving pills more efficacious than any other
single remedy.  They should  be continued for several weeks:
  R  Extracti  conii,  vel lupuli, 3j.;  argenti  nitratis, gr. x.; capsici pulv.,
quinias  disulphatis, aa. Bij-  Misce; Fiat massa, in pilulas xl.  dividenda.
Capiat unam bis terve in die.
  There is a troublesome and often an obstinate form of gastric  irritabi-
lity, denominated by the French  estomac glaireuse, in Avhich the patient
occasionally ejects by eructation,  a tasteless, wratery fluid, and Avhich is
accompanied often by a severe burning pain in the epigastric region.  This
variety of the disease is arrested Avith great certainty by the exhibition of
either the preceding, or the following pills.
   # Extracti lupulinas,  5j.; argenti nitratis, gr. x.; bismuthi subnitratis,
3iss.;  quiniae  disulphatis, Bij.  Fiant  pilulas xl.; cujus sumatur unam bis
terve in die.
   In aU forms of chronic disease,  attended with acute pain,  as well as in
all painful nervous affections, in the treatment of which, for any cause, full
doses  of opium  are contra-indicated, the  foUoAving combination may be
administered  with great advantage :
   R Extracti hyoscyami, gr. xv.; extracti stramonii, gr.  iv.; extracti hu-
muli, 3j-; morph. sulphatis, gr. iss.  Misce.  Divide in pilulas xxx.; qua-
rum capiat unam  omni semihora,  donee leniatur dolor.
   Of the therapeutic  effects of muriate  of ammonia, when internally ad-
ministered, but little is known, as in this manner it is but rarely employed
in this country.   With the German physicians it has obtained a high repu-
tation as a good alterative, and a promoter of healthy secretions in chronic
diseases of the mucous  and serous tissues.  It not only promotes the  mu-
cous secretions, says Dr. Sunderlin, but the cutaneous exhalations, and im-
proves also nutrition and assimilation.  Combined Avith a sedative and  nar-
cotic, we have found it highly valuable in  allaying irritation and in pro-
moting expectoration, in the early stage of phthisis.
   R Ammon. muriatis, 3 ss.:  opii pulv., gr. x.; digitalis pulv., scillas pulv.,
aa. Bj-  Misce.   Divide in pilulas triginti.  Sumat unam quaque sexta
hora.
   Sleeplessness occurring in hypochondria, hysteria, and  indeed in all ner-
vous affections, may le overcome with great certainty by the administra-
tion of the following pills:
   R Assafostidas, 3j.; morphias sulphatis, gr. iij.   M. Fiant pilulas triginti,
quarum exhibe unam vel duas hora decubitus.
   The above pills—two to four exhibited daily—are very efficacious in ar-
resting the dry cough which is occasionally consequent on disordered men-
 struation in nervous females.
   Tonics and Stimulants.—The following combination of a chalybeate 
MEDICINES.
213
with a stimulant and a sedative has, for many years in our hands, proved
a most  valuable  tonic, particularly wdien administered  during convales-
cence from disease, and in all debilitated and anmmic cases.
  R  Extracti  conii, 3y.; sesqui-oxydi ferri,  3iij.;  tinct. calumbae,  |iss.;
sir. toluta. |ss.; ol. gaultherias, gtt. x.; aquas  fontanas, §ij.  Fiat mistura;
cujus sumat coch. par v. mane ac nocte.
  Or the folloAving may be substituted :
  R  Sesqui-oxydi ferri, extracti taraxaci, aa. §ss.; vini Xeris, §vj.;  tinct.
gaultherias, gss.; aquas font., §iv.  M.  capiat coch. magn.  bis in die.
  The following is a very excellent tonic, and may be exhibited whenever
any of the ferruginous preparations are indicated.
  R  Ferri citratis,  3ij-; sir. citri, vel aurantiae,  aquas menth. pip., aa. §ij.;
aquas purae, |iv.   M. exhibe cochlearium purum ter  quaterve in die.
  In young ancemic females, wdth indications of a  chlorotic condition of
the system ; and  also  in children of  strumous habits, the phosphate of
iron,  exhibited in  combination with  the  sulphate  of quinine, is a thera-
peutic agent of great value.
   R Ferri phosphatis, 3j.; quinas  disulphatis, gr. xij.   M.  Fiant pulv.
xij., quarum capiat unam bis terve in die.
   A physician of great experience,  and  celebrated for his successful treat-
ment of diseases of females, has employed for many years, and Avith  much
advantage, the subjoined combination of  an  alterative and a tonic in the
management of certain forms of uterine diseases.
   R  Sirup, ferri iodidi, §j.; tinct.  actasae racemosas,  3v.; tinct. rad. ac-
 coniti, 3iij.  Fiat mist, cujus cap. gtt. xx. ter in die.
   We have seen engorgement of the os tineas and non-malignant indura-
 tion of this organ disappear rapidly under the persevering internal admi-
 nistration of the above tonic ; while  at the same time, the following oint-
 ment Avas applied once a week, by means of friction with the finger, to the
indurated os.
   R Extracti hyoscyami, extracti conii, extracti belladonnas, aa. p. e.
   To each ounce of which mixture add one drachm of iodide of  potassa—
mix thoroughly, and apply as above.
   R Ferri sulphatis, 3\j-; potassae iodidi, 3iss'.; tinct. calumbae, sirup zin-
ziberis, aa. §ij.  Fiat mist, capiat coch. parv. ter in die.
   This mixture may be  exhibited Avith  advantage whenever we desire to
promote the absorption of glandular enlargements, and in all cases where
a tonic and an alterative are indicated.
  Not unfrequently the  general  practitioner will encounter cases of ob-
stinate intermittent;  and of uncontrollable  neuralgic affections^ which
will  resist,  altogether, the effects of the ordinary antispasmodics,  when
singly administered.  In such  instances,  we have  often succeeded per-
fectly, by the combination and exhibition of a vegetable and mineral tonic
—as the following:
  R Liquor potassae arsenitis, f. 5iss.;  tinct. cinchonas,  giij.; sir.  auran-
tiae, §j.  M.  Hujus mist., sumat cochl. min. bis terve in  die.
  During the last two years, intermittent fevers have occurred more fre-
quently, in some parts of this city, and in the vicinity of  the city, than for
many previous years.  In  some  of  these cases, where the disease has
proved obstinate, not  yielding  to large doses of quinine, long continued,
we have found it to be promptly arrested by the administration of  a tea-
spoonful of the following mixture, twice or  three  times a day—the last 
214                          MEDICINES.

dose being administered a short time before the period of the anticipated
paroxysm.
  R Quinas sulp. 3j.;  liquor  potassae arsenitis, f. 3ij.;  acidi sulph. aro-
mat., f. 3j.; tinct. cinch, co., sir. zingiberis, aa. §ij.
  When the preparations of arsenic are employed, it is safest to give the
medicine  after a meal.   When thus  exhibited, larger, or more effectual
doses may be given Avith more safety than Avhen  taken fasting. ' Should,
however, gastric  irritation arise, under its use, or swelling or stiffness of
the eyelids occur, the medicine should be immediately discontinued. _
  Should it from any cause  be desirable to administer these remedies in
the form of a pill, we may employ the following formula:
  P Acidi  arseniosi,  gr. ij.;  quinas disulphatis,  3j-;  conserv. rosas, 3ss.
Misce  optime, et fiat massa, in pilulas xxx. dividenda; sumat unam bis
quotidie.
  We have had recently much experience in the  use of the different pre-
parations of manganese,  and have become fully satisfied, that this mineral
tonic, in its  different combinations, Avill prove a most valuable addition to
our pharmaceutic preparations.
  The most important preparations of manganese for pharmaceutical pur-
poses,  are the phosphate, the malate, and the iodide of manganese.
  After the subjoined formula, we have  administered, in  tuberculosis, to
a large number of patients,  the phosphate of manganese, with most favor-
able results.
  $ Manganesii  phosphatis, 3y. ; tinct. cinchonas, §iij.; sir.  sarsas, §iv.;
mucil. acacias, |j.; ol. gaultherias, gtt.  xx.   Fiat mistura, cujus sumantur
coch. duo vel tria minima bis terve in die.
  Or we may administer, under similar circumstances,  and to the same
amount, the manganese combined with some of the preparations of iron ;
as in the folloAving:
  R Manganesii phosphatis, 3iss.; ferri phosphatis,  3iij.;  tinct.  calumbas
|ij.: sir. tolutan. §iv.;  ess. gaultherias, f. 3j.
  These mixtures should be kept in well-closed bottles, and as the manga-
nese is not altogether soluble,  the medicine should be shaken before being
administered.
  The malate of  manganese is considered, by some practitioners,  a more
eligible preparation, inasmuch as  it is quite soluble, and the base of the
salt is in the form of proto-oxide, the acid being easily digested.
  R Manganesii malat., 3ij.; tinct  cinch., |ij.; sir. simp. giv.; ess. limon.
f. 3j.   Fiat  mistura, date coch, parv. mane ac nocte.
  The iodide of manganese is  an efficient remedy in the treatment of glan-
dularenlargements, especially those of the neck, and of the spleen, in con-
stitutional syphilis, and in the anemia arising from scrofula and from can-
cerous affections.
  It may be administered in the form of pills;  or as a mixture in  the fol-
lowing formula:
  R Manganesii iodid., 3y.; tinct. cardamom., %y;  sir.  sarsas, §v. Misce.
Sumat coch. parv. bis terve  in die.
  M. Petrequin has found manganese and iron, especially useful in blood
diseases, such as the chloro-anasmia, after hemorrhage, operations, metror
rhagia, etc.  In the  chlorosis which appears  about puberty, in  that also
which occurs at the  critical  period of Avoman,  especially when  profuse
hemorrhage prevails, and in the depraved state of the blood, which sue- 
MEDICINES.
215
 ceeds intermittent fe\rers, M. Petrequin has found the ferro-manganese
 preparations of remarkable efficacy.                  Part xxxiL, p. 271.
   Phosphate of Lime.—This substance may be rendered much more so-
 luble, and therefore useful, by uniting it with carbonate of lime in the fol-
 lowing proportions: phosphate  of lime, 4 grammes; carbonate of lime, 8
 grammes; sugar of milk 12 grammes.                Part xxxiii., p. 284,
   Muriate of Ammonia, internally.—It may be given in many chronic
 inflammatory diseases, as chronic bronchitis, enlargement of the lymphatic
 glands, chronic skin diseases, and chronic rheumatism.  Dr. Watson testi-
 fies  to its efficacy in certain forms of facial  neuralgia, nervous headache,
 toothache, and sciatica.  Its action is sometimes remarkably beneficial;
 when the secretion from the  pulmonary mucous membrane is tough and
 tenacious, it  speedily becomes  altered  in  quality and consistence.   In
 chronic periosteal inflammation, having a syphilitic origin, it  seldom fails
 to give  relief.  In indolent bubo  a strong solution (3y. to §j.) may  be
 kept constantly applied, and five to ten grains  may be given internally
 three or four  times a day.   In neuralgic affections, Dr. Ebden has given
 from 25 to 30 grains for  a dose.                      Part xxxiiL, p. 288.
   Bichromate of Potash for Preservative Solutions.—This  salt, in pro-
 portion of about four grains to an ounce of water, constitutes a solution
 quite equal to alcohol in its antiseptic powers, and  which costs only about
 twopence a  gallon.  It  will deprive a specimen already partially decom-
 posed, of all odor, and preserve it for any length of time.  As, instead  of
 hardening, it a  little softens tissues immersed  in it, it has a great advan-
 tage over both alcohol and Goadby's solution, for all objects which are  in-
 tended to be reexamined, especially if the microscope  is  to be  used.
 Preparations long kept in it become of a light oliA-e green color externally,
 but retain most  perfectly their  natural  appearance at a little depth from
 the  surface.   The change of color in the case of red structures  such as
 muscle, may be prevented by the addition of a little nitrate of potash.   In
 the  same Avay, if it is desired, the softening may be prevented by the use
 of alum.  Unless in combination Avith both the two last-named ingredients,
 it is scarcely adapted for a permanent solution.   The great advantage over
 all others is,  in respect to specimens intended to be kept for limited periods,
 either for private dissection or for exhibition. Those intended for the micro- '
 scope are far less spoiled by it than by any other Avhich I am acquainted
 with.  The only odor which it gives to  specimens is a very  peculiar one,
 resembling that of new  kid gloves.   The cheapness and  efficacy of this
 salt  will, I think, make it quite a boon to pathologists.
                                                   Part xxxiiL, p. 292.
   Chlorodyne.—This agent  given internally in  doses of about twelve mi-
 nims in a  little A\;ater is a most pleasing anodyne.  Its effects last for seve-,
 ral days.  It is particularly  useful where  opium cannot be tolerated.
                                                  Part xxxvi., p. 299.
   Strychnia, Uses of.—In cases of organic lesion of the nervous centres,
 epilepsy, chorea, paralysis agitans, it is useless or even  injurious.  It is in
 cases of functional derangement where the nervous powers are Avanting in
 vigor, where lassitude is  a prominent symptom, as in dyspepsia of literary
 men and dehcate females;  chlorosis is perhaps  the  typical disease  where
it is  of most  use ; if you substitute strychnia for quina in the  usual pre- 
216
MEDICINES.
Bcription of quinine and iron in this disease, the effects will be truly aston-
ishing.  There is a double citrate of ironand  strychnia analogous to the
well-known preparation of iron and quina ; this is  particularly applicable;
it contains one grain of strychnia to every hundred of the salt.   Another
convenient way of giving strychnia is to dissolve a grain in two minims of
sulphuric acid, and add this to thirty ounces of  water in which one drachm
of ammonio-citrate of iron has been dissolved; the Avhole may be then
placed in a gazogene and  charged Avith carbonic acid.  Give  a Avine-glass
full of this daily, immediately bjsfore lunch.  A very remarkable  case of
the efficacy of the above is related by Dr. De Ricci.  Part xxxvii., p. 49.

  Pepsine.— This must not be expected to digest a large quantity of meat
at once.  A patient taking it must not eat more meat than a mutton chop
at once.  Pepsine  loses its poAver in  a week or ten days, by Avhich time
either the stomach has regained its tone, or some  other remedy must be
employed.   About fifteen grains  of Boudault's pepsine must  be given
about twice a-day, before meals, and  spread between two thin slices of
bread like a sandAvich.                              Part xxxvii., p.  78.

  Prescriptions containing  Henbane  or  Belladonna.—Never  in  any
prescription combine any  caustic-fixed alkali Avith tincture or extract of
henbane, as the latter is  thereby completely  neutralized.  Where it is
desirable to administer an alkaline remedy with henbane, order  either a
carbonate  or bicarbonate, ivhich  are quite as efficacious.  The same pre-
cautions apply to belladonna and stramonium.      Part xxxvii., p. 258.

  Cocoa-Nut Oil Ointments.—The cocoa-nut oil is a more eligible body for
the formation of ointments than lard, keeping much better, not staining the
linen, and admitting of more complete absorption.  To render the oil of
commerce fit for pharmaceutical employment, it is in general sufficient to
liquefy it at a moderate temperature, and strain it .through linen.  But if
it retains its peculiar odor too strongly, and is of too  yellow a  color, it
may be purified by digesting it  for  some hours in a water-bath, *with
some coarsely poAvdered vegetable charcoal, and  filtering it  Avhile warm
through paper.   The  folloAving are  some of the formulas that have been
tried with success:
  R Iod. pot. Jj., ol. cocos. §j.
  R Ext. bellad. Bj-, ol. coc. 3iij.
  R Veratrini, gr. iij., ol.  coc. 3iij.
  R Sulph. quin. Bj, ol. coc. §j., ol. rosar. gtt. x. (very useful  in pityriasis
capitis.)
  R Chlorof., ol. coc, aa.  |j. (of great service  in neuralgic and rheumatic
pains, rendering the chloroform more fixed, and its action more durable.)
  R 01. terebinth., ol.  coc, aa. |j.
  R Hydr. ox. rub. gr. iv., ol. coc. §ij.              Part xxxvii., p. 265.

  Citrate of Jron and Strychnia.—-The citrate of iron and strychnia is a
preparation Avhich has lately been used with  considerable success at the
Royal Free Hospital, by Dr. O'Connor.  The dose is about three grains
three times a day, and taken immediately after a  meal.  In cases of dys-
pepsia of an atonic character, in atonic affections of the uterus, as an em-
menagogue, and in chorea, it has chiefly proved useful.
                                                 Part xxxvii., p. 272, 
MEDICINES.
217
  Glonoinc—Nitrate of Oxide of Glycil—If nitric  and sulphuric acids
be added  to  glycerine, and the whole be kept at a freezing temperature,
a compound  is obtained, which is a  nitrate  of oxide of  glycyl;  this^ is
possessed of the most powerful properties. For use, one drop diluted with
ninety-nine of rectified spirit is the proper quantity, so energetic are its
properties ; of this, give a  quarter of a drop in a dessertspoonful of Avater.
In all spasmodic and painful affections, this will give instant relief; it has
not been tried in tetanus and hydrophobia.  If the pain or spasm be not
simply neuralgic, but dependent on  some deeper seated cause, it will of
course only act as a palliative. Great  caution must be exhibited in its use.
                                                  Part xxxvii., p. 295.

   Opium and Sulphate  of Q'linine—Antagonistic Action.—M. Gubler,
in a paper read before the  Societe Medical e des Hopitaux, has attempted
to establish a direct  antagonistic  action betAveen the sulphate of quinine
and opium.   He states, that while opium causes  cerebral congestion, qui-
nine possesses a diametrically opposite influence.
  In support of his theory, the author relates a case in Avhich 30 grains of
quinine and  5 grains of extract  of  opium simultaneously administered,
failed  to produce  either the characteristic intoxication of  quinine or the
somnolency to be expected from opium.            Part  xxxviii., p. 248.


   Imitation of Natural Spas.—Dr.' Aldridge gives the folloAving:
   The spas  that I have hitherto  succeeded in imitating are the Rakoczy
 and Pandur  Brunnens  at Kissingen, and the Elizabethan  Brunhen  at
 Homberg.   These are all so similar to each other—only varying  in the
 proportions  of their constituents—that it Avill be  only necessary,  at pre-
 sent, to give the formula for one of them.  The one that I propose for this
 purpose is that of the Rakoczy:
   Lime Avater, 3  wine pints;  carbonated solution of magnesia, 11 ozs.;
 BeAvlcy and  Evans' soda Avater (No.  4),  12 drs.;  sulphate of iron,  8 grs.;
 sulphate of  manganese, 1 gr.; phosphate of soda,  2 grs.; chloride  of
 sodium, 1 oz.; carbonate of potash, 10 grs.; muriatic acid (1160),  4 drs.;
 bicarbonate of soda, 5 grs.; silicate of soda, 30 grs.
   Dissolve and filter  the  solution ;  divide  into  tAvelve  equal parts;  put
 each part into a bottle capable of holding a Avine-pint; fill up with Bewley
 and Evans' soda water (No. 1), and cork rapidly.
   The contents of one  of the above bottles, taken in  divided portions,
 about an hour before breakfast, will be found to possess all the physiologi-
 cal effects of the spa drank at the source.  It will be found useful in cases
 of gout,  dyspepsia,  epigastric fullness,  habitual constipation, neuralgia,
 obesity, etc.   ~t is Avell not to continue its use for  a longer period than
 nine days or a fortnight, and to folloAV the treatment by the exhibition of
 some mild tonic.   Its employment is unsafe when there is weak action of
 the heart or where  there is a tendency to cerebral congestion, or  hemor-
 rhage from any surface.                            Part xxxviii., £>. 292.

   Iodide of Calcium.—This salt is very valuable in cases in which the
 iodide of potassium is inadmissible.   It does not occasion iodism, or  re-
 sorption of the healthy  tissues.   It  does not excite the  circulation, nor
 irritate the  stomach  and  bladder, by passing off too rapidly by the kid- 
 218                          MEDICTNES.

 neys.  Its solution in milk is perfectly tasteless.  It is particularly useful
 in squamous diseases of the skin, aiid  chronic metallic poisoning by mer-
 cury, lead, and copper.                             Part xxxviii., p. 292.

    New Method of Preparing the Phosphate  of Lime of Bones.—On
 the ground of the necessity which exists for the administration of phos-
 phate of lime  in the molecular state Avhich is best adapted for its incorpo-
 ration into the living organs, M. Dannacy,  of Bordeaux, proposes the
 following preparation of this  salt:  Beef-bones Avashed and powdered, com-
 mon water, and pure carbonate of potash or soda, are boiled together for
 an hour, when a perfectly homogeneous substance is'formed; this sub-
 stance is thrown upon a paper filter, and the alkaline liquid Aoavs out;  the
 mass is Avashed at several intervals Avith hot water; it is then dried and
 passed through a silk sieve,  when a  poAvder of excessive tenacity is ob-
 tained, soft to the  touch,  and of a mobility equal to that  of lycopodium.
 This powder contains all  the natural elements  of bones, but without the
 gelatine Avhich holds them together ; the disaggregation attains its utmost
 limit, and is truly molecular.   The phosphate of lime  of bones thus pre-
 pared is easily kept  in suspension  in  potions and in cod-liver oil, and it is
 easily molded  into different pharmaceutical  forms, as pastilles, pills, etc.
                                                   Part xxxviii., p. 293.

    Substitute for Human Milk.—[The  human milk  contains, besides salts
 of lime, chloride of potassium. Noav, in common with carbonic acid, this
 salt enjoys the peculiar property of dissolving carbonate of lime or chalk.
 An absence of it in the food, as  in  wheat bread,  is very injurious to a
 growing child.   Hence a child fed on pap for a time grOAvs fat, but  the
 bones are soft; frequently it sickens,  and severe symptoms supervene.]
    Amongst the vegetable substances, that which comes closest to milk in
 its composition is,  Avithout doubt, lentil  powder, or, as  it is called for  the
 purposes of obtaining a better sale, Revalenta Arabica, containing both
 phosphoric acid in abundance, and chloride  of potassium;  it also includes
 casein, the same principle which is found in  milk in its constituent parts.
 Moreover, its nutritive matter is to its calorifiant matter in the proportion
 of 1 to 2\, milk being in that of 1 to 2.  No Avonder, therefore, that under
 its influence many children  affected  with  atrophy and marked  debility
 have completely recovered.
    Lentils have also a  slightly laxative effect, and therefore, in many in-
 stances, where the  child  is of a constipated habit,  they are to be recom-
 mended.  Peas and beans in this respect  resemble lentils;  the former,
 hoAvever, are objectionable, on the ground  that they produce much flatu-
 lency.  The latter is not generally obtainable ;  still the bakers take advan-
 tage of this fact in regard to beans, and usually, where wheat by partial
 germination has lost some of its nitrogenous aliment,  or  where the flour
 used is poor in quality, they  add  a proportionate quantity of Avhite bean
 flour, to restore it to its proper nutritive value.     Part xxxviii.,^. 294.

    Tests for Adulterations of Medicinal Substances.—Dr. Squibb having
 had much practical experience in the preparation  of officinal substances
 for the United States' navy, believes that advantage may  attend the pub-
* lication of a few simple tests of their purity, requiring little time, skill, or
 apparatus for their application. 
MEDICINES.                          219
   Ether.—A strip of unsized paper, or a clean glass rod dipped into the
 ether and alloAved to dry for a moment or two, will, by the odor it gives,
 afford evidence of  the  less volatile  impurities  it commonly  contains.
 There usually remains a someAvhat aromatic, slightly pungent odor, that
 is not hurtful  in  the more dilute ether used for common medicinal pur-
 poses, but the disagreeable oily odor often found is more  objectionable,
 Avhile really good etiier should have  no odor Avhateverr  The ether used
 for inhalation  should leave no foreign odor whatever.  The strength of
 ether is less easily ascertained;  but  w ith a little  practice,  and having  a
 good specimen for comparison,  a very satisfactory  estimate may be found
 in the slowness or rapidity of its  evaporation  from the palm of the hand.
 Ether for inhalation should give off bubbles of vapor  rapidly at the tem-
 perature of the palm.  A thin test tube, containing  the  specimen, should
 be grasped firmly for a minute  or two,  and then the ether should be
 Btirred at the time of observation..
   Hoffman's Anodyne.—Two drops of officinal compound spirit of ether,
 stirred into a pint of water, gi^e to the mixture a distinct oily surface, and
 the peculiar fruity, aromatic  odor of the  heavy oil of Avine free  from  the
 odor of ether and. alcohol.  Sixty drops render the water decidedly tur-
 bid : while, with four fluid  drachms, a scanty precipitate  of minute oil
 globules occurs after a few minutes standing.  The fruity, apple-like odor
 is characteristic of the chief anodyne  ingredient, the  oil of Avine, and is
 entirely wanting in  the ordinary commercial  article; and Avithout this oil
 the preparation is a stimulant antispasmodic.   With the oil it is a highly
 valuable anodyne antispasmodic, particularly adapted to nervous irritation
 and hysteria.   The liquid universally sold is a residue of the ether-making
 process, containing varying proportions of ether and alcohol, with a little
 etherole or light oil of wine; hut in no instance of the many examinations
 made by the writer, has any true heavy oil of wine been found.
   Spirit of Nitric Ether.—Two  or  three fluid drachms of good sweet
 spirit of nitre, not more than seven or eight months old, plunged in an or-
 dinary test tube, into wrater heated to 164°, will boil pretty actively; and,
 if fresh, or if  well preserved from light and air, no matter Avhat its  age, it
 will boh actively in water at 156°.  From  the fact that this, among other
 liquids, may be heated far  above its  boiling point without ebullition, it
 becomes necessary to drop a few fragments of broken glass into the test
 tube with the  spirit, after the latter has been heated and while  still held
 in the water.   Again, the formation of  small  gas bubbles  around the
 fragments of glass, which occurs, as a fine effervescence, at any tempera-
 ture above 140°, in any spirit that contains hyponitrous ether at all, must
 be distinguished from true  ebullition, in which  the  bubbles are much
 larger, and form, as they successively reach the  surface, beads around the
 edge of the liquid—this latter only occurring at the temperatures named.
 The preparation should not  be quite  colorless, but of a pale straw tint,
 and it should effervesce very  slightly  on the  addition of carbonate of
 ammonia.   When slightly acid the ammonia is  the  best corrigent,  as the
 salts formed are  therapeutically  similar.   The officinal  preparation is a
 solution of five per  cent, of hyponitrous  ether  in alcohol, while in com-
 merce it is  rare to  find it containing more than three per cent., and in a
great majority of cases it is below two per cent., and often in a proportion
too small to be detected except by the odor.  It  thus happens  that the
physician who  prescribes it for its diuretic or diaphoretic effects is disap- 
220                           MEDICINES.
pointed, so much alcohol being substituted;  and the preparation is falling
into consequent  disuse.            *
   Choroform.—When equal volumes of chloroform and colorless concen-
trated sulphuric  acid (or the strong  commercial oil of vitriol) are shaken
together in a glass-stoppered vial, there should be no color imparted to
either liquor, or but a faint tinge of color,  after twelve  hours standing.
Nor should there* be any heat  developed in the  mixture at the time of
shaking it first.  All particles of dust, cork,  or  other organic  matters
must be excluded, or  coloring will  be produced  ; and  if at the end of
tAvelve hours the acid be only faintly tinged, it  may be attributed to some
such accidental cause.   If, howeArer, then or sooner it has become yellow,
broAvn, or any dark color, the chloroform should be rejected.   If warmth
takes place on first shaking the mixture, it indicates an admixture  of alco-
hol.  One or two drachms of chloroform, spontaneously evajjorated  from
a clean surface of glass or porcelain,  or  from clean, unsized  paper, should
leave no odor. Commercial chloroform  will generally turn the acid brown
in two  or three  hours, and will often renchsr it black  and tarry-looking
within two or three days; Avhile Avith. chemically pure chloroform  there is
absolutely no. reaction Avithin many days.
   Calomel.—The most common and  injurious. contamination is corrosive
sublimate, which is easily detected by  shaking a drachm or two in a test
tube, Avith distilled Avater, and when the Avater has become clear, adding a
drop or two of liquor ammonia.  This will precipitate the sublimate, and
render the Avater cloudy.
  Iodide of mercury is  often  irritant and  harsh  in its action, owing to
contamination Avith biniodide  from  faulty preparation.  This is detected
by rubbing  a  little of  the  iodide in a  mortar with  strong alcohol, and
leaving it a feAv  minutes to dry.  The evaporation of the alcohol leaves
the red iodide as a border to the iodide around- the pestle, and in this way
a minute contamination  is detected.
  Mercury with  chalk has of late been often found harsh and irritating in
its action, oAviug to faulty preparation, a portion of the mercury becoming
oxidized, instead of being simply comminuted.   To detect the peroxide a
drachm or two should be treated Avith  an excess of acetic acid, filtered,
and then a few drops of hydrochloric acid  added to  the clear solution.
If the preparation be good only a slight precipitate of insoluble subchlo-
nde will  take place, from  the small  quantity of acetate of suboxide
formed.  If the preparation be old or badly kept, a pretty copious precipi-
tate results.  The clear  solution is again filtered or decanted off this pre-
cipitate, and liquor ammonia is added.   If the preparation is contaminated
by the peroxide  it will be thrown doAvn in the form of white precipitate.
  Blue pill may also contain  the oxides of mercury, and thus  lose its
mild character.  They may be detected  in the same Avay as in the mercury
with chalk.                                         J                J
  Iodide  of potassium  is occasionally contaminated  with carbonate of
potassa, to the  extent of impairing  its medicinal power.  This is easily
detected by adding hme-Avater to the  solution of the iodide, when car-
bonate ot  lime will be precipitated, rendering the  mixture cloudy
  Bitartrate of potassa frequently contains  much   tartrate of  lime
which may be detected  by stirring a few drops of liquor  ammonia into a
mixture ot a few grains of the specimen in  two or three drachms of cold
water.   The  ammonia   renders  the otherwise insoluble  potassa  quite 
MELANCHOLIA—MELANOSIS.
221
soluble, while it has no immediate effect on the tartrate of lime._ If then
a portion remain undissolved after the application  of this test, it may be
regarded as an  impurity.                          Part xxxx\\\.,p. 294.

.  Preserving Fluid for Microscopical Preparations.—M. Pacini strongly
recommends the folloAving fluid for the  preservation of blood globules,
nerves, ganglions, the  retina, and  all the  soft tissues, which keep their
form and appearance Avhile they become  hardened; perchloride of mer-
cury  1, chloride of iodine  (chlorure iodique)  2,  glycerine  (at  25°  of
Bauine) 3,  and  distilled water 113 parts.   The mixture should stand for
two months, and then  one part of the liquid is  to be diluted with three
parts of distilled water and filtered.                Part xxxviii., p. 296.

  Iodate of Potash.—Messrs. Demarquay and Custin consider that the
action of this salt is more powerful  than that  of the chlorate of the same
base, and that it has yielded excellent results where  the chlorate of pot-
ash had failed.   The dose varies from five to twenty-two grains, and  it
has been used in diphtheritis, mercurial and gangrenous stomatitis, etc.
                                                 Part xxxviii., p. 296.
                    MELANCHOLIA.
   Use of Seton.—In cases of obscure melancholia, a seton to the nucha,
sometimes acts like a charm.   It is particularly beneficial, in the shape of
thin single filaments of gutta percha, or some other substance not perme-
able to pus.                                       Part xxxiii.,  p. 237.

   Vide " Insanity."

                              ■■  HI----■
                          MELANOSIS.
  Melanosis.—[There is an error in applying this term to  all tumors and
deposits  of a dark color,  no matter what their character or situation.
Melanotic swellings appear to be pigment-colored morbid  products, very
variable in character, especially cancerous.  Mr. Coote thinks the charac-
ter of this affection, as described by Mr. S. Cooper, is calculated to put it
in an improper light.  He says:]
  Chemical analysis by MM. Lassaigne and  Foy, has shown that melan-
otic matter differs but little from blood in its ultimate elements.  A solu-
tion of chlorine will bleach the black mass from a melanotic eye, conse-
quently, it differs essentially from the carbonaceous deposits in the lungs
of miners.  This statement receives further confirmation from microscopi-
cal examination.   Melanotic  tumors do not  consist of an  unorganized
deposit;  the  cells have their periods of  growth, maturity, and decay  ;
neither can they be regarded as mere accumulations of pigment, for the
cells have a totally different form from those  of healthy choroid.
  In order to establish the view that melanosis, Avhen fatal, is combined
with the  elements  of cancer, it is necessary to define wdiat these cancerous 
222
MELANOSIS.
 elements are.  In the sooty-black non-vascular patch, characterizing cuta-
 neous melanosis (an affection which Mr. Lawrence regards as malignant),
 I never could discover any structural  affinity with cancer, medullars, or
 fungoides.  It is  true, that cancerous  tumors may be sometimes colored
 by pigment deposit, but that is no proof of the patient being affected with
 melanosis.  The cavity of the globe may be occupied by a mass partially
 black and partially white, or of reddish hue;  but  it must be remembered
 that diseases of different characters often manifest themselves in the same
 tumor.   Melanotic tumors occasionally  present a spotted  appearance,
 some parts  being of a lighter color than others ; but this may depend upon
 variations in the quantity of the'pigment granules contained in the cells
   The constant occurrence of primary melanosis in situations Avhere, in the
 healthy state, pigment  is often deposited ; the chemical composition of
 such tumors; the appearances which they present both to the naked eye
 and Avhen placed under the microscope, warrant the inference that this is
 a disease  sui generis, manifesting itself by the accumulation of pigment
 cells in a morbid state.  It is difficult exactly  to define the meaning of the
 term " malignant."  In man, however, melanosis is a rapidly fatal disease.
 When once fairly established, Avhether  the primary tumor be extirpated
 or not, the  patient dies, in the course of one  or tAvo years,  of accumula-
 tions of similar character in all parts of the body.  In the horse the disease
 is not so fatal. Mr. Spencer has known an animal live for ten years  after
 the removal of the primary tumor,  being fit for Avork the whole time.
   [In the human subject, melanosis is most frequently met with  from the
 40th to the 60th years.'  Mr. Coote goes on to say:]
   Melanosis of the  eye commences between  the choroid and retina; the
 former membrane remains of its natural consistence ; the latter is  com-
 pressed, pushed to one side, or to the centre of the globe, but not other-
 wise altered.   In the earliest  stage  the eye  becomes amaurotic, without
 obvious cause; frequent attacks of inflammation come on; but from five to
 eight  years may elapse  without any  morbid change  being observable.
 Then, if the groAvth proceeds from  the posterior part of the eye, the retina
 is pushed forward ; the vitreous  humor is absorbed ; the posterior capsu-
 lar Aessels  are destroyed, and the lens,  rendered opaque, protrudes, to-
 gether with the iris, into the anterior chamber.  The conjunctival vessels
 become enlarged, tortuous, and distended with blood ;  the sclerotic coat
 yields unequally, and presents an  irregular lobulated appearance, resem-
 bling staphyloma.  Sudden attacks of inflammation, attended with pain
 and  chemotic SAvelling, come on; the  sclerotic coat gives way, either a
 few lines from the margin of the cornea, or near the entrance of  the optic
 nerve; and the  melanotic mass, freed  from restraint, protrudes, covered
 by conjunctiva, from the eyeball.  Primary melanotic tumors of the skin
 are either cutaneous  or  subcutaneous.   The  two  commonly occur to-
 gether.
   Cutaneous deposits  (melanose  membraniforme,  Andral)  appear  as
 smooth black spots, with a defined margin,  varying in size from a pin'a
' head to a shilling, lying upon the cutis, and covered by the cuticle, which
 is not raised.  Subcutaneous  deposits (melanose tuberaforme, Andral)
 exist  as  dark colored tubercles, varying  in  size  from a pin's head to a
 small orange.  Invisible Avhen small, they distend the skin as they acquire
 bulk,  and appear  as prominent  bluish-black  spots;  the  color deepest in
 the centre, gradually fading away to the circumference. 
MELffiNA—MENINGITIS.
223
  The integuments at last give way, and a black mass protrudes ; the sur-
rounding vessels pour forth some  blood, and  a dark-colored fluid  flows
from the open surface.  If  the mass be removed wholly, by the knife, or
partially, by ligature, the wound will heal, but the  disease inevitably re-
turns, either in the cicatrix  or some distant part.
  The primary disease  advances with unequal rapidity, but secondary
accumulations generally  form before the primary tumor has attained very
considerable size.  The  absorbent glands are rarely affected.  The* deve-
lopment of internal disease  is marked by general lassitude, and undefined
pains over the trunk and limbs ;  the rest is disturbed ; the appetite fails,
and emaciation commences.   The liver, rapidly increasing in size, projects
Avith irregular  surface from the loAver margins of the ribs, and distends
the abdomen; dark-colored matter is voided  by the bowels or ejected
from the stomach; the diarrhoea, if arrested, alternates with violent and
uncontrollable  pains  in  the head,  and the patient  dies exhausted, but
retaining his faculties to  the last.
  Upon examining  such a case after death, melanotic  matter is  found
accumulated in every part of the body, except, perhaps, the cornea, syno-
vial membranes, and tendinous structures.             Part xiv.,p. 128.
                            MEL.ENA.
  Acute Melmna cured by Gallic Acid.—Dr.  Durrant,  secretary to the
Ipswich  Medical Society, mentions  the  case of a cachectic  young man
with acute melasna, in which antiphlogistic remedies, acetate  of lead, and
turpentine with tincture of opium,  wrere given without  benefit.   Four
grains of gallic acid were then administered every four hours, Avith tinc-
ture of opium, and the discharge shortly ceased.         Part xv.,p. 120.
  Treatment of Melazna.—Give oil of turpentine (which by its  stimu-
lant properties will excite the  intestines to contract, and so mechanically
check the bleeding) and small doses of gallic acid in the solid  form.  And
let the diet be liquid, concentrated, cold, and  given in very small quanti-
ties at a time.  (Dr. Neligan.)                         Part  xxi.,p. 362.
                         MENINGITIS.
  Tubercular— Case of.—A fine boy of nine months old, was suddenly at-
tacked with convulsions.  He recovered from these, and cut his first teeth
shortly afterward; he was  soon observed to fall away, to become listless,
and to lose his  appetite, without any condition of tongue which could in-
dicate intestinal derangement.  His bowels became constipated, his pulse
irregular, and he began to vomit and to become torpid.  Fever Avas soon
added to his symptoms,  and it was evident  that  he was the subject of  *
meningitis.  Leeches were applied, and calomel given, but in  spite of
treatment he lapsed into  complete coma.  As soon as the latter symptom
became distinct, tartar  emetic ointment Avas rubbed  into the scalp every
four hours over a space the size of a croAvn piece.  Free suppuration en-
eued,  and signs  of amelioration were speedily witnessed.  The child be- 
224                         MFNORKHAGIA.
came gradually more sensible, his appetite returned, and in a fortnight all
traces of his malady had vanished.   Dr. Hahn continues :
  When there have been  no previous  symptoms indicative of tubercular
diathesis, bleeding must  be employed and calomel given.  The latter is
chiefly to be relied on ; but  we must not salivate unnecessarily.   Cold
effusions will be found useful, sometimes availing to arouse the child after
the supervention of complete coma.  But in the comatose condition, fric-
tion of* the scalp Avith tartar emetic  ointment, repeated  every tAvo hours
till pustulation is established, will be of the greatest value.  When symp-
toms denoting general tubercular cachexia precede the cerebral affection,
blood-letting, except loc.dly and sparingly, is contra-indicated, and calomel
cannot be pushed to the same extent.  But the counter-irritation may be
employed as in the previous case.                       Part xxi.,p. 73.
  Meningitis, Tubercular.—By judicious management blood-letting may
be almost dispensed with,  in this as in most other diseases of infancy.  Its
effects may be obtained by the  use  of the warm bath,  antimonials, and
diuretics, the latter medicines having a very striking antiphlogistic effect;
purgatives would serve the same  end, but they cannot,  except  enemata,
be safely used in many diseases of children. In the more  advanced stages,
" calomel for the removal  of lymph, and iodine (liq. potassae iodidi comp.)
for  the-absorption of effused fluid, are Avell  known and trustAvorthy re-
medies."
  It is \rery difficult in the cerebral affections of childhood, to distinguish
cases which require  antiphlogistic treatment from  those requiring stimu-
lants.  The occurrence  of febrile  disturbance  will  generally show that
active treatment is required ; -but if the fever is intermittent, leaving the
patient depressed in  the  intervals, we  must be very cautious how we use
lowering measures.   (Dr. Copeman.)                    Part xxi., p. 74.
  Syphilitic Miningitis.— Vide Art. " Brain."
                          MENORRHAGIA.
    Ergot of Rye.—Speaking of the effects of ergot of rye in menorrhagia,
  Dr. Burne says:
    I have heard  persons express doubts of its efficacy; but so many cases
  under my own care have been benefited or cured by it, that I cannot but
  regard it as a most valuable addition to the materia medica.  .  . .  Cases
  in which an exhausting draining hemorrhage has persisted for five or six
  weeks after abortion, have yielded at once to the influence of the ergot.
    It is very important that the  ergot should not be at all in a state of
  decaF-                                                  Part ii., p. 33.
    Gallic Acid in Menorrhagia.—In a paper read  before the Medico-
. Chirurgical Society of Edinburgh, Professor Simpson stated that for tha
  last year he had employed  gallic acid  in some cases of menorrhagia, with
  the most successful results.    Like all the other remedies directed against
  that disease, it had also occasionally failed in his hands. Some of the ca^ea
  which had completely yielded under its use were of an old standing and
  aggravated description.  He gave it during the intervals,  as well  as during 
MENORRHAGIA.
225
the discharge, in doses of from ten to twenty grains per day made into
pills.  It had this advantage over most other antihemorrhagic medicines,
that it had no constipating  effect upon the boAvels.       Part viiL, p. 65.

  Treatment of Menorrhagia.—Dr.  Ditterich recommends the internal
use of nitrate of  silver as  a remedy for this  troublesome and  obstinate
complaint, as Avell as for the leucorrhoea which is present during the inter-
vals and the nervous symptoms. '  The prescription is:  R Nit. argenti,
gr.  iij.;  aquae destil. 3ij. sol\re.   Of this solution ten drops are to be taken
tAvo or three times daily, and  gradually increased to fifteen drops.   The
author affirms that the use of this solution, for a period of from four to six
Aveeks, will  perform a certain  cure.   After the lapse of about  ten days,
the leucorrhoea diminishes, and by the second  menstrual  period, the cata-
menial secretion is reduced to the proper quantity, and the nervous symp-
toms  disappear.   Koph has  also recommended the nitrate of sih'er for the
same  disease in  doses of one-tenth  to one-twelfth of a grain  every two
hours.                                              Part xiii., p. 361.

  Treatment of  Menorrhagia by Indian Hemp.—[It appears that the
value of Indian hemp is not confined  to neuralgic cases.  Dr. Mitchell re-
commends it in uterine hemorrhage.   Dr. M. says,]
  There are tAvo tinctures  in use, one of the herb, and  the other made
with  the resin—the former  is of little use, but the latter is a poAverful
medicine;  when  mixed Avith water  it becomes milky, owdng to the sepa-
ration of the resin,  to obviate which it is better  to combine it  with muci-
lage,  or a small quantity of spirit: the dose that I have given of it is ten
minims  repeated every four hours;  sometimes the first dose succeeds in
checking a discharge which has lasted months, and that notAvithstanding
the employment  of  the most  energetic means usually resorted to, includ-
ing the Avhole range  of astringents and plugging the vagina.  In these
cases it  acts almost like magic.  There is another form of hemorrhage
Avhich the practitioner will also find it of great value in; I allude to that
distressing, debilitated sort of draining which  occurs  in some  women
Avhen pregnant.   In these  cases the  ordinary astringents frequently fail,
and the  ergot of rye, in consequence of inducing uterine contraction, is
inadmissible.  In these cases the tincture of hemp will be found peculiarly
useful.                                               Part xvi., p. 276.
  Thlaspi Bursa Pastoris,  in  Menorrhagia.—Give decoction of thlaspi
bursa pastoris (shepherd's purse) ; a  handful  of the fresh plant in three
teacupfuls of water, boiled doAvn to two—dose, a cupful twice a day.
                                                     Part xix., p. 270.

  Oxide of Silver  in Menorrhagia.—Give oxide of silver, in doses of
half a grain or a  grain three times a  day, combined Avith a small quantity
of morphia  or opium. It  is almost  a specific for those  cases in which
there  is  no organic lesion.   If there are  high inflammatory symptoms,.
these  must be subdued before beginning ivith the remedy.  Oxide of sil-
ver blackens the stools.                                 Part xx.,p. 228.,

  Menorrhagia.—During an  attack of the  hemorrhage, let the patient
take  of  ext. matico  alcohol, gr. v.; plumbi diacet., gr.  ij. M., ft. pil. ij.
quartis horis. R Secalis  cornuti, sodas bitorat., aa. 3j.;  mist, acacia?, §ss.
aquas  cinnam., §iij.   M. ft. haust. sumat demid. cum pilulis.  Mr. Hooper
    VOL. II.—15 
226
MENORRHAGIA.
prepares a combination of the diacetate  of lead with  the spirituous ext.
of matico, than which no styptic appears more powerful.
                          J1    ^                 part xxvii., p. 354.

   Profuse  Menstruation, commonly termed Menorrhagia—When Me-
norrhagia takes place in  plethoric habits, says Dr. Oke, it is manifestly
remedial, and  ought not  to be hastily restrained.  In such a  case the
plethora is the object to be kept in vieAV, rather than the discharge; and
it will be best treated by a cooling diet, the recumbent position, and the
mixture (a).             k                                 ...
  (a) R Magnesias sulphatis, 5yj.; infusi rosas comp., gvss.; sirupi  simpli-
cis, Sss.; acidi sulphurici diluti, §ss.  Misce.  Fiat mistura, cujus capiatur
fluiduncia ter quotidie.
  But  when the discharge has continued for a considerable length of time,
producing an anaemic condition and great  debility, the indication of cure
will clearly be to restrain the uterine flux  as speedily as possible  by gene-
ral and local means.
  The  system may be strengthened by (b).
   (b) R Confectionis rosas, gss.; infusi rosas comp., giij.; decocti cinchonas,
§iij. Misce et cola.
  Colaturas  adde
  Acidi sulphurici  diluti, 5j.; tincturas opii, ntxxx.   Fiat mistura,  cujus
capiat  quartam partem ter quotidie.
   Opium, in menorrhagia, from this cause, is a valuable remedy, as it is
found to increase the force of circular muscles;  whilst henbane, hemlock,
and belladonna relax them.   Hence it is  that the former contracts whilst
the latter dilates the iris ;  and  hence,  also, the  great  use of opium in re-
straining profuse and dangerous hemorrhage after parturition, by causing
contractions of the muscular walls of the uterus.
   The bowels, if necessary, should be  regulated by gentle aperients, such
as the  following:
   R Pulveris rhei, balsami copaibas, aa. 3ss.  Misce ;  et divide in  pilulas
xij., quarum capiat  duas hora somni pro-re nata.
   Turpentine and the secale cornutum have  also been found efficacious in
restraining menorrhagic discharge.
   The best  local remedy is the sulphate of alum hip-bath, Avhich may be
made in the proportion of tAvelve ounces of alum to two gallons  of Avater.
It may be  used daily for  about  twenty minutes, first  tepid, thence gra-
dually reducing it to the normal temperature.
   Should the discharge continue unabated, notwithstanding the use of the
above  remedies, a polypous growth  or  some  morbid  condition  of the
uterus is to be svpected; and the uterus must then be examined.
                                                   Part xxviii., p. 287.
   Use of Cinnamon in certain Examples of Menorrhagia—-The  symp
toms usually presented are briefly these :  the catamenia appear regularly
every  twenty-eight  days,  and are at  first  only of the  proper  quantity;
but, instead of  ceasing after a duration  of three or four days,  they con-
tinue unabated for ten or  fourteen, and occasionally even for three  Aveeks.
The general symptoms which arise  from  this  debilitating discharge are
just such  as  might be expected.  There is general Aveakness, languor,
mental depression,  with pains in  the  head, loins, and  so on; the patient
Buffering, it is to be remembered, not from  any diseased condition  giving 
MENSTRUATION.
227
rise to the hemorrhage, but merely from the loss of blood itself.  In other
instances the discharge continues a less  time, but the flow is more abun-
dant, clots being frequently discharged; this variety is generally folloAved
by leucorrhosa.
  Dr. Tanner was led to try the use of cinnamon, and ha\dng derived the
most beneficial effects from its  employment, recommends 2j". doses of the
tincture of cinnamon every six hours, to be continued for fourteen days
after the symptoms have disappeared.  If the case has been an obstinate
one, continue the dose once daily for a month.        Part xxviii., p.  288.

  Menorrhagia.—A A^ery common cause of menorrhagia  is uterine poly-
pus.  Vide Art. " Polypi."
   Use of Digitalis.—When unconnected with organic disease, it may be
readily checked  by infusion of digitalis.  If there be organic disease, it
will control the discharge, but its effects wdll not be permanent.
                                                  Part xxxiii., p.  265.
   Obstinate Menorrhagia.—In two  cases under  the care  of Dr. Henry
Savage, of London, after all other remedies had failed, a cure was effected
by injection into the uterine cavity, in one case, of three drachms of tinc-
ture of iodine of the London  Pharmacopoeia, and in the  other of  four
ounces of a mixture  (equal parts) of tincture of iodine and Avater.  In
the second case the injection was repeated every third day for a fortnight.
Both cases Avere unconnected with pregnancy in any way.  In  both the
uterus Avas rather increased in size, and softer than natural, the os being
slightly  open.   Injections  of  alum and  tannin  had  previously been
productive of temporary benefit in one of these cases.
                                                 Part xxxvii., p.  209.
                   MENSTRUATION.
  In the Negress—Is not earlier than in the European.   Part vi., p. 166.
   Treatment of Remittent Menstruation.—Dr. Tilt says he uses the term
remittent here in the same  sense  as  in the pathology  of  fever.   This
variety of menstrual derangement being characterized by a change from
the habitual type  to some other, so that the menstrual periods are brought
nearer, and tend to run into each other.  The first case occurred in a tall,
slender woman, aged tAventy-nine.   In this case menstruation commenced
between  fourteen and fifteen, and continued regular until six months
since, Avhen  she left her native country, Lincolnshire, for towm.  For two
months, although she menstruated as usual, she was  troubled  with
leucorrhoea  betAveen each menstruation.   The menstrual periods  then
came on every fortnight  and  lasted eight instead  of five days.  The pa-
tient vvas weak and exhausted, but not chlorotic; she had just passed a
menstrual period; there Avas an  absence of pain and  of  other symptoms
of uterine disease; therefore, notAvithstanding a discharge of which she
complained,  I omitted all local treatment, and ordered the folloAving pills
and  mixture:  sulphate of iron, two  scruples;  sulphate of quina, ten
grains; extract of hyoscyamus, a scruple ; mix for tAventy pills, one  to be
taken night  and morning. Camphor mixture, six ounces; liquor potassas, 
228                        MENSTRUATION.
four drachms;  tincture of hyoscyamus, six drachms;  tincture of carda,
moms, two drachms.  Half an ounce to be taken thrice daily.  An opium
plaster to be applied to the pit of the stomach.
  The patient's general health improved,  menstruation returned to its
wonted type, and from that time she only took  one pill every night, until
the approach of the  ensuing  epoch, which  passed on  as it ought to do
and the patient wras discharged.
  Miss L----, aged sixteen, first  menstruated between fourteen  and fif-
teen ;  and regularly, for four months after  its first appearance, did men-
struation adopt the monthly type.  Since seven or  eight years of  age she
had been subject to leucorrhoea, wdiich for the last three  months has pre-
ceded and folloAved  the menstrual flow; the latter has made its  appear-
ance every fortnight.  Still there Avas no intermediate leucorrhoea; there
were no pains  in  the back, none in front, and none were determined by
pressure on the abdomen;  but the thighs Avere  so  painful that she could
scarcely walk, and her legs Avere at  times  much SAvollen.  For this symp-
tom my opinion was  requested by her mother.  The girl had very much
fallen  off, was much debilitated by loss  of blood, and the undue influence
of the generative organ on her system had  caused catamenial headache,
heaviness for sleep, momentary loss of her senses, and often  fits of  lowness
and shedding of tears.   I ordered the following pills: Sulphate of quina,
ten grains; extract of gentian, a scruple;  extract of aloes, ten  grains;
extract of hyoscyamus, a scruple.  Mix for ten pills, one to be taken night
and morning.  I prescribed the compound camphorated mixture, and bel-
ladonna plasters to each of the ovarian regions.
  The symptoms rapidly abated, and menstruation Avas forthwith brought
back to its original type.
  The preceding cases are, in my opinion, samples of an idiopathic  aber-
ration from the normal type  of menstruation, and perfectly independent
of any inflammatory lesion of the ovaries or uterus.  I strongly recom-
mend this practice to the profession, premising that the treatment will not
be  so rapidly effectual, and may even be attended by mischief if the
remittance of the menstrual flow depends, as it sometimes does,'on ovarian
or uterine subacute inflammation, as in the following case:
  E. H----, aged  tAventy-one, of florid complexion, full habit,  and of
middling stature; menstruation first appeared between thirteen and four-
teen,  became regular from the  first, Avas very abundant, and lasted five
days at each period.
  A few months ago the patient Avas attacked by a severe cold Avith fever,
which stopped menstruation for  two months.  When the latter returned
it was scanty, and accompanied by more than usual pain in the back, the
stomach, and head; and, attended by these symptoms, it made its appear-
ance every three Aveeks instead of every month, giving rise also to sensa-
tions  of weakness, trembling, and lowness  of spirits, with which  she had
previously been wholly unacquainted.
  The patient  localized her  pains  in  the  ovarian regions: pressure in-
creased them, so did Avalking  or  any unusual exertion ; she was  slightly
feverish;  the tongue was furred, and the bowels were costive.
  I considered this case as one wherein the  remittance  of menstruation
was dependent on subacute inflammation of the ovaries, and I ordered six
leeches over each ovarian region ; poultices to be kept to the same region
at night;  and a flannel, sprinkled with camphorated liniment, to be ap- 
MENSTRUATION.
229
plied over the abdomen during the day.  Aloetic purgatives and a seda-
ti\re mixture were also prescribed.  The  pain  subsided; the patient felt
well; but menstruation returned at the morbid period of three weeks, and
was still painful, and left behind  it a certain  amount  of abdominal pain.
After giving a brisk purgative, I applied belladonna plasters to the ovarian
regions, and  gave  pills similar to  those taken  by Miss L----.   The
patient  now says she feels ivell, and as menstruation has resumed its phy-
siological type, I believe her to be cured.             Part xxiii., p. 246.
  Management of Women after the Cessation of Menstruation.—[The
superabundance of blood and nervous energy after the  cessation of tho
menstrual flow may be  safely and effectually  kept down  by the habitual
use of small doses of purgatives; and as they may have to be continued for
some length of time, it is best to consult the  patient as to what medicine
would be best tolerated. The purgative to be used depends upon the con-
stitution of the patient.  Perhaps the best is some mild purgative which
has been found to agree with the patient.  Dr.  Tilt continues:]
  I  frequently prescribe the soap and aloes  pill of the Edinburgh Ph.
ordering five or  ten  grains  to be  taken  Avith  the  first  mouthful of
food  at dinner.   Hemorrhoidal  affections I  have never seen  caused by
this frequent  use  of aloes, but I have  seen them  relieved  by  it.  There
must be some  exaggeration as  to the extraordinary property generally
ascribed to this valuable drug, Avhich can be  associated with hyoscyamus,
and is thus said to be  less  liable to  induce  piles.  Kemp  and Hufeland
recommend the following poAvder to be given to those Avho are advanced
in years, and who complain of a tendency to vertigo—Guaiacum resin,
cream of tartar, of each half a drachm, to be taken  at night.  This, no
doubt, Avill  sometimes  be  found a useful laxative ; so will the popular
remedy called the Chelsea  Pensioner, of which  Dr. Paris has  given the
following  formula in his excellent Pharmacologia:  Of guaiacum resin,
one drachm; of powdered rhubarb, two drachms; of cream of tartar and of
floAvers  of sulphur, an ounce each ; one nutmeg finely poAvdered, and the
whole made into an  electuary Avith one pound of clarified honey: a  large
spoonful to be taken at night. I generally administer the flowers of sulphur
alone, or else  to each ounce of it I add a drachm of sesquicarbonate or
biborate of soda, and sometimes  from five to ten grains of ipecacuanha
powder.  One  to  tAvo scruples of these powders taken at night in a little
milk, is generally  sufficient to act mildly on the  boAvels, and I consider
such combinations  as very valuable when a continued action is required.
  Whether sulphur cures by acting on the nerves  or on the bloodvessels,
or by modifying the  composition of the blood itself, is difficult to tell, but
it does certainly cure the diseases I have enumerated.  It forms part of
many popular remedies for the  infirmities of old age, Avas recommended
by Hufeland, and is lauded  by Dr. Day in his work " On the Diseases of
Old Age ;" but its  utility is not generally known in all derangements of
the menstrual function, at whatever  period of life  they may  occur, and
particularly at the  change of life, where, if required, its action may be con-
tinued Avdth impunity for months and  years.           Part xxiv.,p. 299.

  Difficult Menstruation.—Dysmenorrhoea sometimes takes  place from
the  very  commencement  of menstrual life,  and there  is  good reason
for believing that it depends on  the  small size or strictured condition of
the 6s uteri.   The menstrual fluid, after it is formed, or Avhile forming. 
230                           MERCURY.
cannot readily escape; distention of the organ speedily follows, which, by
exciting the contraction of the  uterine fibres, produces  pain almost simu-
lating that of labor.  Even the action of the abdominal muscles is called
into play, and many cases of what are termed " spurious pregnancy " may
be  very  possibly explained in this manner.   It is believed,  too, that
women thus affected rarely, if ever,  conceive or bear children, the normal
healthy function  of the uterus being interfered Avith,  as well as the
woman's health reduced  by the constant suffering and  pain.  Of all the
means  of cure hitherto  tried,  dilatation of the canal of the cervix uteri
seems  to be the best, to Avhich more  recently has been added the intro-
duction of a silver canula, as tried by Dr. Tyler Smith.
                                                   Part xxxii., p. 298.

  Menstruation  during  Pregnancy.—-That a discharge, more or less
identical Avith the ordinary catamenial flow, may occur during pregnancy,
is admitted by the majority of experienced  observers.   The  folloAving
case, under  the care of Dr. G. HeAvitt, is an interesting  example of this
kind:
  M. B., aged twenty-five, had been  married six  years.  She became
pregnant  for the first  time rather  less than  six years ago, and Avas de-
livered of a healthy child, uoav alive.   During this  first  pregnancy, it  is
stated  that every fourteen days a bloody discharge occurred, lasting three
or four days, and this periodic discharge persisted during the whole period
of gestation.  The  discharge was rather paler than that observed before
she became  pregnant.  The child Avas suckled for six months, and during
lactation no trace of bloody discharge was noticed.   A second pregnancy,
attended with precisely the same phenomena, terminated favorably three
years ago.  The  second child, also  noAV  alive, Avas suckled for fifteen
months, and the  catamenial discharge is  habitually rather  excessive  in
quantity,  continuing usually six to seven days; it  occasionally extends
over twelve or thirteen, and this has  been the case since  she Avas married
only.                                             Part xxxviii., p. 203.

                              ---»-*-*---
                         MERCURY.
  Mercury and Antimony—Methods of forming  various Preparations
of.— Vide " Antimony."
  Ferruginated Pill of Mercury.— Vide Art. " Pills.'
  Different Preparations of Mercury and best Modes of administering
them.— Chloride.—Calomel is chiefly useful when  Ave Avish to produce a
speedy and powerful  action  on the  constitution, as in venereal  iritis or
orchitis, but is less adapted to the ordinary symptoms.   On the Continent
it is extensively employed in tubercles of the labia,  Avith or without ulcer-
ation, in various forms of creeping ulcers, and also  in  ulcerations of the
thmat and  nasal fossae.  Desruelles  says, that he cannot too much recom-
mehd this  preparation,  which,  united  to opium  and an antiphlogistic
regimen, may produce the most beneficial results. Ricord employs the fol-
lowing pills in the treatment of  enlarged  testicle, which remains after
inflammation of that organ :
  R Hyd. chlor. 9j.; pulv. conn, sapon. hisp. aa. Bij.  M. ft. pil. xxiv. 
MERCURY.
231
 _  Bichloride.—M. Dupuytren ordered this remedy in small doses, one-
sixth of a grain three times a day, in constitutional syphilis, and on the
Continent it still continues to be extensively used for this purpose.  In
some chronic cases of syphilitic skin disease, I have seen it used with
advantage; but as a general remedy in secondary syphilis it requires more
care, is more dangerous, and altogether is a less eligible  medicine than
blue pill.
   Pilula  Hydrargyri.—This medicine is the  form most  used and relied
on in England, and as it  is one of the mildest, safest, most certain, and
most manageable  preparations of mercury, it justly deserves the prefer-
ence given to it.   In doses of five grains two or three times a day, it is
applicable to nearly all those conditions which we have shown to be  bene-
fited by mercury.
   Proto-ioduret.—MM.  Cullerier, Biett, Ricord  and  others employ this
remedy in many forms of constitutional syphilis,  especially*where second-
ary and tertiary symptoms are combined, and in  primary sores in strum-
ous habits.   Cullerier says, that it is chiefly in constitutional syphilis that
the  proto-ioduret  of mercury is administered with success.   Its effects
are principally evident in secondary ulcerations of the  mucous membrane, *
cutaneous tubercles, exostoses, and chronic affections of the joints, where
the other preparations of mercury have had little  effect.  It should always
be guarded by opium, and given in half grain doses twice or thrice a day.
The  deuto-ioduret  is  more  stimulating,  and consequently  its dose  is
smaller.  Either of these may be employed in friction upon  tumors and
indolent buboes, after the removal of all acute inflammatory symptoms.
   The cyanuret and deuto-phosphate of  mercury are  occasionally em-
 ployed.  The former is said  to be preferable  to the bichloride, being less
apt to disagree, and  less readily decomposed.  It is an  useful external
application in some skin affections, allaying the violent itching and irrita-
tion of what M. Alibert terms herpes squamosum.
   Inunction.—Inunction  by the  mercurial   ointment was formerly em-
ployed to mercurialize the system more frequently than  at  the present
day.   In this A\-ay  the mineral is less apt to  disagree Avith the system,
especially the alimentary canal, although, Avhen used  alone, it  is less
speedy in its effects.   In buboes, I imagine that Hunter was correct in his
opinion concerning  the advantages of making mercury pass through the
affected absorbents.  The ung. hydrarg. is used  in the quantity of half a
drachm to a drachm night and morning, to  be well rubbed  in, before a
fire, on the more  delicate portions of  skin.  Cullerier prefers using mer-
cury by friction in  primary sores : he orders  from a quarter of a drachm
to a drachm and a half of mercurial ointment at each  friction, leaving an
interval between them of one, t\Aro,  or three  days, with the vieAV of not
irritating either the sore or the constitution, by bringing the latter sud-
denly under the influence of the remedy.  Ricord frequently orders the
frictions to the axillas, and they are employed in this manner by Cullerier.
in certain forms of ulcerations of the mouth and fauces.  He narrates two
cases cured by mercurial  frictions in this situation, which had resisted its
employment on other parts.
   Fumigation.—Fumigation of the  whole surface of the body  is at pre-
sent, rarely used as a method of affecting the system, but the apparatus
"formerly employed is still to be found in some of our hospitals.  It is very
speedy in its action. The remedy is, however, employed locally, and with 
232
MERCURY.
great advantage, in some affections of the throat and nasal fossas, directed
to the part by a suitable apparatus, and more generally in some obstinate
diseases of the skin.  For patients ivho have not  strength to rub in mer-
cury, and whose boAvels will not bear the use of internal remedies, it has
been esteemed highly advantageous.
   Topical Applications—As, mere local applications, calomel, black wash
(hydrarg. chlorid.  x. vel xv. grs., aquas calcis, §j.), yellow wash (hyd.
Bichlorid. j.  vel ij. grs., aq. cal. §j-), solutions  of the  bichloride in  dis-
tilled water, the nitric  oxide ointment, the nitrate  ointment, the simple
blue ointment,  and the ung. hyd. c. ammoniaco,  are all of them occa-
sionally applied.  We select from these in proportion to their stimulating
properties, adapting to the condition of the symptoms we treat. _
                                                       Part ix., p. 20.
   Mercurial Ointment— Use of " Prepared Sevum."—Under this title a
very elegant  and valuable  preparation has been  for some time before the
public.  It is employed in the manufacture of mercurial ointment (unguen-
turn hydrargyri), and possesses the singular  property of immediately ex-
tinguishing the globules of metallic quicksilver, and  producing the neces-
Bary degree of oxidation, Avithout at all interfering Avith the intentions of
the Pharmacopoeia.  It resembles in every point very  pure suet, as  its
name implies, and produces a finer article of ointment,  both as to color
and quality, than by the old and laborious process of patient trituration.
   Strong 'Mercurial Ointment.—R Prepared  sevum, 1 oz.' or part; quick-
silver 7 do.;  mix in a Avarm mortar, then  add lard  (softened with heat).
13 ounces or  parts; mix Avell.
   Weak Mercurial Ointment.—R Prepared sevum 1 oz. or part; quick-
silver 7 do.;  lard (softened) 3libs., or 56 do., as before.   Partix.,p. 84.
  Mercury, Administration of.—After mercury has been given for some
time, a portion of it would seem to be retained in the system in the form
of some insoluble compound.  If iodide of potassium is now given, it com-
bines Avith the mercury, forming a neAV and soluble salt, dissolving out the
mercury, and setting it  once more afloat in the circulation.   This new salt,
a double iodide of mercury and potassium, is eliminated from the  system
along with the excess of iodide of potassium, so that the cure Avould then
seem to be radical and complete.
  Mercurial Poisoning.—It is important to know that iodide of potassium
renders medical treatment  in poisoning by certain  salts of mercury more
active, and may, therefore, occasion accidents.  M. Dumas recommends,
that A\men calomel  (the chloride of mercury) is taken, and is  Avished to
remain as such, common salt (chloride of  sodium) should not be taken.
When corrosive sublimate is taken (the  bichloride), to prevent its being
decomposed,  sal ammoniac  (the hydro-chlorate  of ammonia) is to  be
given Avith it.  If doses of  calomel are given to tAvo dogs, and at the same
time iodide of potassium is given to one of them, the dog so treated Avill
die first.
  Chloride of sodium (common salt) would seem to be of value in pre-
venting the attacks of mercurial poisoning.  Those workmen who are ex-
posed to its influence, and who are fond  of salt,  resisting the contamina-
tion longer than those Avho are not.                  Part xxA'ii.  p. 240.
  Mercurial  Fumigations.—A very simple and  effectual plan is to havo
the patient seated  on a caned chair; underneath  this you must have a 
MILK.
233
spirit lamp so placed that  the flame impinges  on a thin metallic plate,
which contains  the mercury to  be volatilized;  this may be from one to
three drachms of calomel for each fumigation, or if the  patient inhale the
mercury according to Mr. Lee's practice, fifteen grains  will be sufficient.
The chair and patient must be closely surrounded Avith a blanket.
                                                  Part xxxiv., p. 222.

  RapidMercurialization—Pass ten or  fifteen grains of the  ung. hyd.
fort. Avithin the sphincter ani three  times a day, and in twenty-four or
thirty-six hours ptyalism will be established.  The patient  must  be  care:
fully watched lest it run too far.                   Part xxxiv., p. 274.
  Mercurial  Fumigation—-The efficacy of calomel  fumes is much en-
hanced when  combined Avith the vapor of hot water.  For this purpose, two
separate processes have been had recourse to,  one to volatilize the  calo-
mel, and the other  to give off steam; but by a very ingenious lamp,
made by Mr. Blaise, both these  processes are  combined into  one.  Mr.
Pollok, Avho  had used it at St.  George's Hospital, finds that  it  is very
useful in private practice for volatilizing sulphur, iodine, etc.
                                                   Part xxxv., p. 187.
                               MILK.
   Extemporaneous Production of Milk.—M. Dichost, a Russian chemist,
 proposed the folloAving plan for the preservation and  extemporaneous pre-
 paration of milk.  He evaporates newly drawn milk, at a very gentle heat,
 till it is all brought into a state of fine  powder.   It is then put into small
 glass bottles, Avhich are completely  filled  and  hermetically sealed, Avith
 ground glass stoppers.  A small  quantity  of the powder thus obtained,
 dissolved in an appropriate quantity of Avater, affords on the instant a milk
 of a very good quality.  The powder will remain good for a great length
 of time.                                                Part vi., p. 85.
  Artificial Maternal Milk.—The  maternal milk differs from the cow's,
 principally in containing less caseine or curd, and more lactine, or sugar of
 milk, and from  ass's milk  in  containing a  little more curd  and butter.
 Therefore a very perfect substitute for  maternal  milk may be made by
 adding about tAvo and a half per cent, of cream to ass's milk, or by remov-
 ing a portion of curd from  coav's milk, and adding a little sugar.
                                                  Part xxxvi., p. 238.
  Substitute for Human Milk.—Lentil poAvder, or, as it is called, Reve-
 lenta Arabica, contains phosphoric acid, chloride of potassium, and casein.
 Its nutritive is to its calorifiant matter in the proportion of 1  to 2\, milk
 being in that of 1 to 2.  Of all vegetable  substances  it  forms the best
 substitute for human milk,  being far preferable to pap, or  pulp of Avheat
 bread, Avhich, from the absence of chloride of potassium and the too fre-
 quent presence of alum (the former of Avhich is necessary to the solution
of carbonate  of lime, and  the  latter  of Avhich forms with  phosphate of
 lime an  insoluble salt,) is totally unfit for  this purpose.   As a food  for
children Avith atrophy and debility lentil poAvder is invaluable.
                                                 Part xxxviii., p. 294. 
234                   MOLES—MORBUS OOXARTUS.
                            MOLES.
   Tattooing of Moles on the Skin.—The part should be Avashed with soap
and water, and rubbed till the  blood is introduced into the most delicate
branches of the erectile tissue; the skin is then made  tight and covered
with color similar to the natural color of the skin, Avhich is formed of white
lead and carmine.  Three  needles,  sunk into  a cork pad, so that their
points project, are then thrust into the skin, and their points from time to
time dipped in  the paint.  In extensive spots, we must proceed gradually,
so as not to produce  too great swelling.   The  most difficult  part  is the
choice cf color  corresponding to that of the skin.       Part xiv.,p. 190.

   Treatment of Moles by Acid Nitrate of Mercury.—Small moles  on the
face, if superficial and not too thick,  may be readily destroyed by the acid
nitrate.   A cicatrix of course results, but it is small, and far less unsightly
than the original disease.  Small cutaneous naevi  are often treated  at the
various  London  hospitals,  by means  of  the nitric  acid.   Unless the
disease be of very small extent, the employment of a ligature appears to
be a much more certain means of  effecting the end desired.  If there be a
subcutaneous base to the morbid structure it often persists in groAving, de-
spite frequent applications of escharotics.  There is a mild form of dilated
cutaneous capillaries  Avhich produces the marks knoAvn  as  " port-Avine
stains,"  " spiders," etc., in the  treatment of Avhich much  benefit may be
obtained by the dexterous  application  of fluid  caustics.  With a  finely-
pointed glass brush, charged either with nitric acid or the acid nitrate of
mercury,  the tortuous vascular  trunks should  be severally  painted,  a
minute  streak of  the caustic being thus left along the Avhole  course. In
this way, by repeated applications, the Avhole of the larger vessels may be
destroyed,  and the disfigurement,  to a large extent, diminished.  The
" port-wine stain" is of course very much more difficult to remove than the
less diffused forms of  this condition,  such, for  instance, as are of frequent
occurrence on the cheeks or nose; even in it, however, much benefit may,
by patient treatment, be gained.                      Part xxxi., p. 241.
                     MORBUS  COXARIUS.
   When warranted  in Removing the  Carious  Bone.—According to
Mr. H. Smith: When  the  head of the femur is carious, and is acting as a
source of irritation and wearing  the  patient down, Avhen we are satisfied
that nature cannot accomplish a  spontaneous cure, and when at the same
time the  caries  is confined, or nearly so, to the femur, and there is no
disease of other and internal  organs, Ave  are warranted in removing the
carious bone   The operation consists in making a longitudinal incision
over the  head and for a convenient distance down the  shaft of the femur
and another transverse one; clearing  away the tissues down to the bone'
turning it out, and sawing off the diseased portion; lastly, in unitin- the
edges of the wound by suture.                        part  xi     ^ 15 
MORTIFICATION.
235
                       MORTIFICATION.
  Treatment of Mortification.—In the treatment of mortification, according
to Prof. Cooper, three primary indications are concerned : 1. To stop the
progress of mortification.  2.  To promote the separation of the dead part
from the living.  3. To heal the wound, if an operation has beennecessary,
or otherwise the ulcer resulting from loss of substance.  These indications
are common to all species of mortification.  In fulfilling the  first of these
—in endeavoring to arrest the progress of  mortification, supposing it to
be acute—you will seek  to remove the exciting cause.
  Where  mortification is evidently the result of inflammation—Avhere in-
flammatory fever and an  excited action of the blood-vessels surrounding
the mortified part exist—a moderate antiphlogistic treatment is indicated.
The excessive action of  the  sanguiferous system should be cautiously re-
duced by leeching, purgative, diaphoretic, diluent  medicines, and  absti-
nence from animal  diet; but  this treatment is only to be  continued  so
long  as the local inflammation and inflammatory fever exist concurrently
with mortification, since by the mortification of any large portion of the
body the system itself is greatly shocked, and rendered unable to  stand
against violent treatment.   In such cases too much circumspection cannot
be  employed, since frequently immediately upon the subsidence of the
inflammatory fever, the  patient sinks into  a state of prostration and nerv-
ous agitation; and in every case there is more or less of Aveakness, and, if
the system has been too much reduced, the consequences are likely to  be
disastrous.
   After the abatement  of the inflammatory or symptomatic fever,  wdiich
usually takes place in the transition from gangrene to sphacelus, the oppo-
site system of treatment  must  be pursued : stimulants, anodynes, and a
more generous diet are  to be given.
   At one time,  bark Avas considered by the surgeons of this country as
almost a specific in resisting the progress of  this disorder ; Avithout  deny-
ing, however, its usefulness in particular cases, this opinion  is altogether
untenable, and is now rejected by men of  experience.  So far from  being
valuable  in all  cases, its exhibition  Avould frequently  be very injurious.
After the first stage of mortification, when the  inflammation surrounding
the mortified part has abated, it will often be advisable to employ it as a
tonic, especially  if the appetite is bad and the patient Ioav ; it should then
be administered  Avith Avine and light diet.  Also, when the constitutional
disturbance is of the typhoid  kind, bark and quinine may be useful.-  As
stimulants, however, ammonia and Avines—those of Spain or  Madrid—are
far preferable.  Opium is also  very serviceable Avhere severe  pain  or
nervous symptoms are present;  the best forms of it are the muriate and
acetate of morphia; and they should-be given frequently in the day, in
order to keep the constitution under their influence during  the whole of
the tAventy-four hours.
  Surgeons trust now more to common means, such as linseed poultices
and fomentations for stopping the progress of mortification.
  The second indication I named Avas to promote the separation of the
slough.  Although  the  slough  is dead,  and may  be . cut, pricked,  or
scratched, without pain,  and no functional connection exists, there remains
the attachment of cohesion, from which it cannot forcibly be wrested Avith-
out pain or danger.                                               •* 
•236
MORTIFICATION.
  Where amputation is not  strictly indicated, the parts should be left as
much as possible to nature, only applying moist and emollient applications.
In the derangement and prostration of the system, always implied in mortifi-
cation, a little violence will bring on an extension of the evil; and therefore,
besides the use of  the  emollient poultice, with or Avithout  a solution of
chloruret of soda,  or Avith a small proportion of finely-poAvdered charcoal,
it is to a general  treatment  that Ave are to look  as  the most efficient
method of expediting  the removal of the slough.   Let the patient have
the benefit of  the fresh air;  let his linen be frequently changed, and his
chamber be Avell sprinkled Avith chloride of lime, and  his constitution be
supported in the manner I have described, and he will then be in the most
favorable circumstances for losing  the slough.   Sometimes  you will find
one half of the slough  healing much better after the other half has been
cut away;  and, as  this  proceeding involves no injury of living textures, it
is, under some circumstances, advisable to -adopt it.   I ought to mention
that Avhen  a slough  separates no hemorrhage generally takes  place; the
blood-vessels are loaded Avith  coagulum ; and this Avill explain Avhy, Avhen
amputation in  mortification is performed a little above the line of separa-
tion, there is often no hemorrhage of importance.
  The  third indication—to heal the  ulcer,  or wound, if amputation has
been necessary—need  not to  be dwelt on, as it will be considered when
Ave  come to speak  of the treatment of ulcers, wounds, and amputations.
                                                     Part xvi., p. 301.

  Chronic Mortification,  ormDry Gangrene.—[The causes of this state
are often diseases of  the valves of  the heart, ossification  of  the large
arteries, and obstruction of the smaller  ones by fibrin.   Mr. Cooper ob-
serves :]
  The  first example of chronic  mortification, or dry gangrene, is the gan-
grena senilis, or mortification of old persons.  This kind of  mortification
differs  in many respects from any other example ; it is peculiar in the dis-
coloration  which takes place being  ahvays preceded by severe burning
sensation in the parts. It commonly occurs in elderly persons—in nine-
teen cases out  of twenty.  Not  that you may not  have similar cases in
youth.   Dupuytren relates several  instances of young persons suffering
from this  disorder.    It  commences at the greatest distance from the
centre  of the circulation, generally one of the toes, in  the form of a dark
purple  spot at the side of one  of the small toes.   Previously, however,
you find the patient has been  suffering pain about the toe, which is often
supposed to be gout;  and you find that the extension  of the disease is
preceded by burning sensation.  Its progress is variously marked in differ-
ent cases :  you find that the foot is gradually, sometimes quickly, affected
as far as the ankle, and has a  dark livid  color; the leg higher up presents
a reddish-brown color, and  the whole  limb has a  mottled appearance.
When  the surgeon examines  the part of the  leg higher up, he finds the
temperature of the limb much lower than natural, and this loss of heat is
found to extend along  the limb.
  Although this is  called dry  gangrene, in most cases there is a separation
of the  cuticle, and a dark bloody serum effused into vesicles, as in acute
mortification, and at  the bottom of the vesicles is seen the cutis, dark-
colored and livid.   Whether you are to have much  SAvelling depends on
th* rapidity with  Avhich the  disease extends: when it advances  rapidly 
MOUTH.
237
there is much swelling, but where the progress is slow the swelling is gene-
rally very slight.
  The patient  sometimes  suffers a good deal of disturbance in the sto-
mach ; he suffers from eructations, and delirium and  coma come on early
in severe cases.  Where the disturbance is  great in the beginning, the
patient often dies before the mortification has  reached to the ankle, about
the tenth or twelfth day, from  constitutional disturbance.
  Now, Avhat are the causes of gangrena  senilis ?  It  has been  generally
supposed that there is ossification of arterial trunks, and sometimes we can
feel very distinctly that the artery is ossified.  The larger arteries are not
invariably ossified in this disease.
  Cruveilhier ahvays  referred gangrena  senilis  to ossification. _  There
must be some unfavorable circumstances  combined with the ossification,
as impaired health, diseases of the heart or its valves,  producing disorder
of the circulation.  Then the venous blood cannot pass freely, and accumu-
lates  in the lower extremities, impeding the circulation ; and this Avill ex-
plain to you  the cause of gangrena  senilis.  It is doubted by many good
surgeons Avhether ossification of the arteries alone is capable of producing
gangrena senilis.   I think it is not.  No doubt in a broken constitution,
joined Avith  ossification, it may  act as  the  exciting  cause.  Dupuytren
thought the cause was arteritis, by Avhich the arteries became blocked up
by fibrin.  It was observed that the blood Avas'buffy ; in consequence of
his vieAV, he tried venesection,  and three-fourths of his  patients were
saved.  This mode of treatment, Avhen tried in this country, did not give
such favorable  results.
   We found that bark was insufficient in this  disease, and that opium Avas
a much more available remedy ; and the opinion is retained by the best
surgeons that opium  is better than bark in  the treatment of  gangrena
senilis.  If opium  or its  preparations  be used, half-grain doses of hydro-
chlorate of morphia should be given every four hours.
  Musk, too, has been tried,  and was found to be a most useful  medicine.
Stimulants, brandy and Avine, ought not to be forgotten.  With respect to
the local treatment, fomentations and emollient poultices  are the most em-
ployed.  I have seen other applications  tried ; I haA^e seen Laburruque's
solution of chloruret  of soda, and this, in one case  I attended, had the
effect of diminishing the fetid smell, but did no other good.
  Applications  of charcoal Avere also tried, but these were no better than
the other.  A r.ew  practice of late has been introduced; in Chelsea Hos-
pital,  Avhere gangrena senilis is very common among the pensioners,  it was
suggested that it would be a very rational plan to maintain the tempera-
ture of the limb by enveloping the Avhole in carded wool.  This  was tried
in a case by Sir Benjamin Brodie; the patient got better, and recovered
with the loss of Iavo toes.                             Part xvi., p. 302.
                            MOUTH.
  Cancrum  Oris, and  Phagedena of the Cheek.—Dr.  Hunt  describes
these diseases as being identical, varying only in the degree of severity—
both commencing by ulceration of the mucous membrane of the  cheek, or
where it joins the gums, and that the external eschar is the consequence 
23S
MOUTH.
of the internal ulceration.   He considers them to proceed from a cachectio
state of the system; that they occur more commonly in  cold and wet
weather—sometimes attacking several members of the  same family simul-
taneously,  and occasionally prevailing  almost like  an  epidemic.   The
author has  treated them very successfully by a free exhibition of the chlo-
rate of potash, the beneficial influence of that salt being generally appa-
rent within forty-eight hours of its being given, that it seldom fails  to
arrest the progress and to effect a cure, if administered  prior to the  pa-
tient being very much exhausted.  The  quantity  of the salt he has been
in the habit of prescribing, varies from Bj. to Bij. in twelve hourSj accord-
ing to the  age of the child.                             Part vii., p. 87.
  Aphthous Ulcers of— Use of Pure Tannin.—Mr. Druitt says : In one or
two cases of lingering atonic phagedasna, I have found it  of some service,
sprinkled thickly on the sore; but  more particularly so in those aphthous
ulcers which sometimes occur in the mouths of adults,  from acidity of the
stomach, and congestion of  the liver.                    Part x., p. 139.
   Treatment of Aphthae by Sulphuric Acid.—Professor Lippich, of Padua,
has recommended the  following liniment  in  the treatment of aphthas:
honey, 15 parts; diluted sulphuric acid,  1 part by weight.  The ulcerated
surfaces  should be occasionally brushed  over with this liniment by means
of a  camel's-hair pencil.  The proportion of sulphuric  acid may be  in-
creased if  the case is obstinate.                         Part xiv., p. 90.
   Aphthous Ulcerations of the Mouth  and Tongue.— Vide Art. " Gallic
 Acid."
   Aphtha.—Apply solution of the sub-carbonate of  soda, or of borax,
 of varying strength.  (When the aphthous crusts have a disposition to fall
 off, it is  only necessary to pencil them with a soft brush dipped in water.)
 A long continued use of alkaline applications is inadvisable ; change them
 therefore  for astringents  and the  mineral acids.   Or apply a solution of
 nitrate of silver, eight  grains to the ounce.  Internally give  soda, aqua
 calcis, or magnesia usta.  If there is a vomiting of the milk, give an emetic;
 if the stools are cheesy-looking, give purgatives, especially castor-oil, or if
 there is  much secretion of mucus, rhubarb or jalap.  To relieve the colicky
 pains give rhubarb and magnesia, or liq. succin. ammon. by the mouth or
 rectum.   Avoid giving medicines in sugar, which being changed into lactic
 acid, favors the growth of the aphtha.  Take care that the milk is of good
 quality,  and that the child is exposed to a free and pure atmosphere.
                                                      Part xvi., p. 144.
    Ulcerative Stomatitis or Noma.—[By this name, Dr. West describes an
 affection of the mouth, distinct from follicular or aphthous stomatitis on
 the one  hand, and from cancrum oris or gangrenous stomatitis on the other.
 It attacks  the gums, and destroys  them extensively  by a process, not of
 gangrene, but of ulceration.  It occurs chiefly in children who have  had
 deficient food and have lived in damp, unhealthy places: but is not preceded
 by any  special-derangement of the general system.  The symptoms areas
 follows:]
    On opening the mouth, the gums are seen to be red, swollen, and spon-
 gy, and their edge is covered with a dirty white  or greyish pultaceous de-
 posit, on removing which their surface is exposed, raw and bleeding. • At
 first  only the front of the gum  is  thus affected;  but as the disease advan-
 ces, it creeps round betAveen the teeth to their posterior surface, and then, 
MOUTH.
239
destroying the gum both in front and behind them, leaves them denuded,
and very loose in their  sockets, but  it is not often that they actually fill
out:  The gums of the incisor teeth are usually first affected;  those of the
loAver jaw more frequently and more extensively than those of the upper;
but if the disease be severe, the gums at the side of the mouth become
likewise  involved, though it is seldom that the two sides suffer equally.
Sometimes  aphthous ulcers, like those of follicular stomatitis, are seen on
the inside of the  mouth in connection Avith  this  state of the gums; but
oftener it exists  alone.  On those  parts of the lips and  cheeks, however,
which  are opposite  to, and consequently in  contact with, the  ulcerated
gums, irregular ulcerations form, which  are covered  with a pultaceous
pseudo-membranous deposit, similar to that wdiich exists on the gums them-
selves.  Sometimes, too, deposits of false membrane take place on  other
parts of the inside of the mouth, the surface beneath being red and  spon-
gy, and bleeding, though not distintly ulcerated.   If the disease be severe
jind long-continued, the tongue assumes a sodden appearance, and is indent-
ed by the teeth, and the cheek  on one or other side is someAvhat swollen,
while the saliva, though rather less abundantly secreted  than  at the com-
mencement of the affection, continues horribly fetid, and is often streaked
with blood, the gums themselves bleeding on the slightest touch.   But
even if left alone,  the  affection usually subsides in the course  of  time,
though it may continue almost stationary for days or weeks together, and
this notwithstanding that  the general health is tolerably good.  It would
be too much to say, that this unhealthy ulceration never degenerates into
 gangrene; but though a very large number of cases of  ulcerative stoma-
 titis have come  under my notice, I have seen only one instance in which
 it ivas succeeded by true gangrene of the mouth.  When recovery has
 commenced, the  disease  ceases to spread;  the drivelling of fetid  saliva
 diminishes; the white pultaceous deposit on the gums,  or on the ulcera-
tions of the cheek or lips, becomes less  abundant;  the ulcers themselves
grow less; and finally, the gums become firm,  and their  edges of a bright
red, though still for a long time showing a disposition to become once
more the seat of the ulcerative process, and continuing for a still longer
time to cover the teeth but very imperfectly.
   Various internal remedies and local applications have  been at different
times recommended for the cure of this affection.  Tonics have been  much
employed, and the supposed analogy between this state  of the gums and
that Avliich exists in scurvy, has led practitioners to give  the preference to
remedies supposed to be possessed of antiscorbutic properties.  Lotions of
alum, or burnt alum in substance, or the chloride of lime in powder, have
all been used locally wdth  more or less benefit.  It Avas my custom also to
prescribe these remedies in cases  of ulcerative stomatitis ; but since  the
chlorate  of potash was introduced to the notice of the profession by  Dr.
Hunt, I have learned to rely upon it almost exclusively.  It  appears, in-
deed, almost to deserve  the name of a specific  in this affection;  for  a
marked improvement seldom fails to be observed in the patient's condition
after it has been administered for two or  three days, and in a week or
ten days the cure is generally  complete.  Three grains  every four hours,
dissolved in Avater,  and  sweetened, is a  sufficient dose  for a child  three
years old, and five grains  every four hours is the largest quantity that  I
have administered to a child eight or nine.   If the bowels be constipated,
a purgative should be previously administered ; but there seems to be no 
240
MOUTH.
form  nor any stage of the affection in which the chlorate of potash is
not useful.  The diet should be light but nutritious, and quinine and other
tonics are sometimes serviceable if the child's health should continue feeble
after the local malady has been cured.                 Part xviii., p.  111.

  Gangrenous  Stomatitis, orCancrum Or as.—[Ulcerative stomatitis is an
affection of such frequent occurrence that many instances of it come under
my notice every year, especially during the damp autumnal months ; Avhile
it is attended with so little danger, that the only case in Avhich I have
known  it prove fatal was one in Avhich gangrene of the mouth supervened
upon it.   Gangrenous stomatitis, on the other hand, is a disease so  rare
that I have  only five  times had the opportunity of witnessing it: but so
fatal,  that in four out of these five cases the patients died.
  Dr. West proceeds to the treatment.  He says :]
  The arrest of the sloughing is the one point to which in the  treatment of
this affection the attention of aU practitioners has been directed.  The small
amount of success  which has attended their efforts is partly attributable to
the circumstance that the affection has frequently been overlooked, until it
has already made considerable progress ; in part also to the .fact that when
recognized, the local remedies employed, in order to check the gangrene
have either been too mild, or have been applied with too timorous a hand.
Unfortunately,  too, there is considerable difficulty in  applying any caustic
effectually to the  interior  of the mouth—for not only does the tense and
swollen condition  of  the cheek prevent our  obtaining easy access to  the
gangrenous parts,  but the child naturally resists an operation which cannot
but occasion it  most severe pain.  Ineffectual cauterization, however, is use-
less, or  worse than useless ; and though every endeavor should be made to
prevent the needless destruction of healthy parts, yet of the two evils, that
of doing too much is  unquestionably less than that of doing too little.  It
is of importance, moreover, not  only that the cauterization should be done
effectually, but  also that it should be practised early.
  When once the mortification has extended through the substance of the
cheek, the chances of arresting its progress must be very few.  As the slough-
ing advances from wdthin outward, it is to the interior of the mouth that our
remedies must be applied, and since the advance of the disease is too rapid
to alloAV of our  trying mild means at first, and afterward resorting, if neces-
sary, to such as are more powerful, Ave must employ an agent sufficiently
energetic at once  to arrest its  progress.  Various caustics have been re-
commended for this purpose, but none appear to be so weU fitted to accom-
plish  it as the  strong hydrochloric or nitric acid.  I am  accustomed to
employ the latter,  applying it by means of a bit of sponge, or of soft lint or
tow, fastened to a  quill, while I endeavor, by means of a spoon or spatula,
to guard the tongue,  and other healthy parts, as far as possible, from the
action of the acid.  In the only case that  I saw recover, the arrest of the
disease  appeared to be entirely owing to this  agent, and though  the alveo-
lar  processes  of  the left  side of  the  lower jaw, from the first molar
tooth backAvard, died andexfohated apparently from having been destroyed
by the acid, yet it  must be owned that life Avas  cheaply saved even at that
cost.  Some increase of the SAvelling of the cheek almost invariably follows
the application  of this agent—a circumstance which may at first occasion
unfounded apprehensions lest the disease  be  worse.   Twelve hours, how-
ever, must not be alloAved to elapse, without the mouth being  carefully ex- 
MOUTH.
241
amined, in order to ascertain AArhether the disease has really been checked,
or whether there is  any appearance of mortification in the parts beyond   *
the yellow eschar left by the first application of the acid.  The cauteriza-
tion may now be repeated, if it appears necessary, and even though the dis-
ease had seemed completely checked,;  yet reliance must not be placed  on
the improvement continuing, but the mouth must be examined every twelve
hours, for fear the mortification should  spread unobserved.   During the
whole progress of the case  the mouth must be syringed frequently wdth
warm Avater, or Avith chamomile tea mixed Avith a small quantity of the solu-
tion of chloride of lime, in order to free it from putrid matters that collect
Avithin it, and to diminish, as much as possible, their offensive odor. Should
the case go on well, the frequent  repetition of the strong acid will be un-
necessary, but  the  surface  may  still require its application in a diluted
form, or it  may suffice to  syringe the  mouth frequently  Avith  chloride
of lime lotion, or  to apply the chloride in powder once or twice a day,
according to the suggestion  of MM. Rilliet  and Barthez.  In the last two
cases of this affection that came under my notice, I likewise employed the
chlorate of potash internally, as recommended  by Dr. Hunt, but it did not
appear to exert any  influence over it;  and valuable though the  remedy is in
ulcerative stomatitis, it Avould, I think, be merely trifling with your patient's
chances of recovery to trust to it in true gangrene of the mouth.
   During the whole  course  of treatment you  have another indication to
fulfill—namely, to support your patient's strength by nutritious diet, and by
the employment of Avine and other stimulants, and the administration  of
quinine, or of the extract or tincture  of bark, or Avhatever form  of tonic
might seem best suited to the peculiarities of the case.
   In conclusion let me remind you, that during the Avhole progress of the
case, your prognosis must be regulated by the state of the local disease,
rather  than  by the  urgency of the general symptoms.   So  long as the
sloughing is unchecked, the affection is tending rapidly to a fatal issue, and
this even though the pulse be not very feeble, though the appetite be good,
and the child still retain some shoAV of cheerfulness.     Part xviii., p. 113.
   " Nurses'1 Sore Mouth."—Dr. Holt states that every case he has treated
of this disease " has  yielded Avithin forty-eight hours to the  use of iodide of
potassium, in gr. v. doses three times a day."          Part xviii., p. 303.
   Cancrum  Oris.—Apply strong nitric  acid  freely to the edges of the
slough, all around, taking care that the little patient takes a full inspiration'
previous to the application  of the acid, so as to obviate the danger of the
vapor getting into the lungs ; and repeat the application every  day, as long
as it may be necessary.   Put on a linseed poultice, Avhich should be changed
tAvice a day; and detach each slough as soon as it can be  done.  Let the
patient  have meat diet, and Avine.  And give chlorate of potash, fifteen
grains and upivard (for children of six or eight years old) daily, in divided
doses.                                                Part xxi., p. 223.
  " Stomatitis Ulcerosa " of Children.—[These  ulcerative affections  in
the mouths of infants and young children are often exceedingly troublesome.
They  may not depend upon  any specific cause, but chiefiy on debility, with
possibly some trivial local affection superadded.   Mr. Mackenzie has em-
ployed the folloAving simple  method of treating the disease  with much suc-
cess :]
  The term " stomatitis ulcerosa " sufficiently and accuratelv expresses the
      vor. :-.—16 
242
MOUTH.
 nature of this affection ; but in its mode of origin, situation and extent, it
 presents many varieties.  Thus, in one form, it commences as  a small in-
 flammatory spot, either  on the frenum of the tongue, the outer  surface of
 the gums, or the mucous membrane of the cheek or lip ;  but wherever it
 commences,  ulceration speedily supervenes, attended Avith  febrile disturb-
 ance,  a coated tongue, profuse salivation, and a disordered  state of the
 tomach and digestive organs.   In another form, it is found to  be connected
 with the passage of some of the larger teeth through the gum, more espe-
 cially  when several are about to make their appearance together.  In this
 case, the gum becomes swollen, painful, and dark-colored; and, after a feAv
 days, the portion over the protruding teeth gives way by ulceration, Avhich,
 in some cases,  extends considerably, attended  with tumefaction of the
 mouth and cheeks, increased  salivary discharge, and febrile  disturbance.
 More  frequently, hoAvever, it commences Avith  a general SAvelling and irri-
 tation  of the gums, together  Avith  much fetor  of the breath, a coated
 tongue, and much gastric disorder.  Along the upper margin of the gum,
 or rather that Avhich is in contact Avith the teeth, a line of ulceration now
 soon becomes developed; and this, ivhen  once begun,  rapidly spreads,
 the  gums, at the  same time, being spongy,  swollen,  and very painful.
 Unless excited by some local  cause, such as the irritation of a decayed
 tooth,  it usually commences in the loAver jaAV, and  from  thence is  com-
 municated to the mucous membrane of the corresponding  cheek.  The
 irritation attending it affects the salivary and cervical glands  in a remark-
 able manner; both become  SAVollen, and the former secrete  so  profusely
 that the child appears to be constantly dribbling.  In this form there is
 generally some febrile disturbance, and much gastro-intestinal disorder.
 If severe, it may not only cause destruction of the gums, but loosening of
 the teeth, suppuration of their  sockets, and partial necrosis of the jaw. Its
 intensity, however, varies very considerably in different cases;  in some it
 is so slight as to require little or no special treatment, ivhilst in others it
 can only be controlled by very prompt and energetic measures.
  In the general management of  these cases, Ave are directed to employ,
 locally, strong solutions of the nitrate of silver, or of the sulphate of cop-
 per or zinc, Avith or Avithout astringent, stimulating, or detergent'gargles,
 and  to administer, at  the same time, quinine, tonics, and a liberal diet.   I
 formerly followed these instructions closely, but sometimes  with equivocal
 success; and  I am now, after repeated trials, disposed  to give the prefer-
 ence to the following  method  of treatment.  It consists in removing, in
 the first  place, any apparent cause of irritation, such as a decayed tooth,
 should it exist, and applying, daily, the dilute nitric acid of the  pharmaco-
 poeia, to  the  Avhole of the ulcerated surfaces, by  means of a sponge,  or
 camels-hair pencil; whilst, at the  same time, the sesquicarbonate of
 ammonia is given in full doses,  combined with citrate of iron.   When the
 tongue is coated, and the alvine  discharges are unhealthy, it is necessary
 to premise an emetic  of  ipecacuanha and squills, as well as'a purgative of
 calomel and rhubarb.  ^ It is  also necessary that the patient should be well
 supported by a nutritious diet, an adequate alloAvance  of malt liquor, or
 wine.
  I Avill briefly add, that the employment of ammonia  in these cases was
first  suggested to me from observing its beneficial effects in the ulcerative
 affections of the mouth and  throat, which occur in children in connection
with scarlet fever.                                    part xxyi^pt 95. 
MOXA.
243
   Stomatitis { Ulcerated) and Cancrum Oris.—In a severe  epidemic of
this  disease, the cases Avere treated by a mild aperient of magnesia and
rhubarb, and by chlorate of potash dissolved in water sweetened with sirup,
in doses of 4 grains every fourth hour.  The mouth was also Avashed with
a Aveak solution of chloride of sodium.  They all recovered in about six
days.                                              Part xxvii., p. 83.
   Thrush.—Dr. Jenner says this disease depends upon the presence of a
parasite.   It  is speedily removed by applying a solution of  sulphite of
soda, 3j.  to the  §j. of Avater.  The secretions of the mouth, being  acid,
combiue  with  the  alkali and set the sulphurous  acid  free, Avhich is the
active agent in destroying the parasite.              Part xxviii.,  p. 227.
   Cancrum Oris.—According to Dr. Fleming, this disease is generally
preceded by  some other malady,  as measles, croup,  etc., folloAved  by
bilious diarrhoea, Avhich induces a state of the system in Avhich there is a de-
ficiency of sulphur. The treatment must consist in the local application
of a  solution  of the biborate  of soda.  The constitutional  remedies are
Fleming's tincture of aconite, six  drops to tAvo  ounces of  Avater; a tea-
spoonful  to be given every three  hours.  This will subdue the vascular
excitement.  The  tincture of nux  vomica  must afterward be given to
stimulate the secreting vessels of the liver, and also sulphur to supply the
deficiency of this element in the system.
         ********
   If you meet Avith the case before it has spread far, remove the slough
with the knife, apply  the strong solution of  the nitrate of copper freely to
the  exposed surface, and paint the surrounding cheek Avith collodion.
                                                   Part xxxiv., p. 80.
   Mouth— Congelation in  Operations on.—It will  be very difficult to
produce  the  required benumbing effect, says Mr. Quinton, except  with
great care. It is necessary that the cold be applied equally and Avith some
pressure.   It is much better to inclose the freezing  mixture in a thin
India-rubber  bag, to prevent  the ingredients  escaping  and  irritating the
mouth.   It -will also be necessary repeatedly to change or  mix  the fluid so
as to maintain the  desired cold.                      Part xxxiv., p. 131.
   Ulcerous Stomatitis in the Army.—M.  Bergeron writes that  during
the Crimean war, ulcerous stomatitis, amongst the young soldiers, assumed
an " endemo-epidemic " form.   The  most rapidly efficacious  method  of
treatment Avas found to consist in the exhibition of chlorate of potash, pre-
ceded or not by an emetic.   If, after some little time, no benefit followed
this treatment, the dry chloride of lime was  substituted for the chlorate
of potash.  In most instances, however, speedy cure resulted from the use
of the chlorate alone.                                    Part xl., p. 58.
                             MOXA.
  Lime Moxa.—When it is recommended to apply a moxa to any part of
the body,  Dr. Osborne, of Dublin, has found  quicklime to answer the
purpose admirably.  The quicklime is to be placed on the skin, inside a
parte moxa, or a strip  of card bent together and  tied so as to form a cir-
cle ; some water is then dropped on and  mixed Avith  it.  " In about two
minutes  the mixture  swells and  becomes  dry, and at  the  same time a 
244
MUSCLES.
high degree  of heat is produced, which, according to some experiments,
may amount to 500° Fahr."  This is certainly a very convenient and cheap
mode of applying the moxa, and may be useful  in making  issues of any
depth.  Dr. Osborne  thinks " that the heat produces a  contraction and
change in the action of the vessels of the parts over Avhich  it is applied,
with great excitement of the absorbents, enabling them to return  to a
state of health after the failure of all other means," as is  Avell known and
acted upon by veterinary surgeons Avhen they use the actual cautery.
                                                       Part v., p. 129.
  New Method of Applying Counter-Irritation—" Electric Moxa."—Dr.
Bird has proposed  a novel method  of producing a persistent discharge
from the skin by means of galvanism.  The making an issue, the insertion
of a seton, the application of a moxa or cautery-iron, all appear  formid-
able operations to timid patients.
  Apply a blister the  size of a shilling to the part where you wish to es-
tablish a counter-irritation, and another of the same size a few inches from
it;  Avhen the cuticle is raised, snip it, and apply to the first one a piece of
zinc foil, and to the  other a piece of silver; connect them by a copper wire,
and cover with wet  lint and oiled silk.  In forty-eight hours an eschar will
appear under the  zinc plate.  Keep  the plates on  until  the  eschar
separates, and then  apply a poultice to the sore that remains.
                                                     Part xvi., p. 293.
                          MUSCLES.
  Affections of  Voluntary Muscles—Some  of the  Consequences  of
Blows and the like Injuries of Muscles.—A bloAV on a muscle  or  on its
nerve may be folloAved by complete wasting.  Total atrophy of the abduc-
tor indicis and adductor minimi digiti has folloAved a sharp and very severe
blow in front of the anterior annular ligament.
  After a severe injury to a joint, the muscles acting on it may pass into
a state of fixed contraction, or may start into contraction at any effort to
move them, whether  actively or passively.  The joint thus  stiffened is
likely to be regarded as one that has been ivrongly treated; the fracture
or the dislocation, if either have  occurred, may be thought to have been
left unreduced, and an incurable anchylosis may be  talked  of.   But the
stiffness of the joint is due to  the muscles alone; and if, by giving the
patient chloroform, they be relaxed and put  beyond the influence of his
will, the joint becomes at once  naturally movable, or nearly so.  This con-
dition has been noticed at the elbow, the knee, and the hip.  Chloroform,
which may first serve as a test of the state of the joint and muscles, may
afterward be used, to give opportunity for painless and free motion of the
joint Avhile the muscles are recovering.  And their  recovery may be ac-
celerated by friction, warmth, passive motion to any extent that they will
allow, and (Avhich is far better) every possible effort  of the patient's own
will to move them.                                 part xxxvii.^. 245.

  Myalgia,  or Muscular  Pain.—Dr. Inman  has written an  article on
myalgia  or  muscular  pains.  The importance of this affection  does not
arise from it, per se, but from its  great resemblance to other painful affec-
tions, as hysteria, neuralgia, pleurisy, peritonitis, disease of the  liver, kid- 
N.EVI.
245
ney, bladder, or uterus ; for all Avhich affections the author has seen it mis-
taken, of course causing needless alarm to both patient and physician.  It
is generally attended Avith want of poAver of the  system; the fleshy parts
of the muscles, or their  tendinous  prolongations, will  not bear the least
stretching, and in many cases the pain  arises solely from this cause, from
over  fatigue, etc.   The  pain is  independent entirely  of the course  of
nerves, is hot and aching, and attended commonly Avith tenderness on the
least pressure.  This affection will be aggravated by antiphlogistic treat-
ment, but relieved by measures calculated to raise the tone of the system,
as stimulants, tonics, generous  diet, etc.             Part xxxix., p. 11.
  Hysterical Muscular Hyperesthesia.—In addition to general treatment,
M. Briquet recommends faradization of the  skin,  as performed by M. Du-
chenne.  By his apparatus the electrical current is limited to the skin.
The hyperassthesia is usually at once dissipated.   Stimulant applications,
as very hot cataplasms, dry heat, chloroform, and acetic ether, locally ap-
plied  (Avhich act more as irritants than  narcotics,) sinapisms, and blisters
will also be of the greatest use in the relief of the local symptoms.
                                                    Part xxxix., p. 87.
                             NiE VI.
   Treatment  by  Caustics.—Speaking of caustics, Sir  B.  Brodie  says,
 Caustics  may he used Avith  advantage in  congenital tumors, nasvi, etc.
 Little vascular spots on children's faces are an object of anxiety frequently
 in the upper classes ; if you look at these you will see  one large vessel and
 several branches supplying them.   You  may destroy these in  the  follow-
 ing manner: Take a glass pen (pointed glass made into the  shape of a
 pen), wdiich will hold nitric acid, and apply it to the principal vessel; or,
 in this Avay, look for the  principal vessel,  puncture it, and insert into the
 puncture a fine point of potassa fusa; a moment's touch  will be sufficient
 to destroy the vessel;  if  the potassa extend  further than you intended,
 apply vinegar.   You may thus obliterate the vessel Avithout leaving a scar.
 There are some  congenital nasvi abounding in the  skin, formed by a very
 intricate  mesh of vessels; the skin is elevated and of a mulberry color.
 If these are of large size,  they must be destroyed by ligature or the knife  ;
 if of smaller size, you may use caustics not unprofitably.  The nitric acid
 is the best application; this makes a slough, the blood coagulates, and the
 parts become indurated.   This is only applied Avhen nasvi  are of small
 size.   In subcutaneous nasvi, which are not of the same color, but purple,
 caustics may be  applied to effect their destruction, Avhether  of a large or
 small size; the great object is to  destroy them Avith  caustic rather than
 ligature.  These nasvi have been cured by  the application of vaccine mat-
 ter, Avhich acts by producing  a  slough, but I cannot depend upon it, not
 having tried the matter  myself.  You may cure these subcutaneous nasvi
 on the  same principle;   by  this method  puncture them Avith  a  finely-
 pointed lancet, then, having a probe  armed Avith nitrate  of silver by dip-
 ping it into fused nitrate of silver,  introduce  it into the puncture, the
caustic presently causes sloughing,  and the vessels are  obliterated.  If the
tumor be of a large  size, the application must be repeated.   I have used
 this plan wdth great advantage, Avhen it was necessary to save the  skin. 
246
N.EVI.
I was called to  see a  child wdth najvus of the  nose;  to have cut it out,
would have disfigured her for life; so I used a narroiy instrument for di-
viding the skin,  and inserted the caustic-armed probe into the Avound ; the
operation, after  having been performed a feAv times, succeeded perfectly,
and a scarcely observable mark only was left.  I have dotroyed extensive
nasvi in this way, without leaving a scar.  The nitrate of silver is the be>t
caustic for such  tumors, and when you apply it, use olive oil to prevent it
excoriating the skin.   I may observe once for all, that  it is necessary to
use this precaution.   If you are employing  caustic potass, have vinegar
by you; if chloride of zinc, bicarbonate of potass, and  so with the other
caustics.                                                 Part ui., p. 12.
  Treatment of Nevus—Operation by Prof.  Pattison—An assistant,
by means of a  spirit  lamp, made the needles red-hot, and they  Avere
passed in  rapid succession about tAventy times into the tumor in all direc-
tions.  There was no hemorrhage, and*the child apparently suffered very
little pain.  The operation Avas repeated tAvice  afterward, after intervals
of a Aveek, and in the  course of a month the tumor had  entirely ploughed
aAvay, and the part healed.                             Part \i.,p. 157.
  Treatment of Vascular Nevus.—Prof.  Smith, of Baltimore, has de-
vised the following method of treating vascular nasvus.  He saturates a
thread Avith  a saturated solution  of caustic potash.   This is dried by a
fire, and a needle being armed with  it, the base of the tumor is transfixed
Avith the needle,  and the thread quietly  drawn through the part.   This is
repeated in different  parts of the tumor.   Dr. S. states that he has now
under care a case treated by this plan,  and the  tumor is rapidly Avasting,
without any distressing symptoms having occurred.      Part viii., p. 160.

  Blepharoplastie.—Dr. Baumgarten was  consulted about a child, six
months old, which had a  large oval nasvus maternus on the loAver eyelid
of the right eye, extending doAvn to the cheek.  Pulsations isochronous
with the pulse could be both seen and felt, and as the period of its burst-
ing could  not be far distant, to judge from its appearance, Dr. Baumgar-
ten determined to remove it by extirpation, and to replace the loss of sub-
stance by blepharoplastie.   In  effecting the extirpation  of the nasvus, it
was found that the vascular dilatations extended so  deeply, that the orbi-
culus muscle Avas cut   across, and the incisions penetrated into the cavity
of the orbit.  The hemorrhage was less than might have been expected.
The flap to cover in the large wound that had thus been made wras taken
from the temple  and united to the vicinal parts by four  sutures.  In spite
of the continual apphcation of cold Avater, some SAvelling of the face fol-
lowed, but soon subsided.   Union by the first  intention  took place
throughout the  part operated on by the third day, and by the fourth the
last suture was  removed.   The Avound by the temple suppurated freely,
the edges, however,  being drawn together, and the bottom  filled Avith
healthy granulations.   In another Aveek the loss of  substance on the tem-
ple was replaced, and  the cicatrices of the eyelid were scarcely visible.
                                                     Part vhi., p. 165.
  Cure of Nevi by  Croton  Oil.—M. Lafarque  states his method of cur-
ing nasvi,  by inoculating with croton oil, as folio ws: Five or six punctures
should be  made  on and around the tumor,  Avith a lancet  dipped in the oil,
just as in vaccination. 
NJSVI.
247
  Each of the punctures causes immediately a pimple, which hi thirty-six
hours is developed into  a  little boil.   These  boils unite and form a red,
hot, painful tumor, covered with white crusts, and resembling a small car-    •
buncle.  Twro days afterAvard the scabs separate, and in lieu of the nasvus
is seen an ulcer, Avhich is to be treated on general principles.  It would
be dangerous to make more than six punctures on a very young infant, as
the irritation and fever are considerable.                Part ix.,p. 179.
   Creasote in Nevus Maternus.—Dr. Thornton informs us that of all the
applications he has tried against nasvus, the most effectual is creasote.  He
had treated three  cases in the course of the year  successfully Avith this
substance.   It is applied two or three times daily, more or less diluted.
Excoriation, ulceration, and gradual disappearance of the nasvus ensues ;
the cicatrix had ahvays been smooth and sound.         Part xi.,p. 186.
  Aneurism by Anastomosis.—Aneurism by anastomosis, or nasvus ma-
ternus,  as it is termed, when congenital, consists, as is  Avell known, of a
congeries of enlarged and dilated arteries and veins, Avhich can be emptied
of their contents by pressure, and gradually refill Avhen the pressure is re-
moved.   Mr. Cooper considers the disease to be of an atonic character,
dependent, not  upon excessive  action, but upon a defective condition of
the coats of the vessel, arising from arrest of nutrition; so that the dis-
ease may be said to originate in the vasa vasorum.
  When the tumor is small, it is often sufficient  to keep the surface con-
stantly wetted Avith a strong solution of alum ; or a saturated solution of
alum may be injected into the tumor wdth a very fine syringe, but this
must not be done  if the  tumor is large.  Pressure, by means of a plaster-
cast bound upon  the part is only applicable Avhen  the disease is situated
over hone,  and is  not ahvays successful; neither is  vaccination.  The ap-
plication of nitric  acid is objectionable, from the  hemorrhage Avhich re-
sults when  the slough separates; the same danger, that of hemorrhage,
attends the practice of excision.  The ligature is the most generally appli-
cable mode of treatment, and may be applied,  if the tumor is small, by
passing two needles through its base at right angles to each other, tying
the ligature tightly round them, and replacing it by another Avhen it be-
comes3 loose. '                                        Part xx, p. 124.
  Treatment of Nevus by a Solution of  Iodine.—-[Dr.. Bulteel has used
with the most satisfactory result, a solution of iodine Bj., in sp. vin. rect.
gss.  He says:]
  The  preparation was applied freely once every day, not  exciting  the
slightest constitutional derangement, and  the  disease every two or three
days scaling itself, if I may use the expression,  and thus disappearing gra-
datim till nothing more  could be seen but tAvo little spots of the size of a
pin's head.  The application at once arrests the groAvth of the nasvus and
nothing but a regular daily application is needed for its final removal.
               b                                      Part xx., p. 126.

  Use of Collodion  in  Nevus—Dr. Brainard. of  Chicago, struck with
the contractile power possessed by the etherial solution  of gun-cotton,
Avas induced to test its application to the surface of  erectile tumors.  The
first case which he treated in this way was an erectile tumor, the size of a
strawberry, situated over the anterior fontanelle of a very young  infant.
Although the tumor was considerably elevated above the general surface 
243
N.EVI.
of the scalp, it was at once reduced Avhen the solution had dried, and, after
a second application, at the end of six weeks, seemed to be cured.
                                                     Part xxi., p. 197.
  Use of Nitric Acid.—Apply a  drop of strong  fuming nitric acid, by
means of a glass rod, and let it dry on.   If the nasvus is very small, not
even a scar will be left.                                Part xxi., p. 261.
  Use of the  Actual  Cautery.—Pass a flat platinum  needle, heated to
whiteness, through the substance of the nasvus.         Part xxi., p. 261.
  Treatment  of Nevi.—The following  methods  of treatment  for  the
cure of nasvi  have each  their advocates, and are  more or  less benficial,
according as the nasvus may be of the cutaneous, subcutaneous, or mixed
variety.
  They may be severally arranged under the three folloAving heads:
  1. To induce atrophy of the new growth, by—
    a. Compression.
    b. Astringents or refrigerants.
    c. Ligature of the vessels of supply.
  2. To excite inflammation in  the tissue of the nasvus, and thus obliter-
ate  the cells of the new tissue, by—
    a. Seton.
    b. Acupuncture.
    c. Laceration of the tissue by punctures.
    d. Incision and the insertion of sponge.
    e. Cauterization Avith potassa fusa, chloride of zinc, etc.
    f. Injections of stimulating solutions.
    g. Punctures with a probe coated with argenti nitras.
    h. Vaccination.
    i. Punctures, with a lancet's point covered Avith croton oil.
  3. The entire removal of the new growth, by—
    a. Excision of the disease only.
    b. Amputation of the part affected, as  of lips, prepuce, labium pn-
          dendi, fingers,  etc.
    c. Ligature in various Avays.
    d. Complete destruction Aidth caustics.           Part xxxv., p. 196.
  Removal of a Nevus  by  Platinum Wire, heated by a  Galvanic Cur-
rent.—[Cases  of fistula in ano and hemorrhoids  having been  successfully
cured in this manner, in University College Hospital:]
  Mr. Hilton has been trying this plan of cutting and searing at the same
time upon a nasvus of the flat kind, situated in front of the ear of a child
two months old.   The operation was performed with  Cruikshank's  bat-
tery and a very thin wire, Avhich was first intended to tie around half the
tumor, Avhich  \yas about  the size of a croAvn piece.  But the  wire ran so
easily through it, that  the whole Avas  completely removed,  and the parts
are  now fast cicatrizing.  This is rather a  quicker measure  than the liga-
ture, and just as secure, since hemorrhage is so rare.   Part xxv., p. 195.
  Treatment  of Nevi.—Mr. Lloyd destroys nasvi slightly raised above
the surface with potassa fusa, and there is  hardly ever a  return of the
growth.  We have seen  him use the caustic upon very young children,
and the latter did not seem to suffer  much pain.  With erectile tumors,
Mr. Lloyd excites the sloughing action, by injecting into the substance of 
nmvi.
249
the growth the aromatic spirit of ammonia, by means of a small  syringe,
with a long and delicate  pipe.  The naevi seldom resist the action of the
c austic fluid, and generally become obliterated in a few weeks.
                                                    Part xxv., p. 196.
  New Instrument for  injecting the Perchloride  of Iron in Cases  of
Nevus, etc.—In several cases in which this remedy  had been employed in
cases of nasvus, two circumstances proved unfavorable to its success.  Iu
the  first place, by its  being in some too freely used,  inflammation  and
sloughing had  been produced; and, in the second, the flow of blood had
prevented the defective instrument acting efficiently.  To remedy this lat-
ter defect, Mr. Furgusson has invented the folloAving:
  It consists  of a very small glass syringe, the point of which terminates
in a fine platinum tube.  This tube is incased in another one, about a quar-
ter of an inch  longer than the first, ending in a sharp trocar-like  point,
and having, near its extremity, an oblique opening in one side.   By rota-
ting the outer tube on the contained one, their apertures may be made to
correspond or  othenvise, at the will of the operator.  Thus, then, the ne-
cessity for two instruments is quite done aAvay Avith.  The  syringe having
been charged, the  operator rotates the  outer tube, so as  to  conceal  the
orifice of  the inner one entirely, and protect it from the ingress of blood.
In  this state  the  instrument is passed into the centre of the tumor, and,
having been  stirred about as much as may be thought desirable, the tube
is turned  back so as to  expose the orifice ;  and the piston being  at  the
same moment depressed, a drop or two of the solution is squeezed  out.
                                                   Part xxviii.,^>. 172.
   Erectile Tumor of tfie Orbit.—The folloAving mode of treatment Avas
quite successful.   A solution of lactate of iron (eight grains to one drachm
of distilled  Avater) Avas  injected into the centre of the tumor.  Violent
pain in the head and vomiting succeeded, but these  gradually disappeared,
and the recovery wras  perfect.  Dr. Brainard, the  author of this  paper,
believes the  injection of the perchloride of  iron into the blood to be ex-
ceedingly dangerous, because it is a substance abnormal to the constitution
of  the blood, and because it produces instant coagulation.  In the case of
the lactate of iron, its components already exist  iu  the  blood, and its
effects are not  sudden coagulation, but a thickening of the coats with de-
position of coagulable lymph from subacute inflammation  being induced.
                                                   Part xxviii., p. 174.

   Treatment of Nevus by  Tartar Emetic.—Apply on a piece of thin
leather, cut  accurately to the size of the tumor, a  compound of fifteen
grains of  tartar emetic to 3j.  of galbanum plaster.  Inflammatory action
is set up and the vessels obliterated.                  Part xxix., p. 207.

   Use of Acid Nitrate of Mercury.—In moles and nasvi  of the face, if
superficial, apply a solution of the nitrate of mercury in strong nitric acid.
There is a mild form of  dilated cutaneous capillaries Avhich produces  the
marks known as " port-wine stains," " spiders," etc., in the  treatment of
which much  benefit may be obtained by the  dexterous application of fluid
caustics.  With a  finely-pointed glass  brush,  charged either with  nitric
acid, or the  acid nitrate of mercury, the tortuous vascular trunks  should
be  severally painted, a minute streak of the  caustic being  thus left  along
the Avhole course.   In this way, by repeated applications, the whole of 
250                            ijjsvi.
the larger vessels may be destroyed, and the disfigurement to  a large ex-
tent, diminished.
   Vide Art.' " Boils."                               Part xxxi., p. 240.
  Nevus—Caustic Collodion.—In cases Avhere excision is impracticable,
there is no better  caustic, when it  is  desired that they should disappear
quickly and certainly, than  a solution of four parts of deuto-chloride of
mercury in thirty of collodion.  It should be applied Avith a camel's-hair
brush.                                            Part xxxiv., p. 211.
  More than a Hundred Nevi on the same Infant.—A case lately occurred
to Mr. Hutchinson of the Metropolitan Free Hospital Avhere  there were
more than a hundred distinct nasvi of the most superficial character on the
same child ; all Avere cured, except about tAvelve on the scalp, by the con-
tinued application of the compound iodine ointment.  To the remainder it
is proposed  to  apply nitric  acid should they not diminish under a conti-
nuance of the former treatment.                     Part xxxvii., p. 138.
   Treatment of Nevus by  Injections with  Tannic Acid.—Mr.  Ilayncs
Walton has recently treated several cases of nasvus in the folloAving man-
ner :  A small tendon knife  having first been pushed into the base of the
tumor a*nd moved about slightly,  to  break up the  tissue, a solution of
tannin, a drachm to an ounce of Avater, is injected by means of  a  syringe
with a small nozzle.  This must be slowly performed, and must be given
up directly the tension  of the tumor becomes apparent; by this means the
blood coagulates, and after the lapse of some Aveeks the tumor  disappears.
There is no risk of sloughing taking place as when the muriated tincture
of iron is used.                                     Part xxxvii., p. 269.
  Subcutaneous Nevus  over  the  Anterior Fontanelle.—Mr. Erichsen
treated a congenital nasvus over the anterior fontanelle of an infant a few
weeks old, at University College  Hospital in the folloAving manner:  A
puncture AAras made through the scalp on one side of the nasvus, and a blunt
needle-eyed probe armed Avith a  ligature Avas passed through  the base of
the nasvus to the opposite side, Avhich emerged through another opening
made Avith  a knife.  This ivas repeated at right angles to  the first thread,
and the four double cords Avere firmly tied, through fissures made in the
skin, around the tumor, and  complete  strangulation effected. No cerebral
symptom Avas manifested during the  process.  In such cases as these Mr.
Erichsen does not use needles in the usual Avay, because the membranes of
the brain might be punctured, and death might ensue.  But Avhen  per-
formed in the manner described, there is  not the same risk, and in about
half a dozen cases thus treated by him no accident or untoward symptom
occurred, and the nasvus was got  rid  of.  When a nasvus  is situated  over
a bone, of course the sharp needles may be employed, as is  commonly
witnessed.
  A nasvus over the anterior fontanelle, common prudence Avould teach us
requires to be managed differently fro & nasvi in  ordinary and less impor-
tant situations.                                   Part xxxviii., p. 147. 
NX.CREMIA.                          251
                           NECR2EMIA.
  Necremia.—This term is applied by Dr. Williams to that condition of
the blood, in wdiich it appears to be itself primarily and specially affected,
and to lose its  vital properties.  It is, in fact, death oeginning Avith the
blood. The appearance of petechias and vibices on the external surface, the
occurrence of more extensiAe hemorrhages in the internal parts, the general
fluidity of the blood, and frequently its unusually dark or otherwise altered
aspect, its poisonous properties, as exhibited in its deleterious operations
on other annuals, and its proneness to pass into decomposition, point out
the blood as the first seat of  disorder; and, by the failure of its natural
properties  and  functions, as the vivifier of all structure and function, it is
plainly the medium by Avhich  death begins in the body.   The blood, the
natural source  of life to the Avhole body, is itself dead, and spreads death
instead of life.  The heart's action is faltering and feeble; the atonic vessels
become the seat of congestions, and  readily permit extravasations.   The
brain, insufficiently stimulated, after slight delirium, lapses into stupor ; the
medulla  no longer regularly  responds to the  besoin de respirer; and the
respiratory movements become  irregular.   Muscular strength is utterly
lost; offensive colliquative diarrhasa, or passive  intestinal  hemorrhage
often occurs;  sloughing  sores, or actual gangrene of various parts are
easily produced; and  putrefaction commences  almost  as soon as  life is
extinct.  The track of the  superficial veins is marked by bloody stains ;
hypostatic congestion  takes place  to a great  extent; the blood remains
fluid, and stains the lining membranes of the vessels.  Rokitansky describes
the blood as often foamy, from the development of gas, and of a dirty red
raspberry-jelly color; its serum dark  from  exuded hematine ; and  its glo-
bules swollen up by endosmosis.   Coagula are either totally absent, or are
very soft  and  small.  The exudations are  of a dirty red—turbid, thin.
There is scarcely any rigor mortis; the tissue of the heart and of other organs
is flaccid and  softened, and stained by imbibition of the serum.   Gas is
quickly formed in the Aressels and in the areolar tissue, giAdng rise to a kind
of emphysema. It is very remarkable that this necra?mic  condition, or one
closely resembling it, may be  brought on by A'iolent shocks inflicted on the
nervous system, as Avell as by the introduction  of miasmatic or animal poi-
sons into the circulation.   Violent  convulsions, overAvhelming emotions,
the shock of an amputation,  a  stroke of lightning, even a severe exhausting
labor, are mentioned by the German  pathologists as having produced this
effect.  More  common causes  are,  hoAvever, malignant  scarlatina  and
typhus, yelloAv  fever, the plague, and the disease called glanders.   It may be
said, generally, that the early  appearance of sinking and prostration in any
fever, indicates that the blood is thus seriously affected.  We are ignorant
what is the exact nature of the changes Avhich take place in this condition
of the blood.   Probably they are more of a  vital  than  merely chemical
kind—that is, they affect the properties of the  blood more than its compo-
sition. The blood globules do not appear to be destroyed; but they circu-
late probably some time before death, as  so many dead particles prove to
be enlarged and to stagnate in the capillaries, and to part Avith their con-
tained hematine.  The fibrin is  in  great part destroyed; but hoAv  this
comes to pass Ave are ignorant.  We can perceive, on the whole, scarce
anything more  than that the nowers of vital chemistry rapidly decay, and
those of ordinary chemical affinity supply their place.    Part xxxi., p. 52. 
252
NKCKOSIS.
                            NECROSIS.
  Chloride of Zinc in Necrosis.—The difficulty of penetrating the hard-
ened  case of new bone Avhen long formed, is too Avell knoAvn to require
any comment; and it not unfrequently happens that any attempt to reach
the sequestrum is  either rendered abortiAre thereby, or occasions such a
degree of disturbance to the Avhole shaft, as to produce more harm than
good.  Mr.  Guthrie, has availed himself of the peculiar properties of the
chloride of zinc, Avhich, attacking the animal tissue of the bone, destroys
it, and thus causes the earthy matter  to soften and become detached. The
sequestrum is by this means exposed, Avith little pain  or disturbance of the
part, and may be dealt with according to circumstances.  Part ii., p. 137.

  Necrosis.—The opinions of medical  men, as to  the source from ivhich
bones are repaired after necrosis, have been divided betAveen the soft parts
and periosteum on the one  hand and the bone on the other.  Bone may
be deposited in most parts of the body, and also by the periosteum and
soft parts in the neighborhood of bone ; but  it does not seem probable
that these are the efficient agents in the process when any extensive form-
ation  of bone is required.  It  seems more probable that this is accom-
plished by bone, and especially by the epiphyses in  the long bones, after
certain dead portions have been extracted.  Hence Avhen no epiphysis is
present, as in the cranial and other flat bones, Ave percieve  little effort to
be made for the reneAval of any displaced portions. So great is this powTer
of reformation in the long bones of young people that in a very interesting
case related by Dr. Lawrie, of GlasgoAV, almost the  entire tibia, Avith the
exception of the epiphyses, Avas removed and completely renewed, the leg
becoming as useful as ever.
  In the treatment of extensive necrosis, two practical difficulties present
themselves: first, in supporting the  constitution, and preventing hectic;
and  second, in the very tedious process of production of new bone, and
the ultimate cure, by discharge of the dead portion.   The latter is known
to consist in the deposit of neiv bone around the old and dead bone, in-
casing it, and subjecting  it to the very doubtful process of absorption, or
of separation, and escape, through the cloacas  in the new bone, and the
ulcers in the soft parts.
  How soon may the  dead bone be removed by operation ?   The  answer
appears to be: As soon as the inflammatory stage has passed, suppuration
been fairly established, and the constitutional symptoms will permit. The
nature of the operation to be performed must depend on the extent of the
disease.   When the entire thickness is involved, the  necrosed part should
be exposed and a portion cut out, and occasional attempts  made to extract
the portions connected with the epiphyses.  There is  little  risk in hurrying
them away  too soon,  provided  violence is not used  in the attempt; they
will become loose Avhen  the natural process of separation  is complete, and
then comparatively little force will be required for their extraction.  When
the surface of a bone only is exposed and necrosed, it seldom happens that
the dead part is incased in a neAV bone.  It generally scales off, and finds
its way through the ulcer in the soft part, or through an abscess.   Should
the dead portion be extensive, and the position  of the bone admit of it, it
would save time to lay open the sinuses, expose  the bone, and remove with
a sharp chisel all the dead portion.                     Part viii. p. 103. 
XKEDLi:3.
253
  Iodide of Potassium.—Recommended  in cases of Necrosis,  by Lis-
franc.— Vide " Iodic Preparations."

  Observation  on Necrosis.—~N ever  attempt  any  operation  until  the
sequestrum is completely detached; and even then, do not interfere, if the
extrusion of the dead bone is going on favorably.        Part xix., p. 133.

  Necrosis,  caused by Exposure to Phosphorus Vapors.—[Mr. Stanley
recently had a patient at St. Bartholomew's Hospital, wdio had  lost the
whole of his  lower jaw by  necrosis.  The affection Avas ascribed to the
influence of phosphorus vapor, to wdiich the man was exposed in his trade
of a lucifer-match maker.   It appears,  however, that means  are  now
adopted  to prei-ent such disastrous effects  occurring in this occupation.
We are told that]
  Workmen in lucifer-match manufactories have now a chance of escaping
the baneful effects of the evolution of phosphorous acid, by placing saucers
filled Avith oil of turpentine about their work-rooms.   As oil of turpentine
is a solvent of  phosphorus, it is expected that it will absorb the vapors
which do so much mischief.  This precaution  is taken at a large  lucifer-
match manufactory in the neighborhood of the London Hospital, and the
very best results  are expected from it.                  Part xxi., p. 189.
  Necrosis.—Whenever tendons  pass over neAvly developing bone, it is of
the greatest importance that union should be  averted  between them, by
commencing passive motion as soon as it may safely be done.
                                                   Part xxxiii., p. 326.
                           NEEDLES.
  Detection of Needles, etc., imbedded in the Body.—[Portions of iron or
Bteel are extremely liable to be introduced into the body, frequently prov-
ing very injurious.  There are means, however, by Avhich their presence
may be  readily determined.  Mr. Smee,  after some remarks on a case
wdiich came under his care, Avhere a needle was introduced into one of the
joints of the finger, and caused suppuration  and subsequent anchylosis,
Avhich might ha\Te been  prevented could it  have been shown that the
needle was actually present, and its exact spot demonstrated, says :]
  You are all acquainted with  the  curious condition which  steel assumes
under certain circumstances, whereby it evinces properties wdiich are called
magnetic; you know, moreover, that  magnetic poles repel,  and opposite
attract,  each other. You haA-e, therefore, but to render a piece of inclosed
steel a magnet, and you will be able  not only to ascertain  its presence,
but to determine by its polarity its general direction; and by the amount
of magnetism it evinces, you  may even infer its probable bulk.  When
you suspect the presence of a piece of needle, or other steel instrument,
you must subject the suspected  part to a treatment  calculated  to render
the needle magnetic ;  and there are two  principal methods by which this
object may be effected.  The first, by transmitting a galvanic current at
right angles, to the suspected part; the second, by placing a  large magnet
near the part affected, so that the object may be magnetized  by induction.
  For my own part, I should use the second plan, or  the plan of magnetiz-
ing by induction, to  render the needle magnetic.   For this purpose, I 
254
KEKVOUS DISORDERS.
haAe  employed a temporary electro-magnet, wdiich  I  magnetized by the
voltaic battery, and you will find, that  by keeping the part affected as
close as possible to the instrument, for about half an  hour, you will suffi-
ciently obtain the desired object.  To test the existence of a magnet Avithin
the body, we may take a magnetized  seAving needle, and suspend it by a
piece of silkworm's silk, when it Avill exhibit certain phenomena upon the
approach of the suspected part, provided it contain a piece of magnetized
steel.   Although this simple contrivance wdll amply suffice, I, myself, pos-
sess a needle, Avhich was made for me, and which is Avell adapted  for the
purpose.   It consists of a dehcate  needle, about six inches long, centred
upon a small agate cup, resting upon a steel point, so that the smallest pos-
sible amount of resistance is  offered to its free play.  When a part, con-
taining magnetic steel, is  brought near the needle, it may be attracted or
repelled, it may move upAvard or doA\rnward, or it may  exhibit disquietude
accordhig to the  position in wdiich  the new magnet is  held.   We may de-
tect the position of the foreign body, when it is of any size, by ascertaining
where its north and south poles lie, and these are determined  by their
repelling and attracting the  opposite poles of the magnetic needle.  The
disquietude or motion upAvard and doAvnward, merely indicates magnetism,
but not the direction of the magnet.
  You will doubtless be surprised Avhen I tell you, that, in this manner, I
haAre detected a piece of needle impacted in the finger of a young Avoman,
although it weighed but the seventh of a grain.          Part xi.,p. 184.
  Exploring Needle— Use of in Pelvic  Abscess.—Prof. Simpson states
that the exploring needle is never used to more adi'antage than when em-
ployed for the exploration of pelvic  abscesses, when  they  happen to he
unusually difficult or doubtful in their  diagnosis. The best exploring needle
is a long, slender  thread-like  trocar, Avith a wire stylet passing through it,
and this instrument may with  safety  be passed into the most important
organs, and the most malignant tumors.   Inflammatory pelvic tumors feel
fixed  and immovable to a degree  seen  in  the case of no  other morbid
groAvth, and more particularly Avhen occurring in the broad ligament—their
most common seat—and lying close  to  the ilium, they feel  so hard  and
adherent that they might almost be mistaken for an osseous tumor.
                                                      Part xl., p. 205.
                   NERVOUS  DISORDERS.
   Croton Oil in Nervous Disorders.—Mr. Cochrane of Edinburgh relates
the following:
  Some time  ago I ivas called to attend  a  patient aged  about 30, of a
strong and robust constitution.  When I first saAv him, he ivas outrageous,
and could not easily be managed by four strong individuals. His gestures,
deportment, and violence Avere such as Avould have  induced many prac-
titioners to have had recourse at once to the strait jacket, but to me they
occasioned little alarm,  as I well  knew the certainty of my remedial
agent speedily producing an effect, at once useful  to the patient, and gra-
tifying to  those around him.  I prescribed as folloAvs :
  R  01. tiglii gtt. x.; mucilag. gum. arab.; sirup simp. aa. §j. Misce. Sign.
Give a teaspoonful every ten minutes until he become calm.
  Half an hour had scarcely passed when he became quiet,  and at the end 
NERVOUS DISORDERS.
255
of an hour, he had so far recovered as to be able to sit up in bed, and give
rational replies to every question.
  I Avas called to attend a female patient, Avhom I found in bed completely
prostrate, and  apparently insensible to everything around her.   In  fact
she Avas completely comatose, her pupils were greatly contracted, her pulse
could scarcely be felt, and, in fine,  she  seemed  all but  sunk into the sleep
of death.   The remedy which I employed in this case, was the croton oil,
in combination AAdth mucilage and  castor oil, thus proportioned:
  R 01. tiglii, gtt. viij.; ol. ricini, §iij.; mucil. G.  arab. 3j.  Misce bene.
Sign, enema.  To be administered in a quart of gruel.
  Though  I  scarcely expected any good to  result from the above potent
remedy, I must say, it had a most beneficial effect upon the patient, not by
producing  an alvine torrent, but by occasioning a very copious discharge
from the bowrels  per anum, as Avell as from the stomach, by vomiting, to-
gether Avith a return of sensation  and motion, and the use of her mental
faculties.                                                Part iv., p. 36.

   Diseases of the Nervous System with the same Symptoms, but arising
from different  Causes.—[We cannot be too frequently reminded how im-
portant it is  in  practice to treat  each case  according to its own  merits,
without being influenced by the name affixed to the disease.  Dr. Cham-
bers judiciously points out the following instances, in which similar symp-
toms arise from totally opposite causes, and therefore require very different
treatment:]
   In apoplexy Ave have a suspension of the functions of the brain, depend-
out upon an  excess of blood in that organ.   In syncope Ave have a similar
state of the cerebral functions from a deficiency of blood.   We have  con-
vulsions dependent upon an excess of blood in the brain,  as in cerebritis ;
and,per contra, Ave have convulsions dependent upon a deficiency of blood;
as in excessive hemorrhage.   In the varieties of delirium tremens, in the
varieties of puerperal  convulsions, and in continued fever, as  contrasted
Avith inflammation of the brain, Ave have a similar type of symptoms,  aris-
ing under  opposite conditions of the system, and  requiring opposite
modes of treatment.
   The delirium tremens Avhich attacks the habitual  drunkard, who be-
comes suddenly deprived of his  drink,  is in appearance similar to the  deli-
rium  that  attacks  the  individual  of usually temperate habits, during an
excessive debauch.  But experience tells us that in the one case Ave have
to deal with  exhaustion; and in the other, wdth a state closely bordering
upon (if not actually), inflammation of the brain.  The  puerperal  con-
vulsions that arise during the efforts of parturition, are in  appearance the
same as the convulsions that come  on  after the birth of the  child, which
merely depend upon fatigue, combined, it may be, wdth too great a loss of
blood ; and the delirium of fever  has so close a resemblance to the dehrium
of cerebritis,  that writers of no mean authority have  been  induced to view
the two diseases  as identical, or more properly speaking, to  consider the
former disease as the consequence  of the latter, and to regulate the treat-
ment  accordingly.   There is not,  I am convinced, in the whole range of
practical medicine, a more fatal error  than this; it  induces  its disciples
(and they are numerous) to haAe recourse  to blood-letting at a period
when their efforts should be directed to the increase and restoration of the
vital fluid.  I have alluded to blood-letting because it generally stands  first 
256
NERVOUS DISORDERS.
on the list of remedies; but it  is quite possible to do an equal or even
greater amount of mischief by the improper use of purgatives and mercu-
rials.                                                   Part xv., p. 45.

  Effects Produced on the  Blood by Mental  Labor.—Intellectual, like
muscular action, probably involves  an expenditure of living material, and
introduces a changing  series of particles, those Avhich have been used giv-
ing place to others Avhich come with the energy of neAV life to perpetuate
the action.   Stagnation may induce decay, but  undue  persistency, haste,
or intensity, especially  in creative efforts, may occasion Avaste.  The author
proceeded to adduce examples.  One instance was an account-keeper, who,
after being for  some Aveeks  engaged twelve  hours daily at the  desk, lost
the power of fixing his attention, and became affected with such sensitive-
ness of the nervous system as  to  be frequently kept  awake  at  night by
tingling of the skin,  and,  when  he fell  asleep, disturbed  by frightful
dreams.   There Avas no emaciation, loss of appetite, or disturbed digestion,
and the urine  Avas natural Avith the  exception  of a feAv oxalate-of-lime-
*?rystals ; but there was a strong venous hum in  the jugular veins, a slight
cut bled freely, and the blood under the microscope exhibited a remarkable
deficiency of pale corpuscles, the proportion not being more than a fourth
of the average in health, or  a twentieth of  what is common in phthisis.
This patient, wdth better regulated habits, and the use  of cod-liver oil and
nitro-hydrochloric acid, has rapidly improved.  The author observed, that
the clergy, being specially exposed to the wear of thought and sympathy, are
peculiarly liable to this disordered condition of the blood, their nervous
system becoming  unduly susceptible, and their  minds rendered too easily
accessible to the delusions of pseudo-science and quackery.  He described
the case of a popular clergyman, who, Avithout impairment of digestive or
muscular power, became affected  Avith sleeplessness  and disturbed  con-
tinuity of thought, the principal physical symptom being jugular murmur.
Nitro-hydrochloric acid, cod-liver oil, and subsequently phosphate of iron,
with phosphoric acid, Avere employed Avith most satisfactory results.  Dr.
Thompson Avas disposed to think, that^the wear of inordinate and anxious
work acted as a succession of  shocks through the nervous system on the
blood, and he illustrated his vieAvs hy histories of effects produced by sud-
den and violent shocks physical and mental, shoAving that railway collisions
occasionally produced  results analogous to those depending on intellectual
causes, and adducing an instance from the practice of Sir Henry Marsh, of
death  from entire  change in the condition of the blood, Avithout any other
organic disease, induced by the mental shock occasioned in a young lady
by having accidentally administered poison to her father.  After relating
instances illustrative of the exhausting effects of exclusive attention to one
object, and  remarking on the  varying phenomena resulting from differ-
ences  of temperament, or from association Avith  indigestion and  other
collateral  ailments, the author proceeded  to  shoAV, that in addition  to
measures directed to regulation of the mental habits, medicines calculated
to enrich the blood were  most important auxiliaries, and that oils could
often  be employed when chalybeates proved too exciting.'  The class of
cases referred to pointed to the conclusion, that over-work  of the brain
may often occasion deterioration of the blood before the condition of other
organs disturbs the brain.                            Part xxxv., p. 30. 
NEURALGIA.
257
                          NEURALGIA.

  Abstracts from the best Writings on Neuralgia.—The following is the
formula of Rauque's celebrated liniment, and we  have found it in several
instances a valuable and powerful application:
  R  Extract of belladonna, two scruples :  laurel  Avater, tAvo ounces ; sul-
phuric ether, one ounce.   Mix.
  Let it be rubbed on the part, and a flannel moistened  with it left applied.
  Dr. Johnson says, that steeping twro or three folds of lint or rag in the
liquor ammoniacas, and inclosing them in the top of a wooden pill-box, and
applying it to the skin from one to  tAvo minutes, is a very valuable  means
of counter-irritation, producing a crop of vesicles, and requiring no subse-
quent dressing.
  The endermic application of morphine is very strongly recommended
by Dr. A. T. Thomson, in all cases  Avhere pain is the prominent symptom.
Dr. T. employs the hydrochlorate, mixing  one or two grains with six of
sugar, and sprinkling it on the denuded blistered surface tAvice a-day.  To
affect the general system, the  nearer it is applied to the head the better.
Smaller doses may be used  at first.   A pustular eruption, often of some
severity, usually folloAvs, and is itself a source of relief.
  Dr. Richab, of Strasburg, attributes great good to  one grain of quinine
and tAvo of common snuff, introduced into the nostril of the affected side.
It has been found to act as a charm, and may at all events be safely 'tried.
Perhaps errhines are too much forgotten  in  affections of the fifth pair.
Frictions Avith the veratria ointment, or by the endermic method, are doubt-
less of value, and perhaps failure  not unfrequently depends on their imper-
fect mode of application.
   Dr. Churchill advises the following form of plaster:
   R  Carbonate of ammonia, one drachm; extract of belladonna, three
drachms.
   Pareira speaks favorably of the tincture  of aconite rubbed  in with a
sponge attached to a stick, till the pain ceases.  One  to three  drachms
were used at each application.  Three minims may  be given internally for
a dose.
  Mr. Jeston after giving one or two doses of calomel and rhubard, gave—
  R  Narcotine, tAvo grains; dilute sulphuric acid twenty minims; infusion
of roses, one ounce and a half.  Every tAvo hours during the  intermission.
It frequently arrested the disease at once.   The same observer advises col-
chicum, especially in rheumatic and intermitting pains.
  Mr. Baily, of Harwdch, obtained much credit fi-om  the following  prepa-
ration  of belladonna: Macerate for twenty days,  tivo ounces of the dried
leaves in a pint of proof spirit.  Dose from twenty to forty drops.
  M. Valleix, in his elaborate treatise on neuralgia, in addition to fly blis-
ters, quinine, steel,  etc., states that  much benefit resulted  from pills com-
posed of equal parts of henbane,  valerian, and oxide  of zinc, given in in-
creasing doses of from one to thirty per day*.
  The hydrochlorate of ammonia, in doses  of a scruple to half a drachm,
three times a day, is recommended by the German and some British prac-
titioners, as  of great value in cases of  facial neuralgia and hemicrania.
  A pound of quicksilver laid on  the affected eye in oil  silk, pencilling the
part with Gourlard extract, equal parls of eau de  cologne and sulphurio
    TOL. II.—17 
258
NEURALGIA.
ether poured on the cheek and forehead, a plaster of opium and  bella-
donna, were also the means of temporary relief.
 •Dr. Baillie Avas very partial to three or four grains of the extract of hen-
bane twdce or three time a-day in facial neuralgia ; and Dr. Warren placed
his chief reliance on small doses of blue pill and belladonna.  Shaving the
head, and washing it Avith cold Avater, and the use of the cold douche for
two or three minutes on  alternate days, has at times succeeded.
  In the " Bulletin  Gen.  de Therapeutique," it is stated that the principle
of treatment is to check  or mitigate the paroxysm by a full dose of opium
and ether, given immediately before the paroxysm, and to administer large
and frequent doses of bark during the remission. Ten to fifteen grains of
quinine, exhibited after the pain has ceased, will at once make an impres-
sion, and often abridge the next paroxysm.
  Many very obstinate cases were cured by giving opium until narcotism
Avas produced.   Some w^re bled during its continuance, and the pain ceased
in  the majority.
  Dr. Christin speaks highly of the folloAving plan:
  R  Acetate of morphia,  one grain; distilled water, four  otmces;  sirup
of acacia, one ounce. Mix.  A tablespoonful every hour.
When the pain is relieved, and sleep commencing, every tAvo hours, sus-
pending if narcotism is induced; the patients to avoid .fluids during its
administration.   It often  caused perspiration, diarrhoea, ami diuresis.
   We think Avell ourselves of small and  repeated  doses of opium.  Dr.
Bardsley, in his Hospital Reports, relates several successful cases from the
free use of morphine.
   Mr. Greenhow read a paper at the meeting of the  British Association
at Newcastle, insisting upon  the value of inducing rapid but moderate
salivation, and relates several cases of success.  It would, no doubt, prove
useful in many cases where the visceral health was principally disturbed.
The suggestion is worth  remembering.
  Dr. Burgess  strongly advises ten grains of the extract of aconite  made
into 12 pills with liquorice powder, and one to be given every tAvo hours,
repeating it till the  pain was relieved.
  Croton oil, has also lately been much  recommended by Sir Charles Bell
and Drs. NeAvbigging and Allnat, as possessing some specific influence on
the ganglionic nerves, apart from its purgative action.
  Dr. Bennett has found the iodide of potass of great use in cases of ner-
vous headache, when the circulation  was not affected.
  Dr. Martinet,  particularly in cases of crural and sciatic neuralgia, advises
 he use of turpentine as follows :
  R  White of egg, No.  1; turpentine, three drachms;  sirup of pepper-
mint, two  ounces;  sirup of orange,  two  ounces.  Mix.   A tablespoonful
three times a-day, adding laudanum if sickness is present.  In most instan-
ces the pain has ceased in a week.
  A drachm of creasote  to the ounce  of lard has been strongly recom-
mended  as a local application-
   Magendie has found great benefit  from inserting two  platinum needles
in the nerve, and passing the current  from  Clark's electro-magnetic ma-
chine,  connecting the  positive  pole with the needle nearest the  origin
of the  nerve.   If  the  pain shifts, we must follow it in the  affected
branch.
   The following is Dr. Graves' neuralgic plaster: 
NEURALGIA.                          25D
  R Powder of opium, two scruples; camphor, half a drachm; Burgundy
pitch, and plaster of lead, of each as much as may be necessary.  Mix.
  This is enough for the  largest plaster.  Steep the part Avith Avarm water
before applying it.                                     Part viii., p. 28.
  Neuralgia of the Urethra.—A woman thirty-two years of age, mother
of four children, suffered for eight months from pain at the lower part of
the abdomen, with  scalding on making water, and a constant sense of titil-
lation at the orifice of the meatus.   The pain became so severe as to pre-
vent the patient from sleeping.  The bladder was examined, but no  sign
of  calculus found.   Various  remedies  were  tried wdthout effect.  Two
issues, Avith the Vienna caustic, Avere noAV made over the hypogastric re-
gion.  The patient had  tepid baths, containing two drachms  of the sul-
phate of potass, and some  pills composed of hyoscyamus  and  extract of
lettuce.  This mode of treatment effected a cure.        Part viii., p. 168.
  Extract of Tobacco in Neuralgia.—Extractum nicotianas Avill cure neu-
ralgia so that it shall not return  again,  and this wdth once using.  It has
been known to cure toothache speedily with one rubbing  on the face.
                                                       Part xii., p. 43.
  Periodic Neuralgia.—Sir B. Brodie recommends in those cases of neu-
ralgia assuming an  intermitting character, large doses of sulphate of qui*
nine, from a scruple to half a  drachm daily.  Combine it if necessary wdth
Fowler's solution of arsenic ;  but omit the arsenic unless unsuccessful with
quinine and other  remedies.                             Part  xiii., p.  62.
  Aconitum Napellus in Neuralgia.—It is of the greatest importance that
it be used Avith caution, or serious mischief wdll be the result.  Dr. Kirby
directs  a liniment  made Avith one  drachm  of tincture of aconite of the
shops, and seven drachms of fresh palm oil, or Avith two ounces of camphor
liniment.  Rub half a drachm or a  drachm of the former, or double the
quantity of the latter, into the part affected,  tAvice or thrice a-day, accord-
ing to its effects.   It must be  Avatched attentively, as the medicine is cumu-
lative.  If its poisonous  effects appear, give  a stimulant, as Avine, or get
the patient into the fresh air.                           Part  xiii., p. 65.
  Intermittent Facial Neuralgia—Mr. Hargrave recommends three grains
of sulphate of quinine, Avith one-eighth of a grain of sulphate of morphia,
an hour before  each expected  attack, and then give five drops  of tincture
of Indian hemp three times a  day, and rub  some cajeput oil on the part
affected.  Continue the quinine three times a day, and increase the Indian
hemp to seven  and  ten drops three times a day till relieved.
                                                      Part xiii., p. 66.

  Cardiac Neuralgia treated by Colchicum.—In cardiac neuralgia, accord-
ing to Dr.  Fife, colchicum was especially useful, either Avith or Avithout a
few drops of  the tincture of digitalis with each dose, when the action of
the heart Avas much increased  as Avell as irregular.   A local application in
these cases, of  great efficacy in relieving both the inordinate  action and
intense pain,  Avas the tobaccodeaf, slightly moistened and  placed over the
region of the heart, care ahvays being taken  to remove it so soon as any
feeling of giddiness, faintness,  or  sinking, Avas experienced by the patient.
                                                       Part  xiii., p. 67.
  Valerianate  of Zinc.—Recommended in most of the protean forms of 
260                          NEURALGIA.
hysterical neuralgia.  Dose, three-fourths of a grain to one grain tAvice or
three times a day, made  into pills Avith mucilage or conserve of red roses,
or in a solution in orange-flower water, or in distilled water flavored Avith
sirup of orange-flowers.   The compounder must bear in  mind that the
crystals of valerianate of zinc do not dissolve  readily in cold  water, float-
ing on the surface in consequence of their lightness ; they should, therefore,
be first incorporated Avith a few drops of water in a mortar.
  Incompatibles.—All acids ; the solid  carbonates; most  metallic salts;
and astringent vegetable infusions or decoctions.         Part xv., p. 64.
  Facial Neuralgia from  Uterine  Disease.—May depend upon ulceration
of the os uteri; if so, cauterize the ulcer with nitrate of silver, or the acid
nitrate of mercury;  as  the ulcer heals the facial affection will  probably
cease.                                                  Part xv., p. 65.
   Tic Douloureux.—Cautiously apply an atropine lotion to the side of the
face, night and morning: R Atrophias sulphat,  gr. ij.;  aquas rosa, §ss. M.
fiatlotio; and give the"folloAving pills: R Ext. belladonnas,gr.one-fourth;
fel. tauris, inspis. gr.  iv.; pulv.  scammon. gr.  iij.; sodas sesquicarb. gr. iij.;
assafoetidas  gr.  ss.  M.  ft. pil. ij. hora somni  sumend.  Give an  alkaline
Avarm bath twice  a-week, and insist upon abstinence from stimulating food
and drink, and upon the patient taking plenty of exercise.  Or try etheri-
zation.   Put two drachms of ether into a water jug wdth a mouth wdde
enough to receive the face, and place this in a hand-basin containing a little
hot Avater.  Direct the patient to breathe into and out of the jug,  placing
a towel oiTer his face to  prevent the  escape of the vapor.  To prevent the
recurrence of the attacks give 5 minims of turpentine  three or  four times
a-day, and let the alkaline  baths, and the effervescing  Pitville  Avaters  be
used.                                                  Part xvi., p. 88.
   Morphine in Frontal Neuralgia.—Let  from a quarter of a  grain to a
grain of muriate of morphia be snuffed up the nostril of the affected side,
daily,  having previously cleansed the mucous membrane by an  emollient
application.                                            Part xvi., p. 89.
   Neuralgia.—Rub in fifteen or twenty drops of  chloroform, and repeat
the application  if necessary.                            Part xix., p. 67.
   Sciatica, Chronic.—Where all the usual .remedies have failed,  electro-
 galvanism may be safely recommended, Avith every chance of success.
         *******        *
   In severe cases, put the patient under the  influence  of chloroform, and
 Avith a red-hot iron make an eschar along the outer part of the dorsum  of
 the foot.                                             Part xix., p. 308.
         ********
   Neuralgia accompanying Herpes Zoster.—Apply a  blister near or over
 the affected part; and Avhen the blistered surface  has  healed, apply a bel-
 ladonna plaster.
   Give grain doses of oxide of silver, combined ivith compound galbanum
 pill and extract of hyoscyamus; and use a liniment containing tincture ol
 arnica montana, tincture of opium, and soap liniment.     Part xxi., p.  79.
    Tic Douloureux remedied by Operation.—A young woman, aged  25,
 was brought to Dr. Allan, a perfect martyr from tic,  beginning over the
 right eyebrow  and extending over the face.   Her  complaint had  been of 
NIPPLES.
261
six  years' duration, and Avas gradually becoming more  severe.  It com-
menced Avith characteristic exactness at a certain hour in the morning, at
times changing its time  of visit until night.   On feeling the pained  eye-
brow, the cellular  substance on both sides seemed very thick.  A hard
body was detected ; and  on cutting doAvn,  a calcareous concretion was
dislodged from its position immediately ove«  the supra-orbital foramen.,
Avhere  it Avas attached to the nerve.  Since its extraction, the girl has been
comparatively free from pain.  Dr. Allan asks: "May not inveterate tic
be often caused by similar deposits in  inaccessible portions  of nervous
channels f"                                           Part xxv., p. 73.
  Neuralgia, Facial.—M. Cazenave rubs the followdng pomade over the
affected nerve, reneiving  the  application according  to  circumstances:—
Pure chloroform, 4 drachms; cyanide of potassium, 3\ drachms; axunge,
3 ounces;  Avax sufficient to give consistence.   If the neuralgia  is in the
scalp, a piece of the ointment the size of a pigeon's egg is to be rubbed
over the part, and the head is then to  be covered with an oilskin cap.
                                                     Part xxvi., p. 43.
   Use of Strychnia.—Dissolve two grains of strychnia in §j. of phospho-
ric acid (P. L.),  and  give five minims  three  or four times daily, either
alone or combined with some other remedy adapted to  the nature of the
case.                                                 Part xxix., p. 54.
   Neuralgia.—Where the simple carbonate  of iron fails to  give relief,
give the saccharine carbonate of iron and manganese.  Part xxix., p. 315.
   Hypodermic Injections.—In Edinburgh the use of narcotic injections
by means of a small glass syringe, Avith a sharp holloAv needle, like the
sting of a wasp, has become almost universal; if, in a case of neuralgia, it
be introduced at the point where there is most pain on pressure, and a
few drops of narcotic fluid be injected, instantaneous relief will often be
afforded.  In the case of elderly people caution is required, as the injec-
tion is apt to take a strong effect.
   For the relief of a localized pain, it is not necessary  to confine  the in-
 jection to the painful part: the injection may be inserted with quite as
striking results in any other part of the body, and thus the tendency to
 abscess in the part, from repeated injection,  is avoided.
                                                   Part xxxviii., jo. 31.
   Dental Neuralgia.—Place in the ear, on the side  on  Avhich the neural-
gia prevails, a little of the folloAving, on cotton wool:  acetate of morphia,
one and a half grains, acetic acid, tAvo drops,  and eau de cologne, §ij.
                                                    Part xxxix., p. 76.
        *      *       *       *       *       *       *       *'
   Vide Ait. " Medicines."
                             NIPPLES.
  Treatment of sore Nipples.—The tincture of catechu holds a high place,
and has been found a very excellent astringent; like the other remedies
of this class, it is best adapted for the simply excoriated or abraded nip-
ple.  Nearly similar to it is the solution of pure  tannin, so  highly rccom- 
262
NIPPLES.
mended by Mr. Druitt.  It is made by dissolving five grains in an ounce
of distilled ivater.  The following  is a favorite lotion with Dr. Johnson,
who has been in the habit of using it for many years:
  R Sub-borat. sodse, 3ij.;  cretae precipitat, |j.; spiritus vini, aquas rosae,
aa.  §iij.  M. fiat lotio.
  This may  be applied alternately wdth the folloAving ointment, or the
latter may be used alone:
  R Ceras albas, givss.;  ol.  amygdal. dulc. |j.; mellis despumat. §ss.; dis-
solve ope caloris, dein add e gradatim, bals. peruviani, 3hss.  M.  fiat un-
guentum.
  In some cases Ave have seen benefit result  from the use of tincture of
galls  and compound tincture of  benzoin (Friar's balsam), in equal pro-
portions.
  It is always wrell to have in  mind a  number of these different prepara-
tions, for it  not unfrequently happens  that one Avill answer our  purpose
when others haA-e failed.  For fissured nipples some authors strongly ad-
vise the application of solid nitrate of silver ;  Dr. Johnson thinks  it some-
times a good remedy in such cases, at a remote  period from delivery; but
that during the puerperal state its  use is not  advantageous, as it is apt to
be followed by mammary abscess.                     Part xviii., p. 303.
  Treatment of sore Nipples by Collodion.—The  following observations
are quoted from Professor Simpson's paper on gun-cotton solution : It has
been  proposed to use the ethereal solution of gun-cotton for other purposes
than the dressing and curing, of wounds—for example, as a substitute for
the starch bandage in fractures; as an application and dressing to ulcers,
etc.  In  abrasions, and slight injuries of the  skin about  the  fingers, it
forms an excellent and adhesive dressing.  There is one extremely painful
and unmanagable form of ulcer in which I applied it eight or ten days ago,
at the Maternity Hospital, with perfect success.  I allude to fissures at the
base of the nipple.
  It acted successfully by maintaining  the edges so  firmly together that
they Avere not again re-opened by the infant: the gun-cotton dressing Avas
not, like other dressings, affected by the moisture of the child's  mouth;
and as a dressing, and at the  same time, by  securing  rest to the part, it
allowed complete adhesion and cicatrization speedily to take place.  I have
applied it also repeatedly to ulcers of the cervix uteri and over various
cutaneous eruptions.  Its application relieves at once the smarting of slight
burns.                                                Part xix., p. 212.
  Sore Nipple.—Apply lycopodium powder mixed with a little oxide  of
zinc.   It  must be powdered well over the part after  every time the  child
sucks.                                                Part xxi., p. 260.
   Chapped Nipples, M. Cazenave's Balm for.—Olive oil,  |x.; Venice
turpentine, §ij.; yellow wax, §j.; alkanet root, gss.; boil together, strain,
and add  of balsam of Peru, 3iis.;  camphor, 9£  gr.; stir constantly until
cold.                                                 Part xxvii., p. 161.
  Sore Nipples.—M. Bourdel recommends the application of a piece of
lint dipped in the tincture of benzoin placed  over the part, then removed,
wetted Avith the tincture, and replaced so as to cover the ulcer Avith a
layer of liquid.  The first application is painful, but the pain seldom lasts
more than fifteen minutes; the tincture forms a coating, Avhich  the action
of sucking does not displace.                          Part xxx., p. 228. 
NITRIC ACID.
263
  Sore Nipples.—M. Legroux has found the fodoAving treatment very effi-
cacious.  Collodion is rendered elastic by the addition of half a part of
castor oil, and 1\ parts of turpentine to 20 of collodion.  It is applied by
means of a pencil over a radius of some centimetres around but not on the
nipple.  Over this is applied a piece of gold-beater's skin, having some pin-
holes opposite the nipple to allow of the passage of the milk.  This, by the
drying of the collodion,  becomes  rapidly agglutinated.  Before suckling,
the gold-beater's skin is moistened ivith  a  little sugar and  Avater,  and
becoming soft and  supple, easily admits of sucking.  If it is cracked it
must be replaced.                                   Part xxxv., p.  255.
  Sore Nipples.—An excellent application is  a mixture of equal  parts by
wreight, of glycerine and tannin ; the  tannin  readily dissolves  in  the  gly-
cerine.                                            Part xxxviL, p.  239.
                           NITRIC ACID.
   Nitric Acid in  Diseases  dependent on Vascular Debility.—[Mr. Wil-
 kinson acknoAvledges that mercury is the only remedy to be relied on  in
 cases truly venereal, but contends that nitric acid  acts almost as a specific
 in many diseases dependent upon vascular debility.   The remedy, he  re-
 marks, is by no means new, but it has  not been properly understood; that
 it has cured  many  cases for which he  recommends it, there is  abundance
 of testimony on record.
   The first case in  Avhich he tried it, Avas one of dropsy of the abdomen,
 with diseased liver.]
   His countenance Avas sallow and shrunken, his abdomen and legs swelled
 to an enormous size, the latter resembling in shape the limbs of an ele-
 phant.   His  scrotum hung half way down his thighs, and  the skin of his
 penis Avas distended to the thickness of a man's arm.  His pulse was small
 and weak, and beat not more than thirty strokes in a minute.  His history
 was soon told.   He had been a constant frequenter of a public houje, had
 been ill about two  years wdth diseased  liver, and then dropsy had super-
 vened about ten months before paying me  his first visit.
   [He was ordered six grains of calomel and ten of eolocynth at bed-time,
 wdiich brought awray two  motions, resembling  melted pitch.  The dose
 was repeated;  tAvo motions like the former followed, a third was brown
 and  looser.   From  his uneasy state and difficulty of breathing, a trocar
 was passed,  and a pail and a half of highly albuminous fluid drawn off.
 Hyd. c.  cret., cream of tartar and jalap, at bed-time, produced a  watery
 evacuation, containing yelloAv bile.]
   I iioav determined  to  give the nitric acid, beginning  with thirty drops
 of the dilute every four hours, in a glass of decoction of cinchona.  This
 was increased ten drops per diem, till he took 250 daily, and continued it
 for two months.  The dropsy had entirely disappeared, and his pulse risen
 to 90 in a minute, and full.  The secretion of bile and urine had returned ;
 he could eat a  beef-steak for  breakfast, and was ready for another before
 his accustomed hour of dining,  wdiich  Avas one o'clock.  In less than six
 months he was  as fat and well  as ever he had been  during his life.  The
 most singular part  of this case  is, that my patient afterward returned to
his old habits of drinking, but, I believe not to his former excess.  I saw 
264
NOSE.
this  person three years  aftenvard; he had no return  of his  complaint
whatever.  He took the nitric acid nearly three  months.  There  is one
thing here I wish to point out, viz., that in all cases of obstinate obstruc-
tion  of the liver, a large dose of calomel must  be given; small doses are
worse than useless.
  I make it a practice of giving the nitric acid  and bark before and after
operations  for scirrhous breast, in chronic erysipelas,  and immediately
after the acute stage of that disease; in debility, after an attack of gout,
and in most nervous diseases; in extreme old age I have found it increase
the appetite, raise the  spirits, and induce sleep, where opium and other
narcotics have  tended  to keep up the disorder  they were  intended to
remove.  In valvular affections and enlargement of the heart by dilatation,
I have found the most  decided benefit, especially if the  liver  perform its
office tolerably.   Of course,  in such cases  as the last, a cure could not
be expected, or even looked for, and I  have seen quite enough of digitalis
to discard  it in toto.   If the nitric acid is taken for some time, it raises
the pulse, it  renders it fuller, but deprives it  of its wiry hardness.  It
does not destroy the teeth, like the  other  mineral  acids, nor turn them
black. I  have never seen it produce  salivation, but  it  will  cause great
redness of the mucous  passages, the tongue and fauces.  Part xii., p. 139.
                               NOSE.
  Cure of Crooked Nose by Subcutaneous  division of the Cartilages.—
[Dr. Dieffenbach remarks that the wrynose  is either a natural deformity,
or is caused  by accident.  He has operated in  tAA-o cases with complete
success: in one, the deformity was  congenital,  and in the other, it Avas
caused by a fall.  He thus describes the operation :]
  With a small curved bistoury I made a  puncture by  the  side of the
bridge of the nose, at the point of union betAveen the cartilage and the
bone, the bistoury Avas then  carried under the skin, so  as to separate tho
cartilage of the side and bridge of  the  nose from the bone.  By a second
puncture, on  the other side, the middle partition of the nose and the car-
tilage of that side were divided.
  The nostrils were then  stuffed Avith  lint, and  the nose  retained in its
proper position with strips of plaster.   The  parts healed quickly, without
inflammation  or suppuration.                            Part iv.,p. 101.
  Case of Nasal Enlargement successfully  treated.—This Avas a case of
peculiar  enlargement of the nose, in a ,young lady, unaccompanied with
pain or any  other inconvenience than  the  size.  Besides constitutional
treatment,  Dr. Clay  made  pressure  on the organ, by means of a  mold
made of plaster of Paris, which was useful not only by pressing uniformly,
but also by its mere Aveight.  The mold was secured to the head by differ-
ent tapes, which were applied so as to  increase the pressure.  In a week
the mold was found too large, and a second one was made; a third, fourth,
and fifth were obliged to be made, as the nose diminished in size till it re-
gained its natural dimensions.                            Part v. p. 143.

  Suggestions for the improvement of the Rhinoplasty operation. — It
often happens  that Avhen a lost nose  is restored by  this operation, i 
NOSE.
265
becomes  a skinny, shrivelled appendage, and  out of all proportion, small.
This may be owing to the circumstance that  Avhen union  of the trans-
planted portion has taken place, the connecting slip betAveen the nose-flap
and the  forehead  is divided.  This proceeding would  cause inadequate
nourishment to be communicated to the new nose, Avhich Avould only be
kept alive by the new vessels  that  inosculated  in  the cicatrix all round :
whereas  if the connecting slip were allowed  to remain for a much longer
time than is often  done, it would assist materially  in keeping up the life
and vigor of the transplanted nose.  Dr. Keith therefore recommends that
the connecting slip be allowed to remain undivided  for a much longer time
than is generally done, and even left undivided altogether.
                                                     Part ix., p. 176.

  Enlargement of the Nose.—[This often consists, according to Mr. Lis
ton, of a kind of hypertrophy of the skin.]
  There is a great enlargement of the follicles, some of them are so larg
that on opening them you can insert the point of the finger—in  fact, they
may often be described as a series of small encysted tumors, containing a
quantity of sebaceous matter, and of different sizes.
  Where these tumors only involve a portion  of the skin they can be
easily removed; and even where they arc of a large size the whole may be
taken away.
  The tumor is of the simplest possible character, and if you take it awray
entirely  there Avill be  no reproduction of it,  and if this is properly gone
about there is  no risk from  bleeding, or from any other cause.   If the
tumor is extensive, involves the  apex  and both alas, an incision must be
made right doAvn the median line of the nose, through the  whole thickness
of  the diseased skin; your assistant puts his  finger in the  nostril and with
a pair of hooked forceps and a knife you dissect the tumor from one side,
and make the  nose as like as possible, in size and shape, as it Avas before.
There is often a good deal of bleeding, but you need not  stop on that ac-
count.   Having completed the  operation on one side, you proceed with
the other, and make the two sides as nearly as you can of  the same shape.
This  may occupy some few minutes.  In this peculiar tissue you cannot
expect to pull  the  vessels out and tie  them, so that if they continue  to
bleed very profusely, small sewing needles must be put through the bleed-
ing points and threads tied  round, them, the  ends of the needles are then
cut short off.   In  general, stuffing  the nostril Avith lint and putting on a
compress and bandage will completely arrest  the Aoav of blood.
                                                       Part  x.,p. 163.
   Case of Aneurism by Anastomosis in the anterior Nares.—[The sub-
ject  of  this remarkable case was  a Avoman  aged thirty, who  became a
patient at Steevens' Hospital, Dublin.  Dr. Wilmot says.]
  About four years and a half ago she observed a small tumor, not larger
than a pea, situated  on the inside of the  left ala nasi.  The formation of
this tumor was  preceded  and accompanied by a good deal of pain, which
was not confined to that spot, but occupied the entire left side of the  nose;
6he also experienced a sense of fullness and tension about that side of the
head, and in a feAv months the  tumor increased  so  much as to attract the
notice of her friends.  She  ivas  now sent to me from the  country by a
friend, who conceived  the tumor to be a polypus.  Upon examination, I
found  the tumor,  Avhich Avas about  the  size of  a small  olive, attached  to 
266
NOSE.
the inner surface of the ala of the left nostril.  It ivas of a dark blue color,
soft, smooth, and equal on its surface, and upon pressing it, an obsure pul-
sation could be felt in it.  The  coronary artery of the lip and the lateralis
nasi pulsated.strongly, and appeared to feed the tumor.
  In consultation Avith Mr  Cusack  and Mr.  Codes, it Avas agreed to try
the effect of nitrate  of silver applied to the  interior  of the  tumor: to
accomplish this the tumor was  punctured with  a cataract needle, and
through the punctures a small probe, coated Avith the nitrate  of silver, was
introduced.   A rapid flow of blood followed each operation, but Avas soon
stopped by pressure.  The caustic ivas applied in this  manner three or
four times, and during the intervals astringent lotions and pressure Avere
employed.   This plan brought about some reduction  in the size of the
tumor, but it Avas not of long duration; in a very short time it acquired its
former size, or perhaps became  rather larger; the headache,  also, became
very great Avith intense throbbing, not only in the  tumor, but round the
entire left side of the head and  face.
  In this unrelieved  state  she ivas obliged to leave the hospital; but she
returned, after  an absence of  nearly half a year.   The  tumor Avas now
observed to have undergone a remarkable change in size and shape.  It
wras much larger, and had altered its oval shape to a round form.   It now
bore some resemblance to a large hemorrhoid ; it filled the anterior cavity
of the left nostril, and extended a little beyond its margin; its free surface
lay against the septum,  and completely blocked up its passage.   The
tumor preserved the same bluish color and smoothness  on its surface, and
its pulsation could hoav be seen as well as felt.  All the  circumjacent arte- ■
ries Avere enlarged, the lateralis nasi  was dilated to the size of a croAV-quill,
the coronary artery  of  the same side Avas also greatly enlarged, and pres-
sure on either of these arteries  commanded the pulsation in the tumor.
She complained at this time of Avant of sleep from the pain and throbbing
in the head;  she also stated that vision had  been rather dull in the left
eye for some short time back.
  Finding that all  the symptoms Avere rapidly increasing, and that the
seA'eral plans of treatment adopted Avere unsuccessful, we resolved on per-
forating the tumor Avith the actual  cautery.   The operation consisted in
perforating the tumor in tAvo  distinct places with a nail-shaped  cautery
iron.   This operation was repeated  six times, at  intervals of 14 days be-
tween each.  After every application  the tumor SAvelled, became painful,
and in about three days pus Avas observed to ooze through  the openings.
By following up this plan the tumor gradually  diminished, and the en-
larged arteries lessened.   At the expiration of three months she  was dis-
charged from hospital perfectly Avell.  There  Avas then  no  trace of the
tumor, the lateralis  nasi artery could  not be felt, and  the other arteries
which had been enlarged, Avere restored to their natural size.
                                                       Part xv., p. 194.

   Operation for Restoration  of the  Nose.—[In  this case the loss of the
nose ivas due to a blow, received a  long time previously; the patient Avas
now forty years of age.   We are told that]
   Mr. Ferguson  gave,  in this instance, the preference to  the Indian
method;  and the patient having been placed under the influence of chlo-
roform, a triangular piece of leather, cut into the shape of the new  organ,
and made to suit the irregularities of the stump, was spread flat upon the 
UOSE.
267
forehead,  with its base  uppermost;  deep  incisions, wdth  subsequent
parings, were then made along the margins of the deformed nose, follow-
ing the line, where the sides of the flap, to be presently cut from the fore-
head, Avere to be implanted.  When the paring had been carefully and re-
gularly done on both sides, Mr. Ferguson cut  out  the skin and cellular
tissue of the forehead, down to  the periosteum,  according  to  the  shape
above mentioned, and this being carefully dissected from above, downward,
to the root of the  nose, where the dissection was carried deep, to render
the vascular connection  more extensive ; the  flap  was twisted on  itself,
and  its  edges  were brought into  contact  Avith  the grooves  previously
made.  The hemorrhage ivas rather considerable,  and somewhat increased
the already great amount of trouble which this operation entails upon the
surgeon ; the sutures were, however, very neatly applied, three  each side;
they kept the transplanted structure very steadily in  situ, and  the angles
of the raAV surface on the forehead were likewise approximated by sutures.
The cavity of the new nose, which Avas partly supported by the shrivelled
remains of the old, ivas borne up by a small quantity of lint; the same
was likewise put on the raiv surface of  the forehead; the parts  Avere care-
fully and warmly avrapped up, and  the patient removed.
                                                    Part xxi., p. 197.
  Mode of Extracting Foreign Bodies from the Nostrils.—Dr. Homans
for many years has practised the following : Closing  the nostril ivhich is
free, he blows forcibly Avith his OAvn mouth  into the mouth of the patient,
and the result is the  discharge of the body.   He  states that in no case
where such substance  completely obstructed the passage, as beans, peas,
grains of corn, etc., had this method failed of  success; but Avhen the sub-
stance introduced  Avas so shaped as not entirely to  obstruct the passage,
as a button, the air bloAvn in might pass  through and not remove the
body.                                                Part xxi., p. 199.

   Ozena ; or Fetid Discharge from the Nostrils.—Dr. Druitt of London,
gives the following:
   [The fetid odor in ozaena is dependent on putrid or decomposing organic
matter; there  are  several diseased conditions of the nose attended AAdth
these symptoms: in all, our local treatment must be calculated to remove
or destroy putrescent matter, and unless this be attended to, the disease,
no matter  what its original cause, may be  prolonged to an almost indefi-
nite period.]
   What the local treatment  should be  may be  seen from  the folloAvdng
case which I have lately treated:
   A young lady, aged 20, consulted me for an offensive discharge from the
left nostril, of twelve months' duration.  It folioAved  a cold in  the head,
wdiich had been unusually severe, and attended  with much pain in the
bones of the face.   Since that time she had been infested with nauseous
taste  in the mouth, stuffiness and  obstruction in the nostril, and profuse
yellow, offensive discharge, sometimes streaked with blood.  The stench
of her breath was most unbearable.  There Avas no tenderness of the nose
nor any other outward sign of disease.   Her appetite Avas bad,  and spirits
low, inasmuch as she felt herself a nuisance  to her friends, and  her family
doctor had pronounced the case one of disease of the bones, and had pre-
scribed some zinc ointment, Avhich had  done no good.
   I immediately caused the affected nostril  to be syringed by  means of a 
268
NOSE.
large brass  syringe, Avith warm Avater, to which a few drops of Condy*s
disinfecting  fluid had been added.   Several syringcfuls were used without
any  effect or  any decrease of the  odor ; but after persevering  a little
longer, the patient blew her nose, and expelled a small fragment of yellow
putty-like stuff—consisting  evidently  of pus,  in  that  state of decay to
Avhich  the  name  yelloAv, or cheesy-tubercular matter is  applied.  The
syringing Avas proceeded, with, and in  the  course of half an hour the
nostril Avas  completely emptied  of quite a large quantity of this yellow
stuff, the fetor of Avhich Avas so terrible that it clung to the clothes of those
present for  some hours.  The result  Avas, that the nostril was entirely
freed from smell, and although there Avas great irritation, and the eye Avas
rendered very vascular and  swelled, the patient expressed herself greatly
relieved, and quite comfortable by comparison.
  On the folloAving day the irritation  had subsided, and  there had been
no return of ill odor.  There appeared  some swelling and excoriation at
the anterior  extremity of the turbinated bone.  A small quantity of very
dilute citrine ointment Avas directed  to be put up  the  nostril Avith a hair
pencil every night.
  On the eighth day  she called,  and reported that there had been no
return of the  ill odor.   This case is a good example of its kind; accumu-
lation of muco-purulent matter, following catarrhal suppuration, and keep-
ing up a diseased suppurating state of membrane by its presence.
  Slighter and earlier cases of the same class are very common.  An
ordinary " cold,"  i. e., catarrhal  mucous discharge from nose, throat, and
internal ear, is aggravated by a feeble condition of health, or by residence
m a  damp situation,  and is folloAved by suppuration of one or both nostrils.
If the health improves, the  malady gets Avell of itself; or if it comes under
treatment early,  it is effectually treated wdthout  any troublesome local
applications, as in the following example:
  A lady, aged  38,  of consumptive family and appearance, consulted me
for offensive discharge from the nostrils, the consequence of a cold that she
could not get  rid  of.  There was an immense discharge of yellow muco-
purulent offensive matter, and great general debility.   She was speedily
relieved by  bark and nitric acid, ten minims of dilute  nitric acid, and an
ounce and a half of  decoction of yelloAv bark tAvice daily;  and a visit to
Tunbridge Wells  completed the cure.  Moreover, she  inhaled every night
the vapor of creasote, ten drops of which Avere dropped into a large basin
of boiling Avater, so that she might snuff up the steam.
  The sum of the matter is this :
  Ozasna is  an accidental complication of any suppurating or ulcerative
disease of the nose.
  It  is the tendency of  muco  pus to accumulate; and it is the tendency
of the mucous membrane  of the nose, if ulcerated, to exude flakes and
clots of lymph or false membranes,  wdiich matters putrefy, and cause the
smell.
  If these putrefying  substances  be washed away, and  the cavity kept
clean, there  can  be  no  smell;  and  this  process  carried out, as I have
described it, makes the patient at once more comfortable, and conduces to
the radical cure of the ulcer, no matter what the first origin of that ulcer
may  have been.
  As auxiliary measures the citrine ointment diluted, the vapor of crea-
sote, and other astringents may be of use;  and of course such constitu- 
NYMPHOMANIA—02DEMA.
269
tional remedies  as may be adapted to relieve any  existing  cachexia.
Bark and  nitric acid are my favorite remedies; bit the iodide of potas-
sium, cod-liver oil, etc., have their uses.            Part xxxviii., p. 324.
                     NYMPHOMANIA.
  Anaphrodisiac Properties of Bromide of Potassium.—Thielman re-
commends this remedy as an excellent anaphrodisiac  in satyriasis, in the
frequent and painful erections during gonorrhoea, in spermatorrhoea, and in
nymphomania.   He administered it in doses of from  2 to 3 grains  every
two or three hours ; and, at the same time, enjoins a mixed vegetable and
milk diet, and forbids all acid substances.             Part xxxi., p. 222.
                           (EDEMA.                    *
  Acute CEdema of the Lungs.—It occasionally happens, says Dr. West,
that children are attacked with intense dyspnoea, and other symptoms of
disorder of the respiratory organs, Avhich terminate rapidly in death; while it
is discovered, on an examination of the body, that the thoracic viscera gener-
ally are free from disease, but that the cellular tissue of the lungs is loaded
with serous fluid.  This edema of the lungs, hoAvever, though it sometimes
destroys life very speedily, is seldom, if ever, a purely idiopathic affection,
but occurs generally as one  of the complications  of that  acute  anasarca
which not unfrequently succeeds to scarlatina, and even then is not of com-
mon occurrence.
  Bleed freely, and give large doses of tartar emetic.  If the extremities
are very cold, and the surface  livid, apply a large mustard poultice over
the chest, and give a large dose of nitrous ether every two  hours, till the
patient rallies sufficiently to  bear bleeding.   AfterAvard treat the general
dropsy.                                              Part xvii., p. 92.
  QZdema of the Glottis from  swallowing Boiling Water.—Dr. Jameson
says : In all cases where boiling water has been taken, or attempted to have
been taken, into the  mouth, the danger at all times  is imminent; for, al-
though the  little patients seem to suffer  comparatively very little for the
first feAv hours, still symptoms of grave importance set in, sooner or later,
Avhich, if not combated by appropriate treatment, will either  kill the pa-
tient, or call for the operation of tracheotomy. The operation is, therefore,
I think, imperatively called for, when the usual  remedies, such as emetics,
leeches, and the  application of heat to the  surface, etc., fail  in allaying the
urgent symptoms.  But when the breathing becomes stridulous and croupy,
or amounting to a mere pant,  from spasm of the glottis, the  pulse quick
and small, the temperature of the body diminished, the head drawn back,
face congested, eyes half open, inclination to  coma, and difficult deglutition,
I should, on the  first accession  of these symptoms, at once be inclined to
operate ; but Avhen these have lasted a sufficient length of time to cause
complete coma, or if bronchitis or  laryngitis has set in, then, I think, it
will be found useless ; for when patients under such circumstances die after. 
270
OESOPHAGUS.
operation, provided it is not produced by the shock inflicted on the nerv-
ous system,  it is  from  the accession of  bronchitis, laryngitis, or pneu-
monia ;  consequently, if any of these  exist before we operate, we can en-
tertain but small hopes of recovery.                   Part xvii., p. 147.
  OEdematous  Glottis—Apply a solution  of nitrate r*f silver, Avhere it
arises from a sub-acutely inflamed mucous membrane.   Part xxxi., p. 69.
                          OESOPHAGUS.
  Extraction of Foreign Bodies from the OEsophagus.—To extract  for-
eign bodies from the oesophagus, use  a slender piece  of ivhalebone to the
end of Avhich a  thread is attached.   When the instrument is  passed be-
yond the obstruction, the thread is to be drawn tense, so as to bring the
whalebone into  the form of a V, and it is then Avithdrawn, bringing up
the foreign body.                                     Part xvi., p. 186.
  Extraction of a  Fish  Hook from the  Oesophagus.—Two  children
amused themselves by playing at angling, the younger taking the part of
the fish.   After  several  endeavors to catch  the hook  in his mouth, the
child succeeded too well, and, determining, it appeared, to play his part to
perfection, swalloAved the hook.  The consequence was, that  his brother
drew the line, and fixed it  at once in  the oesophagus.  All attempts to ex-
tract it proved  futile, till  the  surgeon took a pistol bullet, and having
pierced it, put it on the line, and alloAved it to  slip down to the impacted
hook. The weight removed the latter, the point of  ivhich, sticking into
the lead, it Avas  safely returned.                       Part xvii., p. 300.
  Stricture of the  Oesophagus.—In some of those  cases where no food can
be taken, employ transfusion of blood, to give the  patient time to rally, so
as to admit the introduction of bougies subsequently.    Part xx., p. 130.
   Vide " Transfusion."
  Extraction of Foreign Bodies from the OEsophagus.—If the body be
small and sharp, as a needle or  fishbone, use a large  goose or  swan quill
feather, with the barbed portion ruffled, and  imbued Avith  oil.   The pa-
tient's head being  supported against the breast of an assistant, loAver the
tongue, introduce  the feather,  Avith its concave side  doAvnward,  into the
throat, turn it rapidly round, and draAV it out.  If the body be large, use
a rather straight lithotrite wdth an imperforate  scoop.  Introduce it with
the blades closed, doAvn to the foreign body, separate the blades sufficiently
to grasp the substance, and after  a feAv gentle turns, A\dthdraAV it.  If the
substance is a piece of flesh, and near the cardiac orifice, propel it onward
to the stomach wdth a probang.  For  extracting coins, use the double ring
of Graefe, attached to the end of a rod of whalebone,  with a steel spring.
                                                      Part xx., p. 132.
  OEsophagus—Foreign  Bodies in the—-Do  not  use the probang indis-
criminately, to push down everything into the stomach.  If the substance
impacted be  meat, or any soft, non-irritating and digestible substance, it
is proper to use  the probang.   But all sharp and pointed bodies should
be extracted; and  the best instrument for the purpose is a Avhalebone rod,
having at one end  a piece of watch-spring, which is connected securely to a 
OIL.
271
flat hook, having a hole in the centre for the attachment of some loops of
rilk wdiich may aid in entangling the foreign body.   If the attempt at ex-
traction is not successful, give an emetic of speedy operation, in the hope
that the foreign body may be either expelled completely, or so altered in
position that it may noAV be easily caught hold of.      Part xxi., p. 220.

   OEsophagus—Stricture of.—According to Dr. R. Bennet, If caused by
aneurism pressing on  the trachea and nerve-trunks, the voice will be stri-
dulous, and paroxysmal attacks of suffocative dyspnoea will  occur.  If
caused by an abscess, the voice will not be lost; if caused by malignant dis-
ease, the recurrent laryngeal nerves will soon be involved, and paralytic
aphonia will result, although the larynx may not be affected.
                                                     Part xxx., p. 135,
                                OIL.
  Local Application of Cod-Liver Oil.—The class of cases  for which it
appears  most applicable, is that of chronic eczematous  eruptions, unat-
tended by acute inflammation of the skin or general pyrexia.  In abating
the troublesome itching which frequently accompanies this disease, espe-
cially in  old people, it has manifested powers decidedly superior to those
of any other application with which we are acquainted.  In the  majority
of instances  it can, of course,  only be expected to  assist constitutional
treatment, not to supersede it.  We are inclined to recommend  the prac-
tice of exhibiting it  simultaneously with  tonics, as  iron, quinine, etc.,
Avhich is now adopted Avith great success at several hospitals.   The diges-
tion and assimilation of the oil appears to be much aided by  such combi-
nation.  In the treatment of cutaneous struma and lupus at the Hospital
for skin  diseases, it is usual to administer along Avith the oil small doses of
mercurials,  which are often continued for many months.  The success  at-
tending  this practice  is  very  great, and appears to much exceed that which
results from  the administration of either drug alone.    Part xxvii.,/?. 76.
  Substitute for Cod Liver  Oil.—Cocoa-nut oil seems to possess the same
valuable properties as cod-liver oil, and  in some cases Avas efficacious where
the latter had been useless.                           Part  xxix., p. 92.
   Cod-Liver Oil.—1.  When too nauseous for the patient, give it floating
on some bitter menstrum, in  coffee, ginger  Avine, infusion  of quassia, or,
better still, in a. solution of quinine, Avith a drachm of the tincture of orange
peel, or give it in very hot milk, or smear the mouth  Avith  marmalade  or
black currant preserve,  and having thus absorbed the attention of the gus-
tatory nerve, immediately swalloAV the oil.  2.  Wlien  the oil  excites sick-
ness.   Prepare the stomach by hydrocyanic acid and bismuth  three times
a-day.   Give first  a little dry biscuit or bread crumb, and  then float  the
oil on the coldest spring water, and give it immediately; give it in  the
recumbent posture, an  hour or two before getting up or after  going to
bed.  3.   When the oil cannot be digested, the  following is useful: R Rad.
rhei, 5iij.; rad. zingiberis, 5ij.; rad. gentian, §iss.; sodas carbon, giij.; aquas
lbs. viij.   The  roots to  be  cut into small pieces ; the  infusion to be made
with cold water, and to stand twelve hours.   Take a  lvine-glassful thrice
a-day for a Aveek before beginning the  oil, and then give it with the oil.
                                                     Part xxix., p. 325. 
272
OMENTUM.
   Cod-Liver  Oil, Test for.—Drop a little sulphuric acid, guttatim,  into
the oil.  It causes a  centrifugal movement, and a beautiful  violet color,
which changes  to  purple on  agitation, and ultimately  to  a rich sienna
brown.  This is best seen by adding one or tAvo drops of the acid to half
a teaspoonful  of the oil spread out on a white porcelain plate.  Sulphuric
acid  when  added to  olive oil  causes  a dirty grey color—to poppy-oil a
deep  yellow color—to ordinary fish-oil a deep broivn color.
                                                    Part xxx., p. 236.
  New Mode  of Giving.—Take the yolk of one egg; sugar, two ounces ;
orange-floAver Avater, one ounce ;  cod-liver oil, three ounces ; essence  of
bitter almonds, one drop.  Either the sixth or eighth  part wdll be a dose,
according to the quantity of oil which is intended for the patient.
                                                   •  Part xxx., p. 319.
   Cod-Liver  Oil Oleine.—When  cod-liver oil is constantly vomited, give
oleine prepared from  the same oil in the same dose; it  will have all  the
beneficial without any of the disagreeable effects of the oil itself.
                                                    Part xxxii., p. 77.
   Glycerine  as a Substitute for  Cod-Liver Oil.—GiAre  one  to  three
drachms of  glycerine in an ounce  of wrater daily as a substitute  for  cod-
liver oil; it is quite as efficacious, much less disagreeable, does not disor-
der digestion, and may be combined Avith any other remedy.
                                                    Part  xxxii., p. 79.
   Cod-Liver  Oil Solidified  with  Gelatine.—Take of pure gelatine, half
an ounce; Avater, simple  sirup, of each  four ounces; cod-liver oil, eight
ounces;  aromatic essence, as much as maybe sufficient.   Dissolve the  ge-
latine in the boiling Avater, and add successively the sirup, the oil, and the
aromatic essence ; place the vessel containing the entire in a bath of cold
water; Avhip  the jelly for fiAre minutes at most, and then pour it, Avhile
still fluid, into a Avide-mouthed glass bottle, furnished Avith a  cork, or Avith
a pewter cap, or if a bottle be not at hand, into  a porcelain or earthen-
ware  pot, Avhich should be carefully closed.   Cod-liver oil gelatinized with
Carrageen or Irish Moss.—Take of fucus crispus half an ounce ; Avater,
eighteen ounces; simple sirup, eight ounces; cod-liver oil, eight  ounces;
any aromatic, according to  taste.  Boil  the carrageen in the water  for
tAventy minutes ; pass the decoction through flannel;  concentrate it until
it  is reduced  to four  ounces by weight; add  the sirup, the oil, and  the
aromatic; Avhip  the mixture  briskly, having first placed it in a cold bath,
and pour it, while still a little Avarm, into the vessel intended to receive it.
The sirup may be replaced by an equal quantity of Gams' elixir, mint or
vanilla cream or rum, etc.                           Part xxxvi., p. 291.

                              —»♦-•—


                           OMENTUM.
  Returning  the Omentum in  cases of its protrusion.—("A young man
was pushing open a door Avith  a gardener's knife, the poi.it of which Avas
toward himself.  As the door was shut he thrust himself against the point,
which entered the abdomen close to the left side of the umbilicus.  About
three  inches of the omentum protruded, Avhich, as the surgeon was unable
to return, Avas pushed back with a bougie.   Mr. Cooper says:] 
ONYCHIA.                           273
  Now I  have to  make some remarks  about returning the omentum in
cases of its protrusion;  in  this instance, a concentrated force was  em-
ployed in order to effect its reduction, but I think some little precaution
is necessary in  handling so delicate a tissue as a serous membrane.  If it
has protruded through an opening too small for it to be returned, the usual
method is to enlarge the wound sufficiently to alloAv of its being replaced  ;
but if it has been so long exposed to external agents as to  be altered in
its character, and be unfit to be  returned into  the  abdomen, it  should be
allowed to remain to slough aAvay,  or, perhaps, in order to avoid the incon-
veniences attending upon a large slough, it may be cut off, and any  ves-
sels that may bleed tied, but do  not push the ligatures in  that case  into
the abdomen.   It might be a question A\rhether any means for the preven-
tion of symptoms Avere to be adopted in apparently so simple a case; if
so, Avhat should be the means ?   Some may say bleed, but in my opinion,
you only disturb the natural functions by abstraction of blood, and render
the patient irritable, and therefore more prone to  inflammation.  In  this
case, perfect quietude, and  regulation of diet, were  the means adopted,
and they have proved sufficient.  Purging is certainly wTrong; for, by  in-
creasing the peristaltic motion of the bowels,  you  interrupt  nature in her
process of cure, by uniting the omentum to the cut edges of the  wound
of the peritoneum lining the abdominal  Avails.   This patient, you observe,
was  four  days Avithout a  motion and even  then I ordered only a small
dose of castor-oil, but it proved  sufficient.               Part xii., p. 197.
                          ONYCHIA.
   Onychia.—Mr. Hamilton gives the following:  Sometimes, in  conse-
 quence of a tight shoe, the flesh of the side of the nail of the great toe is
 pressed against the side and upper angle or corner of the nail.  Now, Du-
 puytren observed very truly, that in consequence of this corner of the nail
 being a little overlapped by a fleshy prominence, the scissors in cutting the
 nail are prevented from going far enough to cut this part of the nail com-
 pletely, so that the angle projects in a sharp little point, which irritates the
 flesh pressed against it, and finally ulcerates a Avay into it.   This is further
 accomplished  by the pressure from above on the arch of the nail;  Avhich
 being flattened  and straightened, the  sides are forced out.   The flesh,
 therefore, irritated and inflamed, swells, reddens, and ulcerates, and there
 is a thin fetid discharge from the corner of the nail; standing or  Avalking
 is painful;  and the pressure of  a shoe  can scarcely be borne; the Avhole
 foot, when the irritation runs  high, gets  sAvollen and red, and even the
 lymphatics up the leg are  inflamed.   This is called the onychia simplex.
 Sometimes only one side is affected, and if so, it is generally the outside;
 at other times, both sides of a nail, and in some instances, both great toes,
 suffer from this painful disease.  I am  inclined to think that, besides the
 local cause I have mentioned, the constitution has something to do with it.
 I have observed so many cases in dehcate  strumous people and  in those
 who labor under other diseases.  I operated on a gentleman who Avas par-
alytic of the Avhole side of the body and  of speech, who had  it  in both
great toes.  There is also a young lady avIio is at present, and has been for
the last three years, laboring under paraplegia, witli cataleptic attacks, and
    vol. n.—18 
274                            ONTCHIA.
who has been bed-ridden for that period, and, consequently, never wore a
shoe, yet for a year and a half has had onychia simplex of the right great
toe nail at the outside.  The onychia simplex is not a disease that gets well
of itself; its progress is usually from bad to Avorse; the swelling of the
toe becomes very great, so much so, that a  case is given by Dupuytren,
where from the size and redness of the toe, the  patient Avas for a long pe-
riod treated for gout—a mistake, hoAvever, scarcely credible.  The more
the flesh swells, the  greater is the pressure on the toe  nail, the deeper
and more extensive the ulceration, from Avhich fungoid  granulations are
seen to rise.
  If you see this disease early, when the upper  end at the side of the nail
is alone engaged, you may stop it in this way: Let the patient lay up, and
poultice the toe  Avith bread and water ;  this lessens the irritation and in-
flammation, and you Avill find that you will be able  to insinuate, by means
of a small lachrymal probe, a minute shred  of lint under the angle and
side of the  nail, and  betAveen it and the flesh ; after it is fixed in, wet it
with a solution of nitrate of silver, 3j. to the ounce; if the lint remains in,
it need not be removed for forty-eight hours.   You will then find the irri-
tation and its consequences lessened, and by reneAving the application two
or three times the disease will be cured ;  and  to avoid a return, you should
caution the patient Avhen cutting his nails, to  cut them straight across, to
be  sure there is no little projecting point at the angle, but also most par-
ticularly against rounding off the angle, Avhich alloAvs the flesh to be pressed
over it the more readily.   I cured hi this way a  large, heavy  man, Avhohad
been previously treated by caustics, poultices, and ointments, Avithout any
good.
  When, hoAvever, the disease  is more  adAranced, the pain  and irritation
excessive, it is better, after rest and poultice, and a purgative if required,
to proceed  Avith an operation, one of the most painful in  surgery, though
happily of short  duration, by slitting up the nail  and  removing it.  It is
done in this Avay: the blade of a strong, short-bladed,  sharp-pointed scis-
sors is passed under the nail, quite to the root, the nail is slit up in the cen-
tre, one side is seized at its middle angle with a strong  forceps, and torn
out by turning it over on itself.  If both sides are diseased, then the other
half of the nail is served in the same manner, a poultice is applied, and in
a few days the part will be well.  It is quite  remarkable  how soon a case
of  a year's  standing is thus cured in so short  a time.
   Chloroform happily enables us to perform this painful operation Avithout
the consciousness  of  the operation.
   Sometimes the toe is bruised by a heavy body falling on the nail; blood
is effused under the nail, inflammation, suppuration, and ulceration of more
or  less of the matrix ensue, Avith a loosening and separation of part of the
nail from its bed.  In this case the nail acts as a foreign body, and no relief
is afforded  until it is torn out.   You have an  instance of this in a boy for-
merly in the house, on whose toe the edge of a pail fell; also in a young
woman, a patient  of  Mr. Adams, to whom a nearly similar cause originated
the injuiy, a bucket having crushed her toe, and Avith so much-subsequent
inflammation, that it extended to the periosteum, matter formed  between
it and the bone, wdth death of the last phalanx, which had to be removed.
   In an unhealthy constitution  onychia  simplex may run into the second
variety, Avhich has been called  onychia  maligna, from the  severity of its
symptoms, not from any cancerous character  it  possesses: it is a disease of 
ONYCHIA.                            275
the matrix Avhich secretes the nail.  This diseased action may be caused by
an injury Avhich crushes or tears the root of the nail in its bed, or  by dis-
ease originally commencing at the root of the nail, with inflammation  and
ulceration, and finally an alteration in the nail itself, as we might  expect
from its secreting structure being diseased.
  The toe is very much swollen, of a deep red color, the nail is either gone,
and its whole  matrix converted into a large, unhealthy looking ulcer, the
surface greenish or black looking, Avith raised Avhite callous edges, and pro-
fuse, thin, fetid, oily, and often  bloody discharge; or if there is a  nail, it
is quite altered, dark, thin, and even shrivelled like Avet parchment, and is
evidently not the cause of the state of the toe, as in onychia simplex.  The.
swelling and redness very constantly affect the foot, and I have even seen
them  extend some distance up the leg.   Sometimes there will be a fungoid
granulation springing up from the centre of the  ulcerated matrix, even
from the bone itself; after the nail is gone and the disease is lessening in
violence, an attempt at a neAV nail will be  seen to be made by some white
homy prominences here and  there.
  It is not always confined to the great toes, as I have seen it affect some
of the smaller toes at the same time.
  The pain is very great, and the  least touch of the part gives exquisite
pain ; Avearing a  shoe  is out of the  question, unless the leather  over the
toe is cut  out.  There is great irritation in the system :  and from that and
restless nights, and Avant of exercise, the  patient gets  pale, and thin, and
low-spirited.   The fetor of the discharge, in spite of every care on  the
part of the patient, is most offensive.
  It is a disease of youth rather than age : I have seen a girl ten years old
affected Avith it.
  The treatment that Dupuytren ivas the first to ""propose, is very severe,
indeed, though, certainly very effectual; it Avas to remove the entire ma-
trix of the nail;  he  made a deep incision with a sharp straight bistoury,
in a semi-circular form, a little  above the root of the matrix, and carried
it round the sides; he raised Avith a forceps the  edge of the integument
next the matrix, and cut under it toward the end of the toe, keeping close
to the bone, so as to remove  the diseased matrix entirely.   The  part Avas
to be examined closely, to see if there Avas any portion of the nail remain-
ing, which Avas to be removed; it Avas then to be covered Avith a pledget
of lint, Avith holes in it and smeared  Avith cerate,  and dry lint outside it,
and not opened for five days.
  In about a fortnight it had generally healed.  You will sometimes haAre
to perform this  operation, but not often.  Mr. Wardrop found that mer-
cury given to salivation effected a cure ; and the late Mr. Colles  Avas in
the habit of treating such cases very effectually wdth mercurial fumigation.
You may combine these, giving three grains of  blue  pill three times  a
day, and apply mercurial fumigation  daily till the  sore assumes a  healthy
granulating surface,  and the surrounding inflammation and swelling sub-
side ;  the simple applications, bread  and Avater poultice, or  simple cerate
dressing, may  be used;  sprinkling the ulcerated surface with  red precipi-
tate powder nearly ansAvers as Avell as the fumigation.
                                                   Part xxxii., p. 191. 
276                    oophoritis, or  ovaritis.
                  OOPHORITIS, OR OVARITIS.

   Oophoritis—Sterility  dependent on.—[As this affection is not well
 known, Dr. Rigby relates a case :]
   C. C, aged 31, brunette ; tall; married six years. One child born about
 a year after her marriage.
   Complains of constant and severe pain of both groins, especially the left,
 with severe  dragging pain in the loins and loAver part  of the abdomen,
 both of  Avhich are increased by stooping, but relieved by standing.  The
 catamenia come regularly and last three or  four days ; they are preceded
 for  nearly a Aveek by much suffering, Avhich also continues  during the
 whole period ; the discharge is very profuse with clots and exudations;
 constant urging to pass Avater, which is turbid; boAvels unhealthy ; tongue
 red and dry ; has had profuse and painful menstruation  from her youth.
 Since the birth  of the  child, the pain has  been considerably relieved,
 although the discharge has been increased.
   Examination  per Vaginam.—Nothing  Avrong about  the  os or cervix
 uteri; the uterine sound passes easily to the  full distance  (2£ inches) Avith-
 out pain, but is followed by profuse discharge of blood.
   Examination per Rectum.—High up in the direction  of the left ovary
 a hard body can  just be reached, Avhich is acutely sensitive to the touch,
 and which she describes as the  centre of her pain.
   The folloAving remedies comprised the principal treatment of this pro-
 tracted case, and Avere varied from time to time, pro re nata.
   R Ung. antimonii pot. tart, inguini sinistro omni nocte  applicand.
   R Pil. hydrarg. chlorid. co. gr.  v., alternis noctibus.
   9 Sodas potassio tart. 3j.  o.m.
  ~# Aeidi nitr.  dil. mxv.  ex infus. gentianas computer dje.  Hirudines
 vj. ovario sinistro.
   R. Aquas menthas  viridis, aquas destillatas, aa. 5vss.;  acidi sulph. dil.,
 mx; sirupi rhasdos, 3ss.   M. ft. haustus ter die sumendus.
   It is difficult, and  sometimes impossible,  to trace the  history of these
 cases to their origin; but from the fact of  her having suffered from dys-
 menorrhea up to the time of her marriage or pregnancy, and never after-
 ward, Ave have reason to  conclude that the canal of the cervix, or os uteri,
 had been unusually small, and produced considerable resistance to the free
 discharge of the  catamenial fluid.   That this form of dysmenorrhcea is not
 necessarily a barrier to  conception  is a Avell-knoAvn fact, although it  is
 equally certain that  sterility is  the more frequent result; but Avhen preg-
 nancy does occur under these circumstances, the expulsion of the fetus,
 even when very  premature, produces such  an amount of dilatation in the
 contracted canal as effectually to  remove the cause of dysmenorrhcea.  I
. have long since pointed out the fact, that obstructive dysmenorrhcea, Avhen
 of sufficient  severity and duration, is  frequently attended with  ovarian
 inflammation, Avhich may be reasonably accounted for by  the severe strug-
 gle and  painful efforts Avhich the uterus is excited  to  make  at the men-
 strual periods, for the purpose of expelling the catamenial fluid Avhich has
 accumulated wdthin its cavity.  This state of uterine  excitement must be
 a source of considerable irritation to the ovaries, occurring at a time when
 they are knoAvn  to  be highly  congested, and their vessels in a condition
 near akin to that of inflammation.  That the  uterus suffers great distention 
OOPHORITIS, OR OVARITIS.
277
 from the menstrual  fluid  accumulated Avithin its cavity is known by  the
 fact that the patient  herself will frequently feel it like a hard painful ball
 behind the symphysis pubis, Avhich disappears  as soon as the  discharge
 conies on.  In a  great  many instances I have reason  to  knoAV that  the
 uterus never entirely clears itself of the catamenial fluid, but remains  full
 for many days afterward, and probably retains a certain quantity until it
 is expelled at the next period,  as in many of these  cases the moment a
 dilator is introduced, a quantity of broAvnish-red  shiny discharge comes
 away, the characters  of Avhich are also evident from its peculiar smell.  I
 may  also add that, in almost all cases of long-standing obstructive dys-
 menorrhcea, the cavity of the uterus is considerably  enlarged, being fre-
 quently half and sometimes a Avhole inch longer than natural, and alloAvdng
 the sound to move about with an unusual degree of freedom.
   [One of the most prominent symptoms in another case was prof use and
 long continued menorrhagia.  Dr. Rigby observes :]
   I know no form of menorrhagia Avhere the discharge is more profuse or
 the disease more obstinate, than  Avhen it is  dependent  on an inflamed state
 of one or both ovaries;  and here again I may observe  that in by far the
 majority of cases, it is the  left ovary Avhich is  affected—indeed, it is quite
 an exception to the rule Avhen we find that it  is the right one.   It is diffi-
 cult al\\rays to account for these peculiarities, and Ave are apt to theorize
 in attempting their explanation  ; but it has frequently struck  me  that a
 loaded state of the sigmoid flexure of the  colon, from the pressure Avhich
 it must exert on the  neighboring parts, would render the left ovary more
 liable to congestion  by obstructing  its returning  circulation.  As  in the
 case above alluded to, Avhich had also been for many  years of her life one
 of obstructive dysmenorrhcea, the history of the symptoms and the exami-
 nations  distinctly prove  the existence of ovarian inflammation; and  its
 relief by appropriate treatment also shoAArs that this affection was  the cause
 of the menorrhagia, Avhich ceased as soon as the oophoritis Avas relieved.
   The symptoms of oophoritis varied somewhat in this case from the ordi-
 nary  course,  and  depended upon the  position of the ovary, being much
 more backward than usual, and almost approaching the hollow of  the
 sacrum; hence she had none of  the  inguinal pain Avhich is so frequently
 observed in these cases, but it ivas confined to  the region of the sacrum, as
 is usually  seen  in cases  of  retroversion, and was  necessarily greatly
 increased by the passage of fasces down the rectum.   This displacement
 of the ovary doAvnward and backAvard  into the recto-vaginal pouch, when
 in a more marked degree, forms  one  of the most agonizing affections Avith
 which I  am acquainted; the paroxysms of suffering  are really  frightful,
 and Avhilst they last the patient  is nearly Avild Avith torture.  In three or
 four cases Avhich I  have seen  the ovary has been found lower than usual,
 and approaching very nearly to the central line of the  sacrum.
  The slightest touch produces severe pain, of that sickening and intolera-
ble character which pressure on  the corresponding organ of the male pro-
duces, especially Avhen inflamed.  In the present case,  no movement of the
ovary Avas produced by pressure  in the left groin, while the finger of the
other hand was examining per rectum, but the anterior wall of the uterus
 was felt inclining more than usual toAvard  the bladder, as in anteversion,
from the uterus being probably  pushed somewhat forAvard by the ovary
behind.  The  attacks of heat and  SAvelling of the vagina, and the great
tenderness of the os externum, Avere  connected with considerable  derange- 
278
OPERATIONS.
ment of the assimilating organs, and form a part ol  a scries of affections
which I have endeavored to describe under the term of uterine gout—the
general state of the circulation indicating a close resemblance to that of it
in a gouty diathesis, but the affection localizing itself on the uterus and
organs belonging to it.
  [In the next case reported by Dr. Rigby the sterility appeared to be
owing  to a contracted state of the os and cervix uteri, attended, as this
state often is, Avith  ovarian irritation or inflammation.  The principal sym-
toms Avere irritability of the  bladder, and  severe pain in the  right groin
and front of the right thigh, wdth exacerbations at the menstrual periods.]
  Oophoritis, or, at least, ovarian irritation is a frequent attendant upon
that form of  dysmenorrhcea Avhich arises from a contracted os  and cervix
uteri;  the continued  repetition  of uterine irritation, at the  catamenial
periods, arising from  the efforts Avhich the uterus is excited to make for
the purpose of expelling the fluid which has been secreted into its cavity,
after a time brings  on  an irritable state of that organ (the ovary), which
is so closely connected with the process of menstruation.
                                                    Part xviii., jo. 259.
                          OPERATIONS.
  Necessity of Preparatory Treatment, before  Operation.—[Mr. Cooper
strongly insists  upon the  necessity of Avell ascertaining the  state of a
patient's health, as to the absence of organic disease, the condition of the
bowels, state of the  urine, etc., before undertaking an operation. We
are often tempted to perform slight operations at  the moment, but it is
dangerous  to  do so, especially as to operations on the head  and face—
encysted tumors of the  scalp, for instance.   On this subject, Mr. Cooper
says:]
  A lady applied to an  eminent surgeon, to ascertain from him A\diether
a small  encysted tumor  could be removed with perfect safety from her
head ; to which he replied, " certainly;" the operation was immediately
performed, but seven days afterward she Avas dead from an attack of ery-
sipelas.
  A short  time ago, an individual  came under  my care with an external
pile and a fissure in the mucous membrane of the rectum;  he was con-
siderably out of health and attributed all his ailments to the sufferings he
experienced in the  passing of his motions, OAving to the local disease : he
urged me to relieve him by operation.  I kept him, however, a week or
ten days under my  care before I operated, and by soothing remedies had
someAvhat improved his condition, when I  removed the external pile, and
drew the bistoury across the fissure, the Avhole time of the operation  not
exceeding half a minute.   The patient felt immediate relief after the ope-
ration, he had little or no pain in passing his motions, but in the course of
four or  five days he Avas  seized Avith symptoms of subacute peritonitis :
calomel and opium, and leeches, Avere ordered; but four days afterward he
died.
  Upon examination of the body, he Avas found to be the subject of granu-
lar kidneys (the morbus Brightii), Avhich no doubt had caused his death.
It  had been  ascertained,  during life, by my dresser, that his urine  Avas 
OPERATIONS.                          279
albuminous; but I considered the  severity of his suffering demanded the
performance of this slight operation : although the sequel renders it a mat-
ter for consideration Avhether  I Avas right, under these circumstances, in
subjecting him to a fresh source of irritation.
  From such cases as these you must be impressed Avith the necessity of
doing everything which the science of surgery can insure, so far as lies in
your power, to place your  patient  in the greatest state of security before
you subject him to any surgical operation, and  even then never promise
that any operation, hoAvever simple, will be perfectly free from danger, for
depend upon it,  it is as umvise to  treat  slightly the most trifling incisions
of the skin, as it is dishonest to attach to  an operation  more importance
than it justly deserves.
  Some surgeons suppose  that it  is better to perform  what  are  usually
considered simple operations at the moment  than to allow the dread of
anticipation to remain on the mind of the patient, and then proceed to act
upon this  opinion w ithout  any preliminary precaution.   There are, how-
ever, I believe, but feAv  patients Avho will not duly appreciate the cautious
recommendation of a surgeon to  submit to some little preparatory dis-
cipline, and he Avill gain much more  confidence from the patient by this
display of judgment, than from the hasty recklessness which evinces bold-
ness and self-reliance, rather than  judicious precaution.
                                                   Part  xvii.,  p. 140.
   Plastic Surgery—Hints on.—A transplanted  flap of  skin will not unite
readily to the denuded edges of a defective part, such as an old cicatrix.
Even,if it did unite, it Avould become raised and thickened.   The Avhole
of the epidermoid  surface  of the  old cicatrix should, therefore, be pared
away, so  that two raAv surfaces  may be  brought into contact.  Before
applying  the  transplanted  flap, the  pared edges of the defective part
should be loosened from their attachments to the extent of  two or three
lines, by flat strokes of the knife.   If this be not done,  it is probable that
the two edges will not be on the same level, the transplanted part wdll be
raised.                                             Part xxxi., p. 181.
   Contributions to Operative Surgery.—Dr. Knox remarks : '
   Systematic  Avriters on surgical  anatomy and  operative surgery usually
devote a  considerable section of their  Avorks to Avhat they term " simple
operations," practised indifferently on all, or nearly all parts  of the body;
such as division, cauterization, compression, dilatation,  extraction, reduc-
tion, reunion,  etc.   But it  seems to me superfluous to speak of such ope-
rations at any length.  The student can only acquire  a knoAvledge  of them
by seeiug  them put in practice by  others, and  by practising them  himself.
The reunion of divided parts by needles, stitches, adhesive and other plas-
ters ;  the reduction of dislocations ; the extraction of foreign  bodies ; dila-
tation  by  means of the fingers or  by instruments; the  application of the
heated iron; compression  by bandages;  and division  Avith  the  knife or
scissors, constitute nearly the Avhole of the surgeon's manipulative educa-
tion.   Should  he neglect practising it on the dead,  he  wdll  have to learn
it  on  the  living; sometimes  at his own  cost, sometimes at that of his
patients.
   In the selection of instruments the young surgeon should follow the ex-
ample  of the best operators of his day, selecting the form they prefer.  Let
him remember always that an operation is not a dissection, but a series of 
280                          OPERATIONS.
incisions and steps taken agreeably to a plan previously laid down toward
accomplishing a clearly understood  object.   Where the fingers can  be
used, they are preferable to knives or forceps.   Never press on inflamed
or suppurating parts,  lest the  pressure cause  sloughing.   To  employ
caustics advantageously merely requires judgment and a little dexterity.
Rust, of Vienna, made the actual cautery fashionable for a time, and with
Baron Larrey  the  moxa ivas  a  universal  remedy.  A sounder  pathology
l^as greatly  diminished the frequency of appeal to these violent remedies.
Nevertheless  they are of easy application,  and  prove  sometimes suc-
cessful.
  Hemorrhage is the accident  Avhich the surgeon most dreads, whether
occurring in consequence of accidental wounds, or caused by operations.  In
Avbatever Avay it happens, the surgeon must look carefully to it,  and  ascer-
tain its source. Be in no hurry, but  lose np time.   If the bleeding come
from a vessel of any appreciable size, seize it carefully and  steadily Avith
the forceps used in dissection, and request an assistant to place a ligature
around the vessel, clear of the points of the forceps.  If  the bleeding
come from a vessel or vessels  Avhich cannot be discovered, the>surface may
be exposed for some time  to the air, or moistened wdth cold Avater and
vinegar, or  a  thin linen rag  dipped  in these, and kept moist, may be laid
over the part.  Occasionally simple pressure applied for a time by the
fingers of an assistant will arrest a hemorrhage;  the elevation of the limb,
should the bleeding occur there, is at times very successful.  Other means
for arresting hemorrhage occurring from the  division of small vessels have
been recommended, such as torsion  or twisting, Avhich may be  done Avith
the common forceps, touching the part with lunar caustic, applying tur-
pentine, tincture of the muriate of iron, etc.   I have followed  Mr,  Aber-
nethy's mode of treating certain hemorrhages Avith marked success.
  In the  terrible  hand-to-hand conflicts Avhich  took place on the memo-
rable  18th of June  betAveen the French and English  cavalry, a young
soldier of the English received a Avound in the parotid region, immediately
below the ear.  I did not see  this soldier until about three Aveeks after the
accident, wdien it fell to my lot  to bring  to England the first ship-load of
those Avho, though Avounded,  but not yet recovered, had escaped the ter-
rible field.   These wounded  men, about ninety in number, embarked at
Ostend, and were  placed ultimately  by me in Haslar  Hospital.  The first
object ivhich-caught my attention, on gaining the  upper deck of  the ves-
sel, Avas this young man.   He lay extended on the deck, pale, exhausted,
almost  exsanguineous,  and seemingly dying.   He spoke with difficulty.
The wound  below the   ear had  never closed, and it bled daily, so that he
could no  longer  sit upright.  As usual, a pile of rags, lint, portions of
bandages, etc., steeped  in blood, and  hoav hardened, concealed the wound,
and  kept the danger  out of  sight.  The sergeant, my only assistant,
cautioned me not to remove this pile, as  he had seen dangerous results
repeatedly in this case,  Avhilst on their route from Brussels to Ostend.  Re-
gardless of this, I put Mr. Abernethy's plan in force, removed all pressure,
exposed the Avound to the air, applied a rag loosely to the wound, directing
it to be constantly Avetted  wdth  vinegar, and directed his head to be  raised
on pillows.  The hemorrhage never returned, and he rapidly recovered.
  In 6ome persons there exists  a hemorrhagic constitution, amounting to
h, serious disease.
  A retired officer of the  Cape Regiment of Infantry had been for some 
OPERATIONS.
281
years subject to this hemorrhagic tendency.   The slightest wound of the
skin occasioned  a  considerable loss of blood, wdiich  flowed all the more
that he continued to Avash the Avounded part with cold water.  I found
that pressure Avith the fingers, employed for but  a short time, closed the
wound uniformly, and arrested the hemorrhage.
   In unhealthy  sores, Avhether originating in wounds or otherwise, great
caution is required in the avoiding incisions into such diseased structures.
   A soldier in the Royal African Regiment of Infantry had for some time
suffered from a corroding, ill-conditioned ulceration of the fingers and  back
of one of his hands.  The surgeon under whose Care he was Avrote to me
to come to head quarters, to assist him in amputating this hand.
   On examining the disease, I found  that the bones of one finger w*ere
carious, and at least contributed to maintain the disease.  I recommended,
therefore, that instead of amputating  in the forearm, the three phalanges
of this finger should be removed; but the surgeon, aware of the alarming
hemorrhages Avhich  had followed all incisions, hoAvever slight, made into
the semi-putrescent fingers and hand,  declined attempting it.  Persisting
in my opinion, the  case was handed over to me, to act as 1 thought fit.  A
straight probe-pointed  bistoury was passed close  to  the bone, as high as
the lateral ligaments connecting the first phalanx to the metacarpal bone,
and these  ligaments Avere cautiously divided  successively,  and the three
phalanges  Avithdrawn from the ulcerating mass.  No bleeding followed,
and the hand  recovered under the use of lotions and  nitrate  of silver.
   In general, the common  dissecting-forceps  is  the best instrument for
seizing hold of the divided artery, and securing it until a ligature  can be
applied, but  the  surgeon should also be provided with   a  tenaculum.
When the tongue  is Avounded, for  example,  by a tooth  accidentally
driven into it, the closeness of the tissue renders the forceps useless.  You
must transfix  the bleeding orifice of the vessel with the tenaculum, and  tie
in a small portion of the surrounding  texture.    The arteries in  the  palm
of the hand are  difficult to be secured, and may require the use of  a tena-
culum. They must be tied Avhere divided, and, if possible, a ligature put
upon both  orifices, lest the freedom of anastomosis render  your ligature
of no avail.
   Lastly, Avhen  a  large trunk, such  as the bronchial, femoral,  etc., has
been accidentally punctured or Avounded, the vessel must be  secured where
wounded, by placing a ligature  above, and  another  below,  the AA-ounded
part.  In my  younger days, surgeons mistook Avounded arteries for aneu-
rism, and to the tumor caused by the  effused blood they gave the name
of traumatic aneurism.  One error naturally produces another ; they mis-
applied Mr. Hunter's ingenious treatment of aneurism by employing it in
cases of wounded arteries.  I  denounced this extraordinary practice in my
earliest lectures  on anatomy, but it continued to be in vogue for a  lon«-
time.  When the  brachial artery was Avounded at the bend  of the elboAv,
the hospital surgeons of the day persisted in making another Avound higher
up, and tying the artery Avhere  it was not Avounded, but  sound.   This
practice, beneficial only to the student, as it  afforded him generally  an
opportunity of Avitnessing several operations instead  of  one, has at last, I
believe, been reluctantly abandoned.   I am at a loss to  comprehend  how
it ever got  a footing amongst surgeons.            Part  xxxiv., p. 265.

  Painful  Cicatrix after Amputation.—Mr. Hancock thinks that this is 
282
OPIUM.
not so much induced by the nerve  or  its bulb being  implicated with the
cicatrix, as  by the adhesion and connection of the  cicatrix by firm, un-
yielding, cartilaginous structure to  the periosteum or bone.  Separate the
cicatrix from the  periosteum by a subcutaneous  incision, and  prevent re-
union by from day to day moving the skin backward and forward.  It is
no use excising the cicatrix ; in the end  matters are only made Avorse.
                                                       Part xl., p. 96.
                             OPIUM.
  Tests for Opium.—Where  opium cannot be detected by the smell, Mr.
Taylor prefers the sesquichloricle of iron as a test, discovering as it does
meconic acid in one hundred and sixtieth of a gr. of opium.  It  might be
supposed, says he, that if, on adding strong nitric acid to a portion of the
liquid, a bright red color resulted, this Avould be a sufficient indication of
the presence of morphia, and  therefore  of opium ; but  a  serious mistake
might be committed in  such a case, unless the operator had previously
employed the iron  test, and determined the  presence of meconic acid in
the liquid.  It is  Avorthy  of  remark,  that the nitric acid test, Avhile it
destroys the color given by the meconate  of iron (a  dark red), will bring
out, when added to excess  to the same portion of liquid, the peculiar bright
amber-red tint Avhich it is  known to give in a solution  of morphia.  The
tests for  meconic acid and  morphia may be thus applied  to one quantity of
liquid.
  Mr. Taylor found that nitric acid detected one-fifteenth gr. of muriate of
morphia, diluted  in 300  parts by Aveight of Avater;  sesquichlor.  iron de-
tected the one-eleventh gr. in 231 parts of water ;  and  iodic acid the one
hundredth grain in 1300 parts  of AArater.   Thus, iodic acid is by far the most
delicate  test,  discovering  as  it does morphia in less than one-fifth of a
grain of opium;  but it is also  the one most open to fallacy,  and cannot
be  employed in colored organic liquids,  containing these small quantities.
Practically its utility is  far less than  Avould be anticipated from the  re-
sult of experiments upon the pure salts of morphia.  Other experiments
Avere performed for the purpose of ascertaining hoAv small a quantity of
meconic acid need be present in a fluid to admit of its separation by acetate
of lead, and subsequent identification by sesquichlor.  of  iron.   No precipi-
tate of meconate of lead occurred when the proportion of meconic acid was
less than one-forty-eight gr., i. e.,  about 0.34 gr. common opium.   Unless,
indeed, soluble matter of several grains of opium exists in the  liquid  for
analysis, it Avill be difficult to  obtain meconic acid and morphia separately.
The iron test for meconic acid is far more delicate than any of the tests for
morphia, and is much less liable to be interfered with.  The one-fiftieth gr.
or  smallest visible portion of solid meconic acid is easily detected when free,
Avhile in  solution, in a small quantity of liquid, even one-five hundredth gr.
may be' discovered.  Thus, the presence of this  acid may be determined in
a liquid from a much smaller quantity  than would suffice to form a separa-
ble precipitate of meconate of lead; for, while  for this  latter one-third of
a grain of opiuuMS required, less than one-hundredth of a grain suffices foi
the exhibition of the acid by the  direct application of the iron test.  The
procural of the precipitate of meconate of lead does not increase the cer 
OPIUM.
283
tainty of the iron test, but merely enables us to obtain the meconic acid in
a concentrated and solid form.                          Part xi.,p. 100.
   Opium.—In reference to the employment of opium generally, the con-
stipation Avhich it  causes  renders it obnoxious to some constitutions.   If
this (as is believed) arises from an arrest of the biliary secretions, the com-
bination with  mercury, rhubarb, or colchicum, will  obviate it.  In  cases
where  any of these are not admissible, the  ox-gall comes to our aid ; and
Avhether it is by directly  stimulating the  secretion of bile, or acting as a
substitute for it, there can be no question of its  being able  to counteract
the constipating tendency of opium.  But this power of causing constipa-
tion  becomes  available  in the treatment  of a very formidable  disease—
namely, in peritonitis from perforation of a portion of the intestinal canal;
and as our object here is to arrest the action of the intestines, to enable the
opening to be sealed up Avith organized lymph, it is evident, that to effect
this object, the uncombined use of opium can only be relied on.   Should
the aid of mercury be required to combat the consequences of the inflam-
mation, its administration must be postponed to an after-period.
                                                       Part xv., p. 87.
   Muriate of Opium.—The folloAving is Dr. Nicol's formula :  Take of the
best poAvdered opium, §j.; muriatic acid, |j.; distilled Avater, |xx.  Mix.
Shake  this mixture very frequently every day, during fourteen days, then
strain  and filter.  The dose is from tAve'nty to  forty drops, according  to
circumstances.
   Dr.  N. says :  I have found by experience, that this is the best anodyne
I am acquainted Avith.   I may mention that I prepared solutions of opium
with acetic, nitric, sulphuric, citric, tartaric,  and muriatic  acids, and also
prescribed them, but the  muriatic  solution Avas vastly superior to any one
in every respect.  All of  them produced headache, with the exception  of
the muriatic.  I prefer muriate of opium to the tincture, wine, or poAvder
of opium, and also to the muriate and acetate of morphia; in fact, to any
other preparation  of opium.   It never makes  my head ache, but all other
preparations do.                                      Part xvii., p. 303.
   Opium—Nausea from.—To counteract the nausea from opium, combine
wdth it 30 minims of dilute sulphuric acid.   The nausea from hydrochlorate
of morphia is best controlled by dilute hydrochloric acid.
                                                   Part xxix., p. 326.
   Opium in the Treatment  of Chronic Ulceration of the Legs, etc.—Mr.
Skey of St. Bartholomew's  Hospital, says: I venture to attribute to this
remarkable drug the property of promoting the formation of  healthy gra-
nulations cm a surface that, notAvithstanding all the previous appliances of
surgery, is yet flat, pale, and ungranulating.   Now, there is no example of
the power of opium to effect this object, more conclusive, or in which there
is more work to be done, than that  form of disease of AvhichI am speaking,
—Avhich consists of a gap  formed on the surface of the body, of greater or
less depth and diameter, and in which there exists not even  a trace of a cu-
rative action,—and yet the object is accomplished by means of this agent,
and often with remarkable celerity.  We call opium a stimulant and a se-
dative.   As a stimulant, it is not very often employed in practice : wdiile
its properties, as a sedative, are  Avell known, and are in daily requisition.
Its property of mitigating pain and of promoting sleep, is that for wdiich it
Li almost exclusively employed, and so completely is its  action associated 
284
OPIOM.
with this sedative principle, that its occasional influence as a stimulant is
almost entirely lost sight of, and the stimulating property has merged in
the supposed sedative.
  I believe that its sedative properties have little concern with the result.
In truth, opium is a most valuable stimulant of the vital powers, and Avhe-
ther its action originate Avith the centre or the periphery of the circulation,
Avhether primarily on the heart or on the capillary vessels, I do not pretend
to knoAV; but there is no drug, simple or composite, knoAvn to our phar-
macologists that possesses an equal power with opium, of giving energy to
the capillary system of arteries, of promoting animal warmth, and thus
maintaining an equable balance of the circulation  throughout the body.
To maintain the balance of the circulation !   How much of meaning is at-
tached to these words !   Hoav many affections of the bodily frame may not
be brought Avithin the range of this  definition !  Take the common chil-
blain ;  what is it but a local congestion of blood caused by defective capil-
lary power ?—there is no better  remedy than opium ; cold feet, as  charac-
terizing a person or a constitution, equally  relieved  ; senile gangrene, the
result of arrest of the  capillary  circulation, or its apparent  opposite,
local hyperemia—these diseases, one and all, manifest a loss of local power,
a failure in the  balance of the circulation.   The  term  " inflammation," a
word formerly in the mouths of our professional brethren on all occasions,
is noAV limited in its application,  and should be yet more limited, and I be-
lieve, in a yet more advanced state of medical science, will be restricted to
an actually rare condition of  the system.  The influence of opium  in such
conditions is that of promoting a genial warmth  over the system,  a gloAV
exactly resembling, and in fact identical Avith, that produced  by the reac-
tion  on the system which is caused by the cold-bath.   It is local health,
and  the  sensation  is most agreeable.   The  benefit derived  from opium,
when administered for the purpose of arresting inflammatory action of the
vessels, admits, I think, of much doubt, and should be resorted to with
some hesitation as a remedial agent, though I am  quite  persuaded that the
evil of its administration  is greatly overrated. But Avho Avill profess igno-
rance in these days of the inestimable value of this agent when resorted to
immediately after an attack of inflammation has been subdued  by a local
or general bleeding?  Here Ave can imagine that, the  activity of the dis-
ease being checked, the diffusing influence of opium  on the circulation may
act as a simple derivative, operating on the vessels at the moment they are
not indisposed to yield up their blood, and to which indeed they are com-
pelled by the diffusive power of the general stimulus.
  Many years ago, and before the introduction of railway travelling, I was
summoned late one afternoon to  see a patient some eighty miles from Lon-
don.  I travelled outside the mail.  This occurred in the month of Decem-
ber, and the night was  extremely cold.   By  some  mistake I omitted to
bring my great-coat; and, for the first hour, I suffered a good deal.  On
reaching a town at some  ten miles' distance from  London, I took the op-
portunity, while changing horses, to run across the street to a druggist's
shop, where I ordered a draught, containing twenty-five drops of tincture
of opium.  I believe I was  the only person outside the coach that night
Avho did not suffer the slightest sensation from cold.
  But it  will be urged by many, who have experimented on, and who have
observed less than I have done, the medical properties  of opium the infi-
nite  importance of studying  the reactive effects  of this daily prison, and 
OPIUM.
285
they would inquire into the condition of a person so treated on the fohW-
ing day.  You may be assured that it amounts to  nil.  You Avill, I am
sure, readilv understand wdiat I mean Avhen I say the cold and the  opium
mutually balanced and mutually neutralized  each other.  There could be
no reaction, because the influence of the depressing agent—viz., the cold,
rather than otherAvise, exceeded in duration  that of the stimulant.  If the
period of prostration  Avere brief, and limited to one or tAvo  hours, the ar-
gument might hold ; but it is but a sorry objection to be urged after all.
  I Avish I could impress on the minds of the medical  authorities in the
Crimea the real benefit that might be derived to our troops, beaten down
by intense cold and suffering in its  various  forms, from the judicious ad-
ministration of opium.   If twenty-five or thirty drops of tincture of opium,
in addition to his ordinary quantum of rum, Avere  administered to each
soldier Avhose nightly services are required in the trenches or on guard,
you would  hear little  complaint of cold  for  that night, neither Avould it
produce the smallest tendency to sleep.
  If cold beget suffering, opium is the  antidote to that suffering, and the
one will assuredly neutralize the other.
  Notwithstanding the prejudices  and the  bigotry that have long  beset
the public  mind  on this  subject, and  from Avhich our" profession is not
totally exempt, there is no comparison  to be draAAm between the practice
of dram-drinking and the excessive indulgence in the use of opium.
  The man wdio indulges in spirituous  liquors makes doily  inroads  on his
digestive powers not  less than on his  brain. His appetite is destroyed,
and the pabulum for  his blood is  withheld from  his  circulation.  He is
stamped for life, and his perfect health is irrecoverable.   The influence of
opium,  when taken  as a means of indulgence, though deleterious,  is not
permanently  injurious.  It exercises no  serious  influence on his digestion
or on his cerebral organs, and, the practice once controlled, leaves him in
a condition to regain, wdthout difficulty, the fullest vigor of  both bodily
and mental health.
  I have related  to you the particulars of several cases of chronic ulcer in
which  recovery was  attributable to the medicinal properties of opium,
and almost to opium alone.  The character of these ulcers strongly marks
the inactivity of their nature, aud hence the  class of society to  wdiich they
belong.  Tliey are  marked by a flat base,  Avhich indicates, by its  pale,
flabby  uniformity of surface, that no reparatory  action has approached it.
It is often  surrounded by a thick, high  ridge of lymph, covered by un-
healthy integuments.    The depth of the ulcer, which  may be seven or
eight lines, is caused partly by the ridge, and partly by the excavation  oi
the ulcer beloAV the natural level of  the healthy  integuments.   So long as
this ridge exists, although granulations may  form, and will form, from the
date of the employment of the opium, yet  cicatrization will  never  com-
plete the process of' cure unless the Avound or ridge be absorbed.   Noav
the action of  opium is not alone exhibited in the development of healthy
granulations,  but in the entire  complement of such  actions as are required
bv the sore, viz., the formation of new material,  and the absorption of the
old.
  The influence of the stimulant is exhibited therefore not on one particu-
lar function.   It does not merely promote secretion, but it stimulates the
healthy  vital  actions  in their  entirety—viz., secretion,  organization, and
absorption contemporaneously ; the granulations are secreted  and orp-an- 
28G
ORCHITIS.
ized, Avhile the circumvallation of unsound  material, the product of years
of groAvth, is gradually absorbed and reduced to the level of the surround-
ing integument; for the removal of this Avail is quite as indispensable to
the ultimate result as the obliteration of the cavity by granulation.  With-
out the tAvo surfaces be brought to the same level, the process of cicatri-
zation, o'- skinning OArer, will never be perfected.
  If,  therefore,  Ave  find that a  disease like  that I have  described, and
wdiich exhibits so palpably a dormant  condition of the remote capillaries,
is amenable to this form of sdmulant, which can only accomplish the cure
by the substitution of healthy for morbid actions, Avhy should Ave restrict
its employment to this class of diseases ?  Why, as I have elsewhere  in-
quired, may we not  experiment with  success on any local  disease depen-
dent  on the  same  cause—viz., an inert condition of the  remote vascular
system?
  In claiming for opium the merit of rousing into healthy action the dor-
mant capillary system, to the end of accomplishing the permanent cure of
ulcer of the  legs in old persons, I by no  means  Avish you to infer that I
consider all other modes of treatment umvorthy of trial. Indeed, I attach
great value to that recommended by Mr. Baynton, of Bristol, and others;
but, having tested their Aralue, I have no hesitation in pronouncing that
Avhich I have recommended, so far as I am competent to judge, as by far
the most certain and efficacious.                      Part xxxi., p. 192.
                          ORCHITIS.
  Treatment of Diseases of the Testicle by compression.—Mr. Langston
Parker states that  in  common swelled  testicle compression  may be em-
ployed as soon as the patient is able to bear the application of the plasters;
and this is generally much sooner than might be supposed, hoAvever acute
the disease may be.  The great advantages possessed by compression, are
almost immediate relief to pain; the  patient can  usually pursue his ordi-
nary duties.  Compression is also ad\dsed in chronic enlargement and in-
flammation of the testis—the result of constitutional syphilis.
  Compression of the testis is to  be  practised  by surrounding the organ
by straps of  plaster, applied as closely and tight as the patient can bear.
The plasters I generally use are those of ammoniacum, Avith  mercury, or
iodine and belladonna. These are to be smoothly spread upon thick Avash-
leather and cut into thin straps ; an assistant then grasps the testicle, and
draAvs it  as far doAvmvard as he can in  the scrotum, which should previously
be Avashed AAdth a little spirits of Avine.  The first strap should be placed
at the upper part,  circularly round the  testis,  and  succeeded by  others,
placed in the same  direction, till  the  whole is covered: a second series of
straps is  then to be placed in an opposite direction  to the former, crossing
them at right angles, from behind forAvard.  One  or  two long ones may
then be placed over these where  they appear to be most needed, to keep
the whole in place.  The parts should  be supported by a well-fitting sus-
pensory  bandage, although  the plasters at once relieve any inconvenience
or pain that may have been occasioned, by the dragging or Aveight of the
testicle.                                              '  part \\^p 109t

  Pressure by Condensed air as a Surgical Remedy.—Pressure  applied 
ORCHITIS.
287
to diseased parts, when judiciously employed, has long been regarded as a
valuable  remedy in particular diseases, in some cases of diseased testicle
for example; this has generally been applied by means of straps of plaster,
or some such  application, which, hoAvever, cannot be properly or durably
applied.   Dr. Krauss suggests the adoption  of compression by condensed
air, in  Mackintosh bags, variously shaped, so as to fit the different parts
of the body Avhich are most liable to require  such applications.  He would
surround a diseased testicle Avith one of these air  cushions,  consisting of
two bags, one hanging in the other, and both  narroAV on the top,  to sur-
round the spermatic cord.  Each bag is open on one side, from the top to
the bottom, and  they are attached to  each other by their corresponding
edges,  so as to leave  between them an air-tight space, accessible only by
means  of an air-tight screAv, fixed to the bottom of the outer bag.  Along
the side opening are holes to lace the double bag,  previously to its being
inflated,  around the testicle, and it  is subsequently filled  AAdth  air, by
means  of a simple air pump.   The inside bag is thus  uniformly pressed
against the whole of  the scrotum  contained in the air bag.  On the swell-
ing of the testicle decreasing, more air can easily be introduced, or, on the
other hand, if necessary, the degree of pressure can be reduced by allow-
ing part of the air to escape.
  Dr.  Krauss proposes an air bag, made in the shape of a cylinder, to
replace the solid bougie for dilatation  of strictures, also an air pessary, on
the same principle, for the support of prolapsions of the womb,  and an air
bag, for the purpose  of Tamponnement in hemorrhage of the uterus.
   He further suggests the application of pressure by condensed air, as a
curative means in certain diseases of the joints—in perforation of the roof
of the palate—for the cure  of ulcers, and for  the dispersion of tumors.
Dr. Krauss concludes by  directing attention to the application of air and
water-cushions to diminish the pressure that artificial legs frequently pro-
duce upon the stumps to Avhich they are applied.
                                                    Part viii., p. 146.

  Acute Orchitis.—Mr. T. B. Curling strongly recommends tartarized an-
timony.   " A quarter of a grain  of tartar emetic may be exhibited every
three or four  hours, and the dose, if necessary, increased until  nausea is
produced.  This is one of the most valuable remedies  that can be employed
in acute orchitis; and Avhen patients are desirous of avoiding the trouble,
mess, and  exposure  consequent upon  the application of leeches, the  exhi-
bition of tartar emetic will generally  render local  depletion unnecessary,
whilst  its depressing  influence being only temporary, the patient quickly
regains his health and strength.   I have seen most acute orchitis arrested
and subdued in thirty hours by keeping up  constant nausea by means  of
this remedy.   When there is much pain or constitutional derangement,
two or three grains of calomel, combined with  eight or ten grains  of Do-
ver's powder, or Avith small doses of morphia, may be given at  bedtime.
In consecutive orchitis, in  Avhich the tunica vaginalis is so generally affect-
ed, considerable  benefit is derived from mercury.  In acute cases, after the
boAvels have been freely acted on, and the pulse has  been lowered by tar-
tar emetic, I usually prescribe mercury, and  continue it until the gums be-
come slightly affected.  I am confident that by this  treatment the dura-
tion of this form of the disease is often materially abridged, and, Avhat is
of some importance, it is succeeded by much less induration and thicken- 
288
ORCHITIS.
ing of the epididymis than  when the exhibition of mercury has been de-
ferred to a later period."                              Part viii., p. 207.
  Enlarged Testicle.—Ricord employs the following pills in the treatment
of enlarged testicle, Avhich remains after inflammation  of  that organ :
  Hyd. chlor. $j.; pulv. conii; sapon. hisp.  aa. 9ij. M. ft. pil. xxiv.
                                                       Part ix., p. 20.
  Treatment of Hernia Humoralis, or Gonorrheal  Orchitis, by Opium.
—In the reports of cases of this description under Mr. Gay, in the Royal
Free Hospital, London, we  find that the  gonorrhoeal inflammation of the
testicles and  appendages  Avere speedily and completely cured, by purga-
tives and opium.  Hyoscyamus has been given wdth equally good effects.
The full and free purgation ivas ahvays necessary before giving the opium.
Fifteen minims  of  laudanum may be  given every four  hours, and the
previous purgative  may  be  composed of  five  grains  of calomel wdth
tAventy-fivc grains of jalap, or a strong black draught.     Part ix., p. 186.
  Orchitis—Incision into the Tunica Albuginea.—M. Velpeau considers
that the excruciating pain experienced in orchitis depends on a species of
strangulation ; the tunica  albuginea, not yielding, compresses the swollen
and inflamed testicle, and  thus gives rise to the intense pain.  He accord-
ingly, acting on these views, recommends an incision into the tunica albu-
ginea.   He has performed it with suscess fifteen times, nor did permanent
injury of the testicle occur in any one case.              Part xii., p. 302.
  Treatment of Gonorrheal Orchitis.—In  taking a review of the method
of treatment usually employed in this disease, Mr. Phillips states that punc-
tures, frictions, and compressions, are of limited application ; purgatives
are not of use except in moderation, to keep the boAvels open ; local blood-
letting produces as much inconvenience as it does good; and general bleed-
ing is usually uncalled for.  The plan of treatment Avhich  Mr. Phillips pre-
fers, is that by nauseants.
  Give a mixture containing epsom salts, and a sufficient  quantity of tartar
emetic to produce decided nausea from the  first; say half a  grain for the
first dose, and then a fourth or a sixth of a  grain every four or six hours,
so as to keep up the nausea for two or three days.     Part xviii., p. 215.
  Treatment  of Orchitis.—Mr.  Cooper  advises  active antiphlogistic
treatment.  Thus, in  persons of plethoric habit, bleed from the arm ;  in
others, in  addition to the application of leeches to the  affected organs, cup
from the loins to about  eight ounces.   Give also  a pill containing a grain
and a half of calomel, one-third of a grain of tartarized antimony, and
half a grain of opium ;  and the folloAving mixture : R Magn. sulph. giij. ;
liq. ammon. acet., 3j.; liq. antim. tart., giss.; tinct. hyoscy., 3iss.; aq. menth.,
§vij.  M. capt. §j.  3tis horis donee alvus bene  responderit.  Keep the pa-
tient on Ioav diet, and in the recumbent position.  And as a local applica-
tion use a lotion containing a drachm and a half of muriate of ammonia,
tAvo ounces each of rectified spirit and liq.  ammon. acet., and four ounces
of Avater.   If the inflammation does not abate,  open the  congested vessels
of the scrotum, and promote bleeding from them by  warm fomentations.
If enlargement and harshness of the  testicle remain after the subsidence
of the inflammatory symptoms, apply strips of  lint spread with the follow-
ing ointment: R Ung.  hydrarg.; cerat.  saponis, aa.   §ij.; camphor a?, gr.
v. M.; and over this, apply adhesive plaster, so  as to make considerable
pressure.  Do not, however  use pressure in the early  and acute sta<*e. 
                         OVARIAN AFFECTIONS.                     289
                                                          •
   Rheumatic and Gouty.—Give alkalies, and  a small dose of colchicum
 at, bedtime.
   Gonorrheal.—Apply warm fomentations to the scrotum, perineum, and
 penis, so as to reestabUsh the discharge, and then give calomel and opium
 every night.                                          Part xix., p. 174.
   Collodion  in Orchitis.—Prof. Costes relates cases of this  disease  in
 which, after covering the scrotum with a mixture of 20 parts of collodion
 and 6 of ol. ricini, the SAvelling and pain were quickly relieved, and a rapid
 and complete cure Avas obtained.                    Part xxxii., p. 293.

                              -----»-♦-•—


                   OVARIAN  AFFECTIONS.
   Ovarian Tumors—Diagnosis—-It has occasionally happened that solid
 growths or tumors of the ovaries, Avhether of  a malignant or non-malig-
 nant character, are attended Avith  an effusion into the peritoneum, or an
 ascites, and may thus be mistaken for the  more usual form of the ovarian
 disease, viz.,  the encysted dropsy.   Dr. Kilgour furnishes us with  some
 valuable hints on the diagnosis of these affections.
   The non-malignant, solid enlargement or tumor of the ovary, and which
 sometimes attains a  very great size, is, generally speaking, of the  same
 character as  the fibrous tumor of the uterus, and unless improperly inter-
 fered Avith,  may exist for many years without giving more disturbam
 than  is occasioned by its bulk.   The  malignant disease is similar to ihi
 met with in the mamma, and sometimes is of the hard form ; in other cases
 it presents the characters of  soft scirrhus, or  encephaloid disease.   The
 non-malignant disease is not attended Avith  pain—the malignant one is so
 generally, but not ahvays.   The latter is  almost invariably attended Avith
 much constitutional disturbance ; it is much more rapid in its course ; and,
 Avhilst it indicates almost its nature by this quickness in  its fatal pace, it
 frequently still further demonstrates itself by attacking the mammae, the
 uterus, or the pylorus.
   The fibrous and  the scirrhous tumors, wdien felt through the abdominal
 Avail, are smooth or rough, or knobbed or tuberose, on the surface;  and
 no diagnosis  of  the  two  diseases  can be  made by this  means ; but the
 semi-solid or  gelatinous cyst  is almost ahvays smooth, and invariably to a
 practised  hand,  gives more a  feeling of elasticity  than  solidity, whilst
 traces of fluid, perhaps faint, will be discovered  in partial spots of the ab-
 domen, viz., in some of the other  cysts.  The  semi-solid or gelatiniform
 and elastic cyst  is ahvays fixed? but  the  solid  tumor is  often  movable,
 and, when  attended with effusion,  it moves  about by slight pressure in
 the fluid.
  Noav, are there any accurate means of distinguishing solid ovarian dis-
 ease with ascites, from encysted dropsy of  the ovarium ?   But, first, how
 is encysted dropsy itself known from ascites?
  Cruveilhier furnishes us with tAvo  very important  diagnostics.  1st. In
ascites the liquid ahvays occupies the most  dependent parts, viz., the pelvis
and lumbar region ;  whilst the small intestines floating in the fluid, corres-
pond to  the  umbilical region, and  the arch of the colon and stomach
occupy the epigastrium.   Percussion, therefore, elicits a dull sound over
    vol. n.—19 
290                     OVARIAN AFFECTIONS.
           •
the hypogastric and lumbar regions; whereas,  in  encysted dropsy, the
cvst  develops  itself anteriorly to the intestines  which it pushes back, so
that  here the tympanitic sound does not existi  In ascites the fluctuation
is more decided than in encysted ovarian dropsy.  2d.  In ascites the neck
of the Avomb is in its proper place, Avhile in encysted ovarian dropsy it is
actually drawn upward, so that it is difficult to reach it;  the pelvic cavity
being also in some measure filled by the tumor; and the general health is
often good ; while in ascites this is not the case, anasarca  also often accom-
panying it.   If a solid ovarian tumor co-exist with ascites, it may gene-
rally be known by its mobility ; it moves up and doAvn in the fluid, strik-
ing the finger  exactly like a child in utero, in what' is  termed the ballote-
ment.   In the encysted dropsy, if a solid tumor is present, it is fixed ; it
is outside the  cyst of the bag of Avater, or forms part of the Avail of the
cyst, and cannot readily move about.  But Ave apprehend that in these as
well as in most, if not all the diseases of the Avomb and the  contiguous parts,
Ave shall find  Dr. Simpson's uterine sound  or  bougie one of the most im-
portant  means of diagnosis Avhich  has lately  been brought before the
public.                                                Part viii., p. 95.

   Treatment of Ovarian Cysts.—Mr. Phillips states it as his opinion, " that
Ave have not  the  means of determining Avith absolute certainty Avhether
a tumor be an ovarian cyst or not;  and that Ave  have no sure  means of
ascertaining the contents and connections of tumors presumed to be ova*
rian."   There  have been numerous  cases, however, in which it may have
been perfectly correct  to operate, but we suspect that these form the ex-
ceptions rather than  the rule.  Mr. Isaac Brown brings forward cases of
ovarian  tumors Avhich Avere dispersed without these  severe proceedings.
He made use of mercurials, diuretics, tonics, tight bandagitig, and tapping.
These cases, however, Avere of young unmarried Avomen, in Avhom the re-
parative poAvers of nature may have  been more vigorous, or in whom the
disease may not have been so obstinate.
  The treatment  was adopted at  the suggestion  of Mr. Gibson, of Hal-
stead.   It consisted of  mercurial friction  over the abdomen, Avith flannel
bandages tightly applied, mercurial alteratives, and steel  medicines, varied
by diuretics,  such as  acetate of potash,  spirit of juniper, and squills.
When the health was  improved, and the size of the abdomen somewhat
diminished, shoAving that the cause of mischief was  somewhat arrested,
tapping Avas  resorted  to;  and after this a pad was made of napkins, and
tightly bandaged, so as to produce a good deal of pressure in the situation
of the tumor :  this pad  Avas  increased in thickness next day, and  firm com-
pression continued.  The mercurial friction  was continued  on  the inside
of the  thighs, and the diuretics again commenced.   The pad was con-
tinued, and the compression increased as the patient could bear  it.   Seve-
ral cases are  related in which this treatment Avas  successful.   It will be
necessary,  hoAvever, to  continue the treatment for a considerable time
after the tumor seems to have been dispersed,  otherAvise it will be likely
to return.                                              Part x., p. 124.

   Case of Ovariotomy.—The following case of extirpation of an  ovariau
tumor seems to have been one of the  most successful yet recorded. Much
credit is due to Mr. Southam for having added to our capabilities of form-
ing a true diagnosis in these formidable diseases.  [Having determined on 
OVARIAN AFFECTIONS.
291
extirpation, the room being heated to 75°, and the bladder emptied, etc.,
it was performed in the presence of Drs. Radford, Clay, Watson, and seve-
ral surgeons, as follows] :
  An exploratory incision, midway betAveen the umbilicus and pubes, ivas
first made, and the peritoneal cavity opened sufficiently to admit the finger,
A characteristic membrane of a bluish wdiite and shining surface appearing
at the opening at once satisfied me of the existence of a cyst, and the fingei
introduced betAveen it and the peritoneum, discovering no adhesions in the
immediate neighborhood, I punctured  it with a full-sized trocar.   After
from sixteen to eighteen pints of clear, lemon-colored slightly mucilagi-
nous fluid had been evacuated, pressure  on the parietes being well sustained
during its escape, the canula Avas Avithdrawn, and using the index finger as
a director, the opening ivas enlarged above and beloAv with a probe-pointed
bistoury, to the extent of betAveen six  and seven inches. Having  ascer-
tained  by the hand introduced into the  abdominal cavity, that there were
no impediments to the extraction of the tumor, it was carefully drawn out,
gentle  pressure being continued on the  abdomen.  Finding that it was  at-
tached to the uterine extremity of the  left broad ligament by a short and
slightly vascular pedicle, I tied it firmly wdth a single ligature of the strong-
est dentist's silk.  The pedicle was now divided, and the tumor being  re-
moved, the margins of the wound were immediately approximated to pre-
vent the ingress of air.  After  a  brief interval,  the  wround  was again
opened to remove what blood had escaped internally, and to ascertain that
the vessels of  the broad ligament wrere firmly secured.  The uterus  and
opposite ovary were also  examined and found healthy.  One  end  of  the
ligature  being cut off, the other was left dependent  at the loAvest point of
the Avound, the edges of Avhich were brought together by four interrupted
sutures and straps of transparent tissue plaster.   Upon these a broad pad
Avas applied, and the Avhole being adjusted by a bandage, the patient ivas
lifted into bed, Avithin twenty-five minutes from the commencement of the
operation.
  [The case proceeded uninterruptedly to a favorable termination ;  the
ligature came away on the forty-ninth day,  and the  fistulous opening then
closed.   After remarking that the difficulty in making a correct diagnosis
forms the chief objection to the operation, which must continue so long as
mere examination of the abdomen, and the history of the case alone,  are
relied on in forming it—Ave are told that in the present  case, though the
enlargement was uniform and fluctuation distinct in every part—]
  An examination per vaginam et rectum, cleared up all doubts, not only
of the existence of an ovarian  tumor, but of its exact nature.   The absence
of any protrusion of the vaginal parietes, the elevated position of the  uterus
in the pelvic cavity, and the inability to cause it to bound aAvay from the
finger, proved that the fluid could not be ascitic, whilst the projection of the
swelling on the left side, the decided influence which raising  and depress-
ing the abdomen produced on the position of the uterus, with its inclina-
tion to one side more than the other, evidently indicated that the  disease
Avas  connected with the left   uterine appendages.  The uniformity in  the
abdominal distention, the  distinct fluctuation in every part of it, and  the
inability  to discover any solid matter encroaching on the pelvic cavity, led
me to infer that it consisted of one or tAvo cysts only ; and the comparative
immunity from any great degree of suffering until Avithin the last  twelve
or eighteen months, the absence in the  history of any previous attacks of 
292
OVARIAN AFFECTIONS.
 peritonitis, together wdth the slight impediment to the action of the boAvels,
 rendered the existence of adhesions doubtful.
   Though somewhat  emaciated, her general health did not appear  im-
 paired ;  appetite good ; tongue clean ;  pulse natural;  boAvels occasionally
 constipated,  but easily acted on by medicine ; catamenia regular, though
 in  less quantity than  formerly ; felt pain at times in the left inguinal re-
 gion, or whenever she lay on the left side, and in consequence of the pres-
 sure of the tumor upAvard, she has been unable to lie  on her back, or in
 any other position, excepting on the right side, for the last tAvelve months.
 The symptoms clearly indicating encysted dropsy of the left  uterine appen-
 dages, advanced to such a stage as  to render  surgical  interference neces-
 sary, and her constitution not being much affected, I considered the case
 was peculiarly favorable for the operation.   In the operation, the  evils of
 both  the major and minor incisions  were guarded against, by making the
 opening no larger than Avas necessary to ascertain the nature and  connec-
 tions of  the  disease, and to  admit of its removal after reducing it by para-
 centesis, Avithout occasioning the least violence or displacement of any of
 the neighboring parts.  Had the slightest obstacle occurred previous to the
 successful termination to the operation, this plan would also have enabled
 me to have receded Avithout much danger to the patient. Part xii., p. 247.

   New Operation for Ovarian Dropsy.—Prof. Kiwdsh  relates the case of
 a peasant, ast. thirty, mother of four children, Avho Avas received into the
 hospital  at Prague on account of obstinate ischuria and constipation. The
 cause of these affections ivas found to be a tumor, the size of a head, lying
 between the rectum and the vagina.  By careful examination the operator
 was satisfied that this tumor ivas not formed by the uterus, but by an  en-
 larged ovary containing fluid.
   With  a curved trocar a puncture was  made in it, through the vao-hial
 parietes.  Through  this about nine pounds  of a chocolate-colored fluid
 was drawn off, upon Avhich  the sac completely collapsed, and the uterus,
 which had been pushed high upward and forAvard on the brim of  the pel-
 vis, returned to its natural situation. The canula was left for thirty hours
 in  the wound, to permit all the fluid to drain off.  In ten  days it was ne-
 cessary to repeat the operation, and on this occasion the opening made by
 the trocar was so far dilated with a bistoury that a finger coulcf be intro-
 duced into the sac; several  pounds of fetid bloody pus  and  numerous
 flakes of lymph were removed.  Water ivas injected into the sac with
 considerable force, and m  order to keep the opening pervious  a thick
 curved uterine tube of tin was introduced into it, and fastened in'front of
 the external genitals.  During the ten  days following the operation there
 was considerable fever and a good deal  of fetid discharge;  but at the end
 of a fortnight the discharge unproved in quality, and  diminished in quan-
 tity ; the tube was then removed for some hours daily, so that the patient
 was permitted to take some exercise, and from this time she gradually re-
 covered   In four weeks the wound had contracted so much that the tube
 could not be again introduced ; and in about six  weeks from  the  date of
 the second operation, the patient was dismissed cured   A  year after  this
 the author  again saw the patient; she was then in perfect health •  the
. uterus was in its normal condition and situation, and behind it the regains
 of the sac could be felt as a small,  hard and  easily  mobile body, causing
 not the slightest inconvenience.                               •r' cauoiub 
OVARIAN AFFECTIONS.
293
  The author states that the following conditions are necessary to insure
success : 1st.  That there be no other complication, and that the tumor be
unilocular; this is to be proved by its being entirely emptied by an explo-
ratory puncture Avith a trocar.  2d. That the  cyst contain  not more than
fifteen pounds of fluid.  3d. That the opening made  be large  enough to
permit the easy introduction of the finger.  4th. That the injections of
water be of such a temperature as shall be agreeable to the patient,  and
that they be throAvn deep into the sac.  5th. That the  tube introduced into
the opening be Avithdrawn at intervals, and  that its use be not entirely laid
aside until the opening has become contracted, and the discharge has be-
come solely purulent; if the opening contracts prior to this, it  must be
again enlarged Avith the knife.                        Part xiv., p. 319.
   Ovarian Dropsy.—As palliatives, Dr. Allison  advises iodide of potas-
sum Avith  squill and  juniper.  After tapping, introduce a  small silk cord
as a tent, by which the water may be occasionally evacuated. For a radi-
cal cure, inject a solution of iodine into the sac.         Part xv., p. 307.

   If the tumor is solid, says Dr. Locock, do not  meddle wdth  it.   If an
unilocular cyst, tap once, and apply pressure for several months;  mercury
and diuretics do harm.  If the tumor is malignant or  many-cysted, tapping
and pressure Avill do no good : in these cases alone is extirpation indicated,
and in these is it least likely to do good.                Part xv., p. 308.
   Case of Ovarian Disease.—[A lady with all the symptoms of ovarian
dropsy, having a large and tense abdomen, and  distinct fluctuation,  Avas
tapped ; no fluid issued from the canula, nor did any folloAV its withdrawal.
The symptoms Avere not aggravated by the operation, but  in a few weeks
she died ;  and post mortem, the trocar Avas again passed Avithout giving
exit to fluid.]
   On opening the abdomen, the ca\dty of the peritoneum Avas found full
of a gelatinous substance like glue, which could be drawn out in long
strings, and would not drop.  This tenacious fluid could Avith difficulty be
removed,  though  a bucketful was taken  out.  There was then found a
cyst of the right ovary, not capable of holding a quarter of the fluid taken
out.  The cyst appeared to have burst, then lessened in size, Avhile the se-
cretion still ivent on from  its lining membrane into the cavity of the abdo-
men, causing the sense of  fluctuation.
   [A case similar to the above in the character of the fluid occurred in
the practice of S. Smith, Esq., of Leeds.  On tapping, the contents of
the cavity Avere found of such a consistence that they could only be evac-
uated by taking hold of the portion which protruded through  the canula,
and drawing it out by winding it over the hands, as one Avould wind a
rope.  In this manner many gallons Avere evacuated.]   Part xv.,p.  311.

   New Plan of treating  Ovarian Dropsy.—It is proposed by Dr.  Tilt
to treat certain cases of ovarian disease by establishing solid adhesions be-
tAveen the tumor and the abdominal Avails ;  effecting a very small ulcerative
opening of the cyst through the centre of these adhesions; and so inducing
gradual discharge of the  fluid, and contraction of the Avails of* the  cyst.
The cases to which this method  is applicable, are those Avhere the cyst is
monolocular, and  Avithout any amount of solid deposit.  These points may
 be ascertained by a  preliminary tapping, by which Ave may judge  also of 
294                     OVARIAN  AFFECTIONS.
the degree of tendency to peritonitis.  If, after tapping, the case is thought
to be a suitable one, the cyst is to be allowed to refill to half its previous
size, and the treatment is then to be commenced.  It consists_in applying
a portion of Vienna paste, so as to produce an eschar of the size of a half-
crown, at some part of the abdomen ;  either at  the spot where the fluctu-
ation is most superficial, or, if there be no such  spot, in the mesial line, an
inch or two beloAv the umbilicus.  The eschar  is to be left to separate of
its own accord, and then, if the thickness of the abdominal Avails requires
it, another portion of caustic applied to the abraded surface.  The second
step in the treatment, the formation of a valvular opening into the cyst,
is not to  be attempted by surgical interference ;  it will take place by ulcera-
tion spontaneously, a few days or Aveeks after the separation of the eschar.
When the contents of the cyst begin to escape, abdominal pressure must
be used ; at first, moderate, Avith a view, not of emptying the cyst, but of
giving support: afterward gradually  increased, with a vieAV of diminish-
ing the size of the  cyst, uoav  become too large for the  quantity of fluid
secreted by its lining membrane.  The contraction of the cyst will  neces-
sarily be slow, and it is of great importance to keep it quite full.   For this
purpose  injections should be used, and their employment should  commence
Avhen the secretion  becomes A^ery fetid.  The point of an india-rubber tube,
eight inches long, and funnel-like in shape at its other extremity, is to be
gently passed through the opening, into the cyst, and tepid Avater gradu-
ally and  gently injected in sufficient quantity, care being taken  to exclude
air ; the patient is then told to strain, AAdien the overplus  of the fluid will
trickle out through the tube.   When the use of injections has  been com-
menced, they should be  used regularly, eArery  day before  breakfast;  and
oftener,  if the fetidity of the secretion requires it.   As to the other modes
of treatment—small tumors  may be  cured by giving large doses of the
preparations of iodine internally, and using them externally.  When the
cyst is voluminous, and bulges into the vagina, it  may be punctured per
vaginam, and an india-rubber sound left in its  cavity, and moderate press-
ure applied to the  abdomen.  Subcutaneous incision into a monolocular
cyst is sometimes warrantable.  Tapping, as a  palliative, is to be deferred
as  long  as possible; and ovariotomy is to be reserved  for multilocular
cysts, and those monolocular ones Avhich contain much solid deposit.
                                                    Part xviii., p. 289.

   Case  of Ovarian  Tumor  containing Teeth and Hair.—The patient
was an  unmarried Avoman, fifty-eight years of  age, Avho  had had a tumor
in  the abdomen, presumed to be ovarian, for tAventy-eight years.  The
SAvelling having latterly increased very rapidly, so that respiration Avas im-
peded by the distention  of the  abdomen and pressure on  the diaphragm,
she Avas tapped, and about seven  quarts of serum Avithdrawn.   She died
forty-eight hours afterward, with symptoms of exhaustion and  peritonitis.
The tumor, on being removed, proved to be a cyst varying in thickness in
parts, but generally about  that of a shilling: "its contents consisted of
teeth, hair, bony deposit, some transparent masses of a cellular structure
 (as examined by the  microscope), serum, sebaceous matter, and granular
fat;  which Avere contained in numerous small cysts.  Teeth Avere found in
all parts of the tumor, and  were  counted to the number of forty-three:
some were contained in  cysts; others  imbedded  in the  semi-transparent
 masses,  and tAvo or three were groAving from the Avails of the parent  c>>t. 
OVARIAN AFFECTIONS.
295
In one part a few were  imbedded in a mass of bone, bearing a strong re-
semblance to an upper jaAV ununited in the mesial line. Pari  xx., p. 235.

   Ovarian Dropsy is  liable to be confounded Avith, 1.  Retroflexion and
retroversion of  the  uterus.   2. Tumors of the  uterus.  3. Ascites.  4.
Pregnancy.   5. Pregnancy complicated Avith ovarian dropsy.  6. Cystic
tumors of the abdomen.  7. Distended  bladder.  8. Accumulation of air
in the intestines, especially if there  has been chronic peritonitis leaving
some ascitic fluid.  9. Enlargement of the solid viscera of the abdomen.
the liver, spleen and kidney.  10. Accumulation of fasces in the intestines.
                                                    Part xxii., p. 289.

  Mr. I. B. BroAvn's new operation for treating ovarian dropsy consists of
excising  a portion of the sac, returning the remaining portion into  the
peritoneal cavity, and closing the wound by sutures, alloAving any fresh
portion of the fluid secreted  by the  remainder of  the  cyst to  escape into
the peritoneal cavity, and to  be there  taken up by  absorption, and dis-
charged  by the  kidneys.  This  plan Avas brought to Mr. Brown's mind
by reflecting upon the numerous cases  in  which a spontaneous cure fol-
lowed an accidental rupture  of the cyst, succeeded by a copious discharge
of urine.  Mr. BroAvn relates three cases thus treated, Avhich, though fol-
lowed by severe peritonitis, ultimately did AvelL       Part xxvL, p. 347.
   Diagnosis of Chronic Ovarian Tumors.—According to  Dr. Tilt, ova-
rian tumors many be confounded with tumors of the unimpregnated womb.
Retroversion and. retroflexion of the Avomb have been  mistaken for inci-
pient ovarian tumors, fallen into the  recto-vaginal pouch, or confined there
by false membranes. The mobility of the tumor, by the uterine sound pre-
viously introduced, Avill shoAV whether or not it be uterine.
   Retroflexion of the Avomb is more likely to simulate incipient ovarian
cysts :
   Ovarian Tumors may be confounded with Abscess of the  Walls of the
 Womb — Case.—Some years since Professor Recamier Avas consulted by a
medical  man for his wife, Avho  had  long  suffered from Avhat was called
ovarian dropsy.  On making a \-ery careful examination, Recamier dis-
covered a round tumor  about  the size of a pigeon's egg, situated betAveen
the rectum and the uterus.   On exploring the rectum Avith the index of
the left hand, Avhile that of the right remained in the neck  of the womb,
more than usually dilated, he felt fluctuation, and  as the pus seemed near-
est to the posterior wall of the neck of  the uterus, Recamier determined
on making an incision there.  To perform  this operation he placed the in-
dex of the left hand in the neck of the  uterus, and  guiding a convex bis-
toury on the pulp of the finger, he plunged the extremity of the bistoury
into the abscess; a feAv teaspoonfuls of pus came  out, and to facilitate its
egress he enlarged the inferior angle of the Avound, by completely cutting
through the posterior lip of the os uteri, the index of the left hand placed
in the rectum serving to guide the bistoury, and  preventing too  deep an
incision.  During the folloAving day  a  small quantity of pus Avas voided.
Frequent injections were made, and  the patient soon got well.  This case
shoAvs Iioav to detect and to cure similar instances of disease.
   Ovarian Tumors may be confounded with  Abscess of the Cavity of
the Womb.—llusson presented to the Anatomical Society of Paris a case
of this description, the neck  of the Avoinb Avas completely obliterated, and
its dilated cavity contained tAvo tumblers of pus. 
296                     OVARIAN AFFECTIONS.
  Ovarian Cysts may be confounded with Hydrometra or a Collection of
 Water in the Womb, and Ave do not doubt but that some of the cases de-
scribed as cases of spontaneous cure of ovarian cysts are to be referred to
the rupture of such uterine tumoKs.
  After fully ascertaining the impossibility of the womb being distended
by a child, it Avould be Avell to imitate Lisfranc, Avho in one of his cases in-
troduced a sound into the Avomb, and cured the patient in a month.
  Ovarian Tumors may be confounded with Cystic Tumors in the sub-
stance of the  Uterus.—By means  of the sound  such a tumor might be
shown to be  uterine, before it attained to a considerable size, or after it
had been emptied.
  Ovarian  Tumors may be confounded with the Uterus distended by the
Menstrual Secretion.—Dr. Williams had such a case in St. Thomas's Hos-
pital.  Examination per vaginam detected a fluctuating tumor, ivhich Avas
freely opened  Avith an abscess-lancet, and a large washhand basin Avas filled
with the retained menstrual fluid.
  The uterus, distended by retained menses, is not always regularly devel-
oped, but may increase to the right or the left, and give that obscure per-
ception of fluctuation Avhich is frequently found in a malignant mass.   On
each side of a central tumor may also  be found smaller elongated tumors,
formed by  proportionally-distended oviducts, Avith obliterated abdominal
ends, as in the case related by Dr. Jackson, in the " American Journal of
Medical Sciences."
  Ovarian Tumors may be confounded  with an Accumulation of Gas
in the Womb.—Mauriceau, Schmitt, M. Lefevre, and many other authors,
have seen examples of this singular occurrence.
  The obliteration of the os uteri on the one side, and the clear sound
furnished by the distended Avomb, will point  to a correct diagnosis.
  Ovarian Tumors may be mistaken for  Uterine Fibrous Tumors.—This
mistake is much more liable to  occur  than any of the preceding, because
the frequency of such tumors is great.
  The absence of fluctuation, the hardness of the tumor, the very gradual
progress of the disease, may indeed allow one to affirm that the tumor is
solid; but were it not for the uterine sound, it would  be difficult to affirm
that it is not ovarian.
  If Aye find  that the uterine sound passes, as it Avere, into the morbid
mass, if there is no possibility of separating the womb  from the tumor, and
if every movement given to the tumor conveys similar movements to the
sound, Ave may consider the tumor uterine; but if Ave find the uterus small
and  movable,  if the sound  passes anteriorly to the  tumor, and can  be
separated from it, and when thrown upon the rectum it appears healthy,
then Ave may  confidently affirm  the  tumor to be ovarian.  The cavity of
the Avomb may be lengthened, and the sound will indicate the modifica-
tion of structure; but although the sound may only penetrate the womb
to its normal depth, or two  inches and a half, still the  uterus may not be
normal, for its enlarged cavity may be filled wdth a fibrous tumor.
                                                  Part xxvii., p. 292.

  Differential Diagnosis of Ovarian Dropsy and Ascites.—The diagnosis
of these two  diseases, the one from the other, is in some cases a matter of
considerable difficulty.   There is, says Mr. I. B. Brown, one symptom of
great value, which is not generally knoAvn.   In a case of ascites  in which 
OX-GALL.                            297
the listention  is so great, that the hydrostatic line of level in front is not
changed by posture, the lumbo-lateral  regions of both  sides will be found
equally dull on percussion, OAving to the intestines floating as far forAvard
and upAvard as their  attachment will permit.  In an ovarian case, no mat-
ter how great  the distention, one loin  will be found.clear, and the other
quite dull, OAving to  the intestines being pushed over to the healthy side.
Thus is indicated also, and with unfailing accuracy, on wdiich side the ova-
rian cyst, if it  exist, has originated.                 Part xxxviii., p. 221.
                            OX-GALL.
  Flatulence.—Administration of ox-gall recommended.  Part vii., p. 92.
  Ox-Gall.—Dr. Allnatt gives the folioAving among other cases :
  I Avas summoned hastily into  the country to  see a lady, seventy-seven
years of age, Avho Avas  apparently sinking from the effects of unrelieved
constipation.  Excrementitious vomiting had taken place, and the poAvers
of fife seemed Avaning.   The question was, Avhether or not, from the vio-
lence of the.inverted action of the intestines, intus-susception had occurred.
On examination, I thought I could detect a hardened mass, impacted about
the head of the colon, and evidences of accumulation below that point!  I
therefore advised, as a last resort,  an enema of ox-gall and turpentine (the
latter ingredient more as a stimulant to the inactive .boAvel  than for any
specific effect), Avith thin gruel, to be vigorously injected, warm, as far as
possible into the intestine.  In less than half an hour, a mass of scybala
was expelled, the  exterior portions of Avhich had been imperfectly softened
by the action of the gall, covered  Avith a coating of thick mucus.   Other
portions speedily folioAved, and convalescence ensued, with  no other unfa-
vorable  symptom than  that of slight pain, which might have been pro-
duced by  the action of the  turpentine  in  immediate  contact Avith the
mucous membrane of the boAvel.   There is  one point, in connection wdth
the present subject, of considerable importance, and that  is, the destruction
of the narcotizing property of opium, wdien  combined with ox-gall.  The
constipating effect of opium is principally produced by its  action upon the
fiver, the secretion of which it arrests, and renders insufficient for the due
stimulation of the  alimentary canal.  In many cases, this is a serious draw-
back to the exhibition of opium, for Ave often require its  sedative, when its
constipating effects  would  be sufficiently injurious  to  preclude its  use.
Five or eight grains of inspissated  ox-gall  will neutralize the effect of a
grain of opium, without destroying its sedative  efficacy.   It also prevents,
in a great measure, its injurious  action upon the brain.
   [In another communication, Dr. Allnatt recommends  the following pro-
cess for the preparation  of the inspissated ox-gall:]
   An open vessel, containing any quantity of perfectly recent ox-gall,
should be plunged into  a saucepan of boiling water, and  simmered until
the bile is of sufficient consistence to be formed into pills.   It should be
frequently  stirred  during the operation to prevent an unequal  hardening
of the mass.   The addition  of a little calcined magnesia will  expedite the
process.   If carefully prepared, it wdll keep for years, and Avhen required
for use should be gently warmed before the fire.  Tavo drachms dissolved 
298                            PALATE.
in a pint of hot water, or thin gruel, will be of sufficient strength for ena.
mata.  One or tAvo five-grain pills may be given  twice or thrice daily,
according to the exigency of the case.                    Part x\\.,p. 91.
                             PALATE.
  Perforating  Ulcer of the Palate—-The patient, under the care of Dr. J.
Ross, Avas a girl, aged  22:  the opening Avas of the size of a goose  quill in
the soft palate, a little  to the left of the mesial line, just behind the edge
of the osseous palatal arch ; no  bone  could be detected by the probe ; her
speech was  considerably affected, and  a portion  of everything  she at-
tempted to swallow escaped by the nose.  There was no reason to  suspect
syphilitic affection.  On the 19th March the opening was touched with a
red-hot Avire; on the 23d the eschar  came aAvay, and  the  raAv surface Avas
now touched every second day Avith tincture of iodine.  By the 13th April
the opening had become much less ;  she spoke better and  could also swal-
Ioav better ;  very little  escaping  by  the nose, and  that  only of any thin
liquid, such  as  Avater.  The cautery  was reapplied : on the 16th of April
the tincture of iodine Avas resumed as before; on the 25th the opening had
still further  diminished, and on the 13th of May it Avas closed  so that no-
thing came  through it; the poivers of speech and  deglutition^, being also
quite restored.  In this case, after a raAv surface had been produced by
the separation  of the  eschar,  consequent  upon  the  application  of the
cautery, the tincture of iodine seemed poAverfully to excite the granulating
or reparative action.  It might also, perhaps, be used in a similar manner
in fistulous openings in other situations.                  Part vi.,p. 119.
   Cleft Palate—Bead Suture.—The operation for cleft  palate has been
improved by an ingenious  suggestion of Mr.  Maclean,  of Dublin, and
carried into effect by Sir P. Crampton and  Dr. Cusack.  It consists in the
mode of tying the hgatures, a part of the operation of acknowledged diffi-
culty.   After the ligatures  are passed through the edges of the fissure and
brought out at the mouth, their ends are to be passed through a small per-
forated metallic bead, such as are used in making purses ;  the bead is then
to be pushed doAvn along the ligatures, closing them as it descends, until it
touches the approximated edges of the Avound; it is then to be compressed
by a pair of strong blunt-pointed forceps, and the ligatures are thus firmly
secured, wdthout a knot at the required degree of tension.  This ingenious
method of securing the hgatures might be extended to other surgical ope-
rations Avhere a knot Avould be difficult to  tie, such as applying a ligature
to hemorrhoidal tumors and polypous masses, Avhich are situated in parts
difficult of access ; in short, AAdth some modifications, we have no doubt the
principle might be made exceedingly useful in many surgical operations
where parts to be tied are deep-seated, in the  same Avay as Ave should
apply the double canula in polypi of the Avomb.          Part vii., p. 115.
   Treatment of the over-large Openings of the soft  Palate.—Very small
openings in the soft palate, that either remain after a partially successful
stitching, or are caused by penetrating sores, may be  closed  by exciting
inflammation in the borders.  For this purpose concentrated tinct. of can-
tharides is the most effectual:  lapis infernalis causes the loss of a layer of 
PALATE.                            299
the organized mass, and the process of inflammation that follows produces
an insufficient granulation, so that the hole generally increases in size. The
concentrated aads recommended by many surgeons for exciting inflamma-
tions, only produce a superficial  corrosion of the  borders;  nor does such
a quick granulation follow their  use as that of the  cantharides.  If the
opening is large and oval, and  the palate soft, the edges are cut evenly to
fit to each other,  leaden  sutures are then put through the edges Avith a
small-eared hook,  and twisted.                         Part xii., p. 191.

   Cleft  Palate and Staphyloraphy.—-The  observations  of Graefe and
Roux in Europe, and Warren in  America, first showed that this congeni-
tal deformity may be treated on the same  principles as the management
of hare-lip.  Mr. Ferguson observes that:
  The fissure in cleft palate may  be  such as only to divide the  uvula, or it
may  extend forAvard through the soft and hard parts as far as  the  lips, hi
which latter instance  there  is generally a hare-lip as well.   In the uvula,
soft  palate, and even  through the  palate bones, as also a portion  of the
superior maxillae,  the fissure  is invariably in the medial line, but Avhen the
alveoli in front participate in the malformation, it is somewhat  to one side.
In certain instances the fissure is double in front, when the  whole of it
may be likened to the  letter Y; the two lines in front leaving betAveen
them the intermaxillary bone.
   The soft velum ought to remain in a state of perfect repose,  and for this
purpose the levator palati, the palato-pharyngeus, and the  palato-glossus
muscles should be divided.  This cuts off all motor influence in an outivard,
upward, or downward direction.  For this purpose use a knife with a blade
like  the  point of a lancet, the cutting edge  being about a quarter of an
inch in extent, and the flat  surface being  bent semi-circularly.  Make an
incision half  an  inch long on  each side of the posterior nares, and divide
the  levator palati muscle on both sides, just aboAe its attachments  to the
palate ; then pare the edges of the fissure, and Avith a pair of long blunt-
pointed scissors, divide the  posterior pillar of the fauces, and, if it seems
necessary, the anterior pillar  too, the  wound in each part being a  quarter
of an inch in extent;  then introduce stitches  by means of a curved needle
set in a handle, the threads  being  tied so as to keep the  cut  edge of the
fissure in exact contact.  The first incision, that for the division of the leva-
tor palati, should be  made midway betAveen  the  hard palate and the pos-
terior margin of the soft flap,'just above the  thickest and most prominent
part of the margin of the cleft.  You may commence cutting either at the
end  nearest you, as you stand  behind the patient, or that furthest off,
as may seem most convenient. For ligatures, those of stout silk, or flaxen
thread, are the best;  and it is of great importance that a  stitch be used
close to the loAver end of the uvula, as  there is a great tendency to separa-
tion  there.  The after treatment the  same as after ordinary operations,
except that the parts are to  be kept at rest as much as possible, and nutri-
ment to be given by means  of enemata of gruel and soups.
   It is only of late that it has been thought  possible to remedy the cleft
in the hard palate, except by plastic operations, succeeding the union of
the soft parts.  Dr. Warren says it may be closed in the same Avay as the
soft  velum: dissect the  soft tissues from  each side of the fissure in the
palate, to such an extent as to make a flap broad enough to join its felloAV
of the opposite side in the mesial line, and stitch the Avhole between the 
soo
PALATE.
uvula and  the anterior ext remit v.  Reunion  to a considerable  extent,
takes place and toAvard the inner margin of the bones, and  also on the
upper surface  of the soft  portion  in the  middle, there will be a cicatrix
analogous to mucous membrane.                       J art  xiu., p. -40.

  Dieffenbacfrs Operations on the Palate.—In cases of small holes in the
soft or hard palate, pencil their borders several times a day Avith a concen-
trated tincture of cantharides.   Inflammation  and granulation come  on
and close the  opening.  Large openings are to be closed by suture, after
paring the edges; and leaden wire is said  to be preferable to silk, for liga-
tures, as it keeps the edges close together, and does not cut  through the
textures.
  When there is adhesion betAveen the velum palati and posterior wall of
the pharynx  occasioning  deafness, and stopping the communication be-
tween the nares and  air-passages, the adhesion must be divided trans-
versely, by means of a long scalpel, about half  an inch beloAV the adhe-
rent border of the velum.   The edge must be fixed by a hopk, and drawn
from the wall  of the pharynx, then, Avith a lancet-formed knife, the surface
of Avhich is curved, directed up\A'ard, the  velum is to be loosened, and the
separation  completed  by  scissors, also   curved  upon  their flat surface.
The upper adhesions are to be destroyed by passing a blunt  cuiwed iron
instrument, like a very small spatula, along the inferior nares.  Next pre-
pare a ligature Avith a  small  curved needle at each end; Avith one of the
needles transfix the velum, a feAV lines from its edge, and bring it out at a
high point on  the anterior surface of the palate ;  the other needle must be
used in same manner, a short distance from the side of the other ; and the
edge of the velum must be  brought about  half an inch from the palate,
All mechanical means for closing the fissured palate, are not only injurious
but dangerous; but if the size  of the cleft, or other circumstances, render
an operation unadvisable, then it may be  covered Avith a gold palate, fixed
to the teeth.   In cases of  holes in the palate, the edges of wdiich are so
callous  that an operation  Avould  be  unsuccessful, the  opening may be
stopped by Avearing a double  piece of India rubber, Avithout fear of its
being enlarged.  Two pieces of India rubber, the thickness  of pasteboard,
are  cut  about four  or five times  larger  than  the opening, and betAveen
them a small round piece, and they are to be transfixed by Avaxed thread:
thus, one plate lies on the anterior, the other on  the  posterior side of the
palate, and the small middle strip  in the  opening.  The patient can apply
it himself, and it should be taken out to be cleaned once a week.
                                                     Part xiii., p. 244.
   Removal of Scirrhous Tubercle from the Soft Palate.—{Mr. Adams re-
cords a very successful case of recovery from the application of ligature in
this rare disease.  A man applied at the" London Hospital in  consequence
of a tumor on the left side of the velum palati. He first perceived it three
years ago, and since that time  it had gradually increased in size, but Avas
unattended Avith pain or inconvenience until lately.]
   The tumor, when examined, appeared  about the size of a small walnut,
 was someAvhat oval in shape, the long axis being from  above downward,
 and Avas evidently situated  in  the substance of the velum  palati between
 its interior and posterior mucous  surfaces.  It  presented  a someAvhat
 ivhitish aspect from the stretching of the anterior layer of the velum ovei
 its surface, to which :t vas formerly adherent.  The velum was perfectly 
PALATE.
301
movable, and the  tumor Avas drawn up  at every movment of the palate,
and a bent probe  could  be introduced behind it.   It had  a remarkably
hard feel, and on running the finger over it,  it gave the idea of true
scirrhus.
  Mr. A. proceeded to strangulate the tumor by ligature.  . This was ac-
complished with some difficulty by the introduction of armed needles, and
with an instrument of firm, though inflexible silver, having a steel point,
armed with a long ligature, and let iiito an ivory handle.   By these  means
the wdiole of the tumor Avas  encircled, and the ligatures being tightened,
it Avas at once apparent that  its complete strangulation had been effected.
Very slight  constitutional  disturbance ensued, and on examination on the
following day the tumor was evidently  sloughing.   Five days  after the
operation he removed the greater part of the mass, leaving a large sloughy-
looking Avound: the  slough, however, had no tendency  to spread.  By
the frequent gargling with a solution of chloride of lime, a healthy granu-
lating action was induced,  and  it  began to heal rapidly.  In the course,
hoAvever, of a few days a warty vegetation sprang up from its surface;
this Avas gradually destroyed by the repeated application of solid  nitrate of
silver, and the disease Avas  perfectly cured.]             Part xx.,p 211.

   Cheap kind of Artificial Palate.—[An anonymous  correspondent of
the " Lancet " says:]
  I have found the substance,  gutta percha, suitable for making artificial
palates, very easily molded  on a cast of the mouth into the  necessary
shape,  and retaining its firmness  and smoothness unimpaired by the tem-
perature to Avhich it is there subjected.   Kneaded out into a smooth sheet,
about the thickness of a sixpence or a shilling, and pressed into the proper
form—the edges  accurately following the sinuosities  of the teeth, and  a
hooked process or tAvo of  the same material adjusted in the usual Avay—it
will be found to ansAver very  Avell, being smooth, light, and firm.  If re-
quired, a slight rim of gold, fitted to a few of the teeth, may be fixed to the
edge of the gutta percha.  If care be  used to mold the material equally
and smoothly, it will be more agreeable in the mouth than a metallic body.
                                                   Part xviii., p. 174.
   Operation for  Cleft Palate.—According to Prof. Syme the best way
of proceeding is to place  the  patient on  a  chair in a good fight, then to
seize one edge of the  fissure  at its middle by sharply pointed forceps, and
introduce the knife, Avhich should be thin and lancet-shaped like the one
of this form used for the  extraction of  cataract, a little  above  the com-
mencement of the cleft, and cut evenly doAvn from this point to  the extre-
mity of the uvula so as to detach a slice of sufficient thickness to expose
the submucous textures.  The  same process being repeated on the other
side of the fissure, nothing remains but to  introduce the stitches, which is
best done by means of a slightly curved needle with fixed handle, AA'hich
should be directed from Avithout inAvard, first on  one side of the fissure,
and then on the other.  The two inner ends of the threads being then tied
together, one of the other ends  is to be pulled until the knot is draAvn
through the edge of  the palate, and sufficiently far out  of the mouth for
the purpose in vieAV.   Tavo stitches are sufficient, one being placed at the
root of the uvula, and the  other midAvay betAveen this point and the angle
of the edges of the fissure.   The threads should be tied Avith the " reef
knot," and, in doing so, resiliency of the textures may be counteracted by 
302
PANCREAS--PARACENTESIS.
keeping  the threads  in a state of tension.   For at least tAvo days the
patient should subsist entirely upon fluids, and of these even have a very
sparing alloAvance.  He should also,  of course, avoid  talking, coughing,
sneezing, and all other actions calculated to disturb the  uniting process :
  Prof. Syme objects  to Mr. Fergusson's advice to take  out the sutures on
the second or third day—since the union, hoAvever perfect in the first in-
stance, can then have little power of resisting pressure, either from food
or the tongue, independently of the disturbing influence of the ^pharyngeal
muscles.   The threads should penetrate the whole thickness of the palate,
and  be tied Avith  no  more force  than  is sufficient to retain the edges in
contact, so that in the event of union taking place, they may neither cause
sloughing of the portion included nor cut their Avay out by ulcerative ab-
sorption.                                            Part xxix., p. 209.

                              ---»-•-•—-.


                           PANCREAS.
   Use of the Pancreatic Juice.—The experiments of Dr. Bernard go to
bhow an error wdiich has been long entertained  by physiologists, namely:
That the bile is the  fluid  by Avhich fatty  matters  are  acted  upon—a
property clearly proved by M. Bernard to belong most exclusively to the
pancreatic juice, Avhich must, therefore,  uoav be regarded as the true agent
by Avhich fatty bodies are digested.
  When fat is introduced into the stomach of the rabbit, the contact of
the gastric juice produces no alteration, nor is it in any degree changed in
its passage along the  intestinal canal,  until it arrives at  that portion where
it is  brought into immediate contact  wdth the pancreatic  juice : and it is
exactly at the mouth  of the pancreatic canal that the lacteals convey chyle
of a  white color ; higher up they contain only chyle of a transparent hue.
  No one can read these details, and not arrive at the same conclusion as
Dr. Bernard, that the  pancreatic juice, hitherto considered as the abdominal
saliva, the use of which was  to soften the food, is in reality charged with
the important office in the exhibition of the cod-fiver oil,  already alluded to.
We  know, also, that the best time to give it  to the patient, is one or two
hours after breakfast, after dinner, and  after tea.  If given at these times
it does not occasion those disagreeable  eructations which are  apt to occur
when it is taken either with, or immediately before food; by taking it at
this time we can now see how these eructations are avoided by the newly
discovered and  peculiar action of the  pancreatic juice.   In no disease is
cod-fiver oil more valuable than in scrofula mesenterica.  Part xix., p. 98.

                              ---in

                        PARACENTESIS.
  Paracentesis Thoracis.—Dr. Hughes, advises, not to allow  air to be ad-
mitted through the canula if it can be  avoided.   It may rekindle inflam-
mation, or convert the adhesive into the suppurative inflammation.  Unless
the lung is capable of free and full expansion, do not attempt to draAV off
all the fluid; remove only so much as  the expanding  lung and  the sur-
rounding compressed  organs are capable of replacing.   Watch the open-
ing  carefully, especially  during inspiration and  coughing, and when the 
PARACENTESIS.
303
stream begins to fail, turn the patient on his punctured side till there is an
alternate Aoav and stoppage of the stream during inspiration and expira-
tion, then immediately  Avithdraw the canula.   Apply a flannel bandage
with moderate firmness around the chest.   Precautions.—1. Always intro-
duce an exploring needle first, to know if the diagnosis be correct.  2. Do
not puncture one side  before  it is presumed  that the other is sound
enough to carry on respiration.   3.  DraAV off the fluid slowdy through as
binall a canula as the density of the fluid Avill admit.  4. Only draw off the
fluid till the air seems to threaten to be admitted.        Part xiii., p. 86.
  Paracentesis of the Scrotum.—[The  subject of these remarks, by Mr.
Skey, Avas a publican, about 55  years of age, Avho Avas laboring under an
advanced stage of ascites and  anasarca.]
  The legs  and  the  scrotum  Avere both  largely distended with  fluid.
Before operating, my attention was directed by Dr. Lobh to the fact, that
pressure on the scrotum entirely emptied  that appendage, wdien steadily
persisted in for some short time, and on removing the pressure and plac-
ing the man  in the upright posture, the fluid again  gravitated into the
bag, wdiich became distended as before. It Avas obvious that the continued
pressure caused by the Avater had broken  down  or  elongated the fibrous
and cellular tissues about the cord, and thus opened  the communication
between the abdomen and the tunica vaginalis.
  Under these circumstances, I  determined to evacuate the serous contents
of the abdomen  through the  scrotum, and with  this view I introduced a
full-sized hydrocele trocar into its loAver and most pendulous part.  The
fluid flowed readily and continuously till some quarts had escaped.
  Practically this case affords matter for more than a passing observation.
Anasarca of the scrotum is a common attendant on ascites in the male sub-
ject.  As a  general rule, it commands but little attention, the interest
which Avould otherAvise  attach  to it being merged in the larger evil.  If
the question ivere noAV asked of the  surgical Avorld, how  often  does the
relation that  existed in the above case prevail  in other cases ?  I doubt
whether a very positive, or even a satisfactory  reply could be obtained.
The fact of the communication is curious, if it be nothing more.  It is very
true that the operation of paracentesis abdominis is neither a difficult nor
a dangerous  operation, but it will hardly be denied,  that simple as it is,
paracentesis of the scrotum is  yet more so.            Part  xxxiii., p. 213.
  Paracentesis Abdominis.—Use neither pressure nor bandage ; allow as
much of the fluid  to Aoav out gradually as the natural elasticity of the cyst
or abdominal parietes will expel;  Avhen the Aoav has quite ceased of itself,
close up the orifice, keeping the patient recumbent.    Part  xxxiii., p. 212.
  Paracentesis Thoracis.—The best point  for the operation is close on
the upper edge of the sixth rib, midAvay  betAveen the  sternum and spine.
The chief danger is from the admission of air into the chest after the ope
ration; this may be very much obviated by having an India-rubber appara-
tus fixed to the instrument, Avhich, by its  elasticity, sucks,  as it Avere, the
purulent secretion from the pleura, and at the same time alloAvs the lung
ample time to expand.                               Part  xxxiv., p. 284: 
304
PARAPHIMOSIS—rARALTSIS.
                        PARAPHIMOSIS.
  Extract of Belladonna in the  Reduction of Paraphimosis.—A child,
three years  and a half old, was  the subject of severe paraphimosis ; the
glans red, swollen, and tender ; the prepuce strongly draAvn back, form-
ing a thick and apparently adherent ring, the  constriction of which com-
pletely stopped the circulation.  This state had lasted eight  days, and the
sufferings were excessive.
  The strangulation became more menacing, and all the  symptoms were
aggravated ; the glans Avas bluish and gangrene was threatened, when M.
Mignot employed frictions around the glans, with an ointment  composed
of thirty parts of simple  cerate to twelve parts of  extract of belladonna.
Under the influence of this remedy the circle of constriction relaxed, di-
lated, and the tissues gradually recovered their normal  condition, Avithout
loss of substance or suppuration following.
  The second patient had acute balanitis, brought  on by a severe  gonor-
rhoea, and  followed by  paraphimosis.   The  patient  refused operation,
although gangrene  Avas threatened, when the belladonna  was applied,
which induced relaxation and rapid amendment.          Part iv., p. 105.
  Reduction of Paraphimosis.—It is necessary to reduce the swelling of
the prepuce as Avell as that of the glans.   Prof. South  advises, to squeeze
the prepuce gently but  steadily  for a feAV minutes, and  if this  does not
suffice, make a few punctures to let out  the serum.  Then press the glans
with the thumbs of both hands while the tAvo forefingers  grasp  the penis
behind the prepuce; or grasp the whole penis Avith the  left hand, and Avith
thumb and  forefinger of the other  hand, empty the  glans.  As soon as
ever a little  of the glans gets beneath the constricting band, continue the
pressure until the whole is returned.  After the reduction keep  the penis
in cold wet cloths for some hours, and afterwrard apply  a Avarm poultice.
                                                    Part xxi., p. 216.
                          PARALYSIS.
  In no Case of Paralysis or Apoplexy should a careful  examination of
the heart's action be omitted.                             Part L, p. 69.
  Aphorism of Practical Surgery.—No disease is  more  difficult of cure
than paralysis of the arm induced by dislocation of the  humerus.  The
paralysis seems to arise from the stretching, compression, and perhaps also
partial rupture of the nerves, which form the brachial plexus.   Often no
remedial means are of any avail.                        Part iiL, p. 115.
  Paralysis of the Seventh Pair of Nerves—-The patient, a young female,
presented herself to M. Magendie, having a complete paralysis of all the
facial muscles supplied by the seventh pair, on the left side, wdth great
exaltation of  sensibility in the auditory nerve.  The  Avhole face was drawn
toward the right side.  Sensibility continued perfect in the face, tongue,
etc.  Galvanism Avas prescribed,  one  needle being placed over the parotid
gland,  the second successively  over the supraorbital^ infraorbital, and
mental foramina.  The patient Avas cured.                Part iv., p. 63. 
PARALYSIS.
305
   Paralysis treated  with Cantharides.—The tincture of cantharides is
given, by Dr. Seymour, in very large doses, in cases Avhere the paralysis
cannot be traced to any affection of the sensorium, and Avhere there  is no
trace of organic disease.  ' In the case Avhich Avas commented upon by Dr.
Seymour in one of his clinical lectures, the patient had entirely lost the use
of the upper limbs and had a weakness of one leg.  In a great majority of
such cases, we  should find a disease of the vertebras  above the seat of the
injury, and there Avould be pain on pressure or ofi percussion ;  but in this
case this symptom was entirely absent, and  if there had  been any actual
disease of the spinal marrow, Ave might have expected to find the diseased
action continued to the loAver extremities, as w^ell as to the upper : but such
was not the case, as every part below the upper extremities appeared per-
fectly sound and healthy.   In such a case as this Dr. Seymour ventures to
give 40 minims of the tincture of cantharides twice a day.  Part v., p. 52.

   Strychnine in Paralysis of the  Face.—Although paralysis of the  mus
cles, those of the face, for example, seldom exist without some organic
lesion, yet we sometimes have reason to believe that  it is truly functional,
and unattended Avith any particular disease.  In  such cases Ave shall find
strychnine of value; and Ave think that its poAvers have been miscalculated,
on account  of  the indiscriminate use Avhich has been made of it.   Even
Avhen the  paralysis  is originally  owdng to some lesion or effusion, that
cause may  have been remedied,  and nothing remains  but  a continued
inability on the part of the muscles to regain their  powers.  Here, then, is
a  case  in which strychnine Avould be of great use, as Avell  as Avhen the
paralysis is strictly functional.  When the face is the seat of the affection,
the strychnine may be applied to the cuticle in the followdng way: About
one drachm of a solution containing about three grains of strychnine  to an
ounce of alcohol, may be applied to each side (when both sides are affected),
three times a day, and the absorption assisted by friction; ivhen only one
side js affected, it will be sufficient to confine the application to the muscles
implicated.  In a case reported by Dr. Joslin,  of New York, this was per-
severed in for about two months, Avith success.  A blistered surface renders
the effects of the application more powerful.              Part vii. p. 46.
   Paralysis from Exostosis of the Spine.—Exostosis, or bony vegetations,
arising from the bodies of the vertebra)  (independent of  any disorganiza-
tion of these bones) are by no means of rare  occurrence ; most pathological
collections contain numerous examples of their different stages, especially
of Avhat seems their natural termination, viz., perfect anchylosis of the
affected bones.   This anchylosis may be more or less extended, affecting
but two neighboring vertebrae, or perhaps the greater part, more rarely the
entire of the vertebral column, Avhile the new bony material  is found to
vary from a thin lamina to a prominent  and rough projection, occupying
the situation of, or more properly covering, the  subjacent intervertebral
cartilage.
   [Although the affection may have advanced  to  complete anchylosis,,
there  may be an absence of all severe pain A\dien the bone is handled ;
which  is  remarkable,  considering the  displacement  and  injury  those
important nerves must undergo Avhich are  so closely connected Avith the
front of the spine, more particularly in the  loAver  part of the  dorsal and
lumbar regions.  Dr. Battersby relates  some interesting cases to prove.
that these nerves do occasionally suffer from the disease giving rise to a
    VOL. II.—20 
306
PARALYSIS.
train of most painful symptoms which have baffled the diagnosis of the most
skillful practitioners.  One case particularly is related Avhich proves this.
A train  of the most painful symptoms terminated in the death of the
patient.]
  On displacing the abdominal viscera, the inter-vertebral spaces of the
lumbar region  Avere at once observed  to be singularly prominent, the
cartilages being partially faced with irregular bony protuberances, so as
nearly to unite the adjoining  bones.  A section of the vertebras was  re-
moved, and a large nervous twig Avas discovered lying stretched over the
most  prominent "of the new formations which engaged the sides of the
vertebras. The anterior vertebral ligament had a marked glistening appear-
ance, and on dissection proved to  be very much thickened, while under-
neath it Avas formed a new dense structure of a fibrous nature, in which all
the characteristics of the periosteum  Avere lost, and the surface of the
bones, to which it was intimately adherent, Avas  rough and irregular.
There was no distinction between the  fine cancellated  structure  of these
and  their  new  processes.  The  bones were  quite healthy, as also the
cartilages.  The spinal canal Avas opened from the sacrum to the middle of
the dorsal region.   There was about an ounce of clear fluid in the interior
of the  sheath of the cord, Avhich, like  its  membranes,  were perfectly
natural.  The only irregularity here discovered was two  little points of
bone on  the  posterior aspect  of  the bodies of the dorsal vertebras, which
felt through the  dura mater, which ivas unremoved, about the  size of
pins'  heads.  The opening for the nerves were perfect.
  This gentleman's sufferings, for the space of nearly two months, could
not be surpassed ; toAvard the conclusion, he used to consume more than a
scruple of the muriate of morphia daily, and that merely with the effect of
mitigating the pain. The new bone,  in occupying the situation of  the  «.
lumbar ganglia of the sympathetic, gave rise to the symptoms of visceral
neuralgia, by irritating these and their branches, Avhile the same irritation
communicated through the lumbar nerves (which are in direct connection
with  the former)  to the  spinal cord, its fuuetions became deranged both
aboAre and below the point of irritation, exhibiting what Dr. Marshall Hall
denominates the morbid, direct and retrograde action of that part.
   The progress of the paralysis was very remarkable as pointing to  the
spinal origin of the symptoms.   It first appeared over the upper part of
the abdomen, then attacked the loAver extremities, and  lastly, the integu-
ments of the chest and arms.                            Part viii., p. 53.

   Diagnosis in Cases of Paralysis of the Face.— [It is  of the greatest
consequence in practice that we distinguish between hemiplegia of the face
and paralysis of the facial nerve, and of this latter  as it occurs within  and
without  the cranium.]
   I had  recently,  says. Dr. Hall, an urgent summons in such a case.  The
patient Avas situated in a lunatic asylum, a circumstance Avhich rather  dis-
posed the mind to expect cerebral disease.  Beside, the patient complained
of pain  of the head at  one time, and Avas  apparently drowsy at another.
The face was drawn exceedingly to the right side.   In the first place I
desired the patient to close  the eyelids; the right eye remained open.   In
the second place  I inquired wdiether  the arm or  leg Avere affected,  and
found that they Avere not.   In the third place I begged the patient to  put
out the tongue; it Avas protruded in the direct mesial plane.  In the fourth 
PARALYSIS.
307
place, I inquired Avhere the patient had been sitting, and we went upstairs
and placed  the  chair near the window, precisely as  it had been occupied
the day before; it was so placed as to expose the right side of the face to
the draught from the wdndow.
  Taking these  facts together, I did not hesitate to  declare that the case
was one of paralysis of the facial nerve :  in hemiplegia the eyelids of the
affected side can always be closed, though not so firmly as those of the
other side.  In so severe a case of facial hemiplegia the limbs are almost cer-
tainly paralyzed, and the tongue is generally affected and protruded to the
affected side.   Still  a question was  raised, Avhether this nerve was affected
within or without the cranium ; there was pain of the head  and droAVsiness.
  Now, the portio dura and  the  portio mollis of  the seventh pair (the
facial and  the  auditory) are placed so  immediately together wdthiu the
cranium that it is scarcely possible for one of these  nerves to  be affected
without the other ;  yet there was no deafness.
   I remained therefore of opinion that the case  was one of paralysis of the
facial nerve, external to the cranium, confirmed, as it had been,  by the fact
which I had almost anticipated, of the special position and exposure of the
patient, as she had sat seAving in her bedroom.  The issue has  proved my
opinion to be the just one.  No affection of the cerebrum has occurred, and
the facial paralysis  is gradually subsiding under the usual local remedies,
viz., leeches, fomentations,  sinapisms, etc.      -           Part ix., p. 40.

   Paralysis.—Sir  Benj. Brodie  gives  cases  of the  different  forms of
paralysis,  with the morbid appearances in the brain or spinal column,
Avhich he  detected; but after most careful examination of these cases
 during life,  he acknowledges that their treatment is often  exceedingly
 difficult, as Ave have not yet sufficiently advanced in our knowledge of this
 complaint, to be able to state  positively whether the disease is of one kind
 or another.  If the disease be an inflammatory affection of the membranes,
 Ave may distinguish it tolerably -well; but if it be of a chronic character, it
 is  difficult to discriminate between softening of the spinal marrow, tuber-
 cles  in the spinal  cord, and effusion of fluid in the theca vertebralis;  be-
 sides, these three affections may be combined  together,  or there may be
 one first and the others may supervene.
    However, let us suppose that  there is  a case of inflammation of the
 membranes of the spinal marrow.   The patient comes to you AAdth a severe
 attack of  dreadful  lumbago, and by and by he states that there is numb-
 ness in his legs, and then difficulty in moving them.   In this case you may
 be pretty  sure that there is inflammation of the membranes of the  lower
 part of the cervical cord.   Hoav is that to be treated ?  In the first place
 take blood by  cupping from the loins,  and repeat it according  to circum-
 stances.   Begin by purging the patient, clearing the bowels Avell  out—a
 right plan to pursue in  all cases of inflammatory disease.  Then put the
 patient  under  the influence of mercury, exhibit calomel and  opium, and
 treat him as you Avould a patient laboring under pleuritis or iritis.
    But  if  you  are  called in at a  late period,  when the  inflammation has
 subsided,  and the paralysis consequent on it remains, even then you cannot
 do better than put the patient under a course of mercury, a mere alterative
 course—five grains of Plummer's  pill, night and morning—the eighth of a
 grain of bichloride of mercury, tAvice a day, in addition to which you may
 apply blisters to the lowrer part of the back. 
308
PARALYSIS.
  The treatment of  a chronic affection of  the spinal  cord producing
paralysis must be, to a great extent, empirical, because you  cannot make
a certain diagnosis.   Let me repeat A\*hat I just now observed, that I have
never seen any beneficial results arise from the use of counter-irritation.
  Probably the bowels are very torpid—they will require to be kept open,
and it is very difficult to effect it.   The stools will be black, like tar, and
the lodgment of the black  secretion in the intestinal cannl appears to
be productive of great  mischief  to  the  system.   Calomel  and a black
draught may be  exhibited every hoav and  then, but a patient cannot take
them  from day  to  day.  Sometimes the comp. ext. colocynth will  be
sufficient, but simple purgatives often fail.  The pills which I am about to
mention, I have  found to be convenient in cases of this kind. Two scruples
and .a half of comp. ext. colocynth; half a scruple of soap ;  one drop of
croton oil. Let  these be Avell rubbed  up and carefully mixed, and divided
into a dozen pills, one or tAvo of which may be taken every night, or every
other night, when Avanted.   These are excellent pills; they cause nothing
like the inconvenience produced by a large dose of croton  oil, and are very
efficient indeed.
  The treatment Avhich I have found to be the most successful, and under
which I have seen the greatest benefit arise, is a grain of zinc made into a
pill and given three times a day, and then a draught of twenty minims of
tincture of cantharides, to Avash it  doAvn.
  It is from the  continued use of the zinc, and not from the exhibition of
large quantities, that benefit is to be derived.
  In other cases I have thought that benefit has arisen  from the long-con-
tinued use of very  small doses of bichloride  of  mercury, combined Avith
tincture of cantharides.  Small doses  do not seem to act as mercury on the
system.   I apprehend it acts  much  in the same way as  the sulphate of
zinc.   Exhibit the sixteenth of a grain of bichloride of* mercury in a certain
quantity of tincture of cantharides, in  a draught three times daily, and such
plan of treatment will sometimes be useful.  But it is right to state, that
in a great number of cases of chronic paraplegia, the disease is incurable.
The disease, however, may go  on  for years before it ascends  to the brain
and destroys life.                                       Part ix.,p. 100.

  Brucine in Obstinate Paralysis.—Brucine  is substituted by M. Briche-
teau for strychnine, in the treatment of obstinate paralysis remaining after
an attack of apoplexy, ivith equally good effect, and with the  additional
advantage over strychnine of being able to employ it in larger doses with-
out danger of fatal  accidents.
  Dose.—A centigramme (1-154  gr. Fr.,=l-6th  gr. avoir.) in infusion of
arnica; increase the dose  one centigramme  daily, until its effects are
evident, and then proceed discretionally.                Part xiv., p. 59.
  Paralysis  of  Sensation.—This  form  of paralysis is less dangerous than
that of motion,  inasmuch as it is  cured wdth less difficulty.  In fact it is
almost ahvays curable, and generally folloAvs hysterical affections.
                                                    #   Part  xv., p. 45.
  Facial Paralysis cured by Quinine.—-Dr. Durant, of Ipswich, mentions
a case of paralysis of the side of the face occurring after a course of mer-
cury,  Avhich was cured by the administration of quinine.  Part xv., p. 62.

  Electricity in  Paralysis.—In the use  sf electricity, says Prof. Matteucci, 
PARALYSIS.
309
 we must remember that the  excitability of the nerves appears to be lost.
 Noav though the contractions excited by an electric current passed down
 a nerve in the direction of its ramifications, i. e. a direct current, are more
 powerful  than  those produced by the passage of a current in the inverse
 direction, yet the direct current Aveakens and destroys the excitability of a
 nerve, while the inverse current augments it.  The best form of electricity
 that can be used in paralysis is that from the electro-magnetic machine.
 Apply the interrupted current,  and at first a very feeble one; and after
 twenty or thirty shocks, let the  patient rest for some seconds.
   Paralysis following Local Injury.—In paralysis following local injury,
 as  concussion of the nerves, Dr. G. Bird would apply electro-magnetism
 from the single current machine, taking care to transmit it in the direction
 of the vis nervosa, or in other words, in the direction of the nervous rami-
 fications.
   From Lead {Dropped Hands).—Take electric sparks from the cervical
 and dorsal vertebras thrice a Aveek;  also from the paralyzed parts,  and in
 recent cases transmit small shocks along the course of the affected nerves.
   Hysterical.—Employ  electricity  either  in the form  of shock, or  the
 interrupted current from the electro-magnetic machine.   If the paralysis
 is simulated, it will rarely resist the pain and surprise of the shock; and
 if  the  affection, however excited  at  first, is  now uninfluenced  by the
• patient's will, the electro-magnetic current is a most valuable therapeutic
 measure.
    Of the Portio Dura.—Use electricity: any form will do, as it is merely
 the stimulus which is required, acting on  the paralyzed muscular fibres,
 and arousing their normal irritability.
    Rheumatic.—(FolloAving the sudden application of cold, independently
 of any evidence of central spinal lesion.)  Take electric sparks thrice a
 week from the spine and the paralyzed muscles.
    From Effusions, etc.—When the primary cause is removed, and the
 paralysis  is still  persistent, apply  electro-magnetism,  the single  current
 transmitted in the course of the nervous ramifications, and patiently con-
 tinued for some time. Be very careful not to use this agent  Avhere rigid
 arteries are suspected, or  ramollissement of the  brain  exists.   Fatal
 apoplexy has been known to follow  the use of electricity in such cases.
   When it  continues, after the disease in the brain is removed, the muscles
 must be artificially excited to action, by electricity or otherwise, to insure
 their nutrition.                                        Part xvi., p. 103.

   Paralysis—Cerebral.—Dr. Todd  says:  It is important to notice the
 state of the muscles of a paralyzed limb; for  if  rigidity of the muscles
 exists at  an early period, local depletion  and counter-irritation  will  be
 attended  with benefit, Avhereas  such measures  are  not applicable when
 complete  relaxation exists.                             Part xviii., p. 80.
   Paralysis of the Portio Dura.—[As facial paralysis, Dr. Todd observes,
 is to a patient and his friends a very alarming disease, it  is important for
 the practitioner to be well acquainted wdth the various kinds of palsy affect-
 ing the face, so that a favorable prognosis, Avhen the case will admit of it,
 may be at once given.  The case Avhich formed the subject of the following
 observations by Dr. Todd, was one  of paralysis  of  the  facial portion of
 the seventh pair of nerves, accompanied by severe pain  behind the right
 ear.  Dr. Todd observes:] 
310
PARALYSIS.
  The leading character of these cases of facial palsy is the inability to
close the eyelids, from paralysis of the orbicidaris palpebrarum muscle;
this is the  pathognomonic  sign Avhich determines the peculiar  nature  of
the palsy, and distinguishes it from the more serious form of facial palsy
which is dependent on disease of the brain and palsy of the fifth nerve.  It
is remarkable hoAv seldom the seventh pair of nerves is affected by disease
of the brain.  I cannot say that I ever saAV a single instance of paralysis of
the orbicular muscle of the eyelids due distinctly to diseased brain; and I
have only seen a fenv in Avhich the poAver of the muscle appeared to  be
enfeebled from  that cause.   Thus Ave have a point favorable and consola-
tory to a  patient  affected  Avith portio dura  paralysis; namely, that the
affection being seated in that nerve affords a strong probability that he is
free from disease of the brain; for diseased brain Avould give rise to a dif-
ferent form of facial palsy, and very rarely, if ever, cause this.
  You have only to examine this patient with care, and you will find that
he has almost every si<m which indicates  that the paralysis has its seat in
the portio  dura nerve.  He cannot close his right eyelids; in making the
attempt, hoAvever, he seems not to have lost the poAver altogether, for  the
upper lid is slightly depressed ; yet if you put your finger on the orbicular
muscle you do not find the slightest contraction of it.
  Our patient is unable to  frown on the right side, Avhile he does so dis-
tinctly on the left; neither can he  move  his scalp on the right side ;  the.
corrugator  supercilii,  and   the  frontal portion  of  the occipito-frontalis
muscles, are paralyzed—and hence these movements  cannot be effected.
The levatores alas nasi, and the zygomatic muscles, are likeAvise, paralyzed
on the  right side, and therefore, the  right nostril is  motionless, and the
angle of the mouth hangs on that  side.  The orbicularis  oris muscle is
paralyzed as to its right half; the  patient is consequently unable to purse
up his mouth, and if you ask him to Avhistle, he will afford you indications
of his inability to perform this as Avell as other actions.   The act of smiling
or laughing is exaggerated  on the left side, and the reason is because the
left muscles have lost completely the resistance  of those of the right  side,
which remain  perfectly motionless, and Avhich from disease have lost their
tone,  and have suffered much in their nutrition.  For the same reason all
the movements  of the features which  act  in symmetry, and which at the
same  time  counterbalance each other, are found to take place to an exagge-
rated extent on  the healthy side.   Hence  in smiling, laughing, and speak-
ing, the face is drawn more or less to the  right side :  the distortion taken
place  on the healthy side, the paralyzed  side remaining unmoved.  The
popular notion, in cases of  this kind, is that the  disease is on the side to
which the mouth is drawn.   No medical man, hoAvever, can fall into this
mistake if  he be at all acquainted Avith the real condition of the patient.
  Another muscle which is paralyzed in  this case, and in all cases of the
same  kind, is the buccinator.  Hence  the  cheek hangs  loose, and as the
patient speaks, it flaps to and fro.  This extreme looseness of  the cheek
is not an early symptom of  this form of paralysis; it manifests itself more
and more, the longer the duration of  the disease, and  ultimately becomes
the cause of symptoms very troublesome to the patient.  It interferes not
only with articulation, from its looseness and flapping  movements Avhile
the patient is speaking, but mastication likewise.  The  palsied muscle
allows the food to accumulate betAveen the teeth and the jawT, and fails in
its functions of supplying the mill with its  proper amount of material to 
PARALYSIS.
311
be ground.  After a little time, patients learn to remedy the defect of
articulation which the paralytic condition of the buccinator muscle causes,
by supporting the cheek ivith the hand; and a similar kind of support
serves to remove the inconveniences of mastication.
  You will observe that  all the muscles paralyzed in this affection are
superficial: they are all muscles more or less concerned in the expression
of the countenance.  The deep-seated muscles are not affected—these are
muscles of mastication—the only muscle paralyzed, which is concerned in
mastication, being the buccinator,  which is, however, only accessory to
that function, and is as much or more a muscle of expression.
  [As the buccinator receives a motor branch from the fifth, in addition
to its supply from the seventh, the circumstance of its being paralyzed,
when the disease or disorder is confined to the seventh pair, is very curious,
and has not as yet, Dr. Todd remarks, received an adequate explanation.
As to the treatment  of this affection, much treatment  is  not generally
required Avhen it has arisen from cold or from constitutional causes;  mild
purgatives, alkalies or sudorifics, or iodide of potassium, and locally warm
fomentations. Leeching or blistering are not so distinctly useful; and strych-
nine, Dr. Todd remarks, is of no use in these cases.  If recent otitis be the
cause of the attack, more antiphlogistic treatment Avill be needed, and some-
times even salivation  will be beneficial.]                Part xviii., p. 83.

   Treatment of Paralysis from Lead.—Prevent  the further introduction
of the poison by cleanliness and frequent Avashings; stimulate the skin by
friction and exercise ; Dr. Todd would also give baths containing sulphuret
of potassium, in the proportion  of  one, two, or three ounces, to as many
gallons of water ; let the patient have good food, and breathe pure air; and
apply galvanism as a local stimulant, for ten or fifteen minutes at a  time,
three times a day.                                     Part xviii., p. 88.
   Paralysis, Facial.—In paralytic affections of the facial muscles, when
the antagonist muscles distort the features, the distortion may be remedied
by the application of collodion;  the parts being  adjusted to their normal
position before the solution is applied, and being held in that position with
the finger until the solution is dry.  (Dr. J.  Starlin.)    Part xix., p. 319.
   Paralysis Facial.—In  facial paralysis from exposure to cold, apply the
"heated hammer," a  modification of the iron recommended by Dr. Corri-
gan, which is to be heated for fifteen or twenty seconds  in the flame of a
spirit lamp, and then run  lightly, being alternately raised  and  depressed,
over the affected surface.                                Part xx.,p. 54.
   Paralysis  Agitans.—Paralysis agitans, says Dr. Swan, is emphatically
a disease of emotion.   Emotion is its first and last cause; without emotion
it would never be called  into existence, or, being once induced, it would
never manifest itself.  This at least is true, of its first phase ; whether any
physical lesion  may  supervene in its protracted  course, remains a deeply
interesting question.
   Alone, reposing, asleep, the agitation is absent. It is renewed when cause
of emotion comes into operation.  It frequently subsides in the society of
the patient's immediate relatives or friends, as his wife and children, and
is reexerted on the appearance of a visitor or a stranger.
   The peculiar shaking, and the equally peculiar powerlessness, or shall I
 sail it paralysis, cease on  giving confidence to the patient.   I may here ad- 
S12
PARALYSIS.
duce an  anecdote :  A  gentleman, a magistrate, confined to his  chair by
paralysis agitans, Avished to consult a legal book.   He asked for it, and his
servant gave it  to him, as he supposed.  On opening it, he found it the
wrong book.   In his anger he rose from his chair, and reached it himself.
Surprised at discovering his poAver of Avalking, he endeavored to repeat the
experiment, and remembering that before he had  risen from his  chair, he
had rather  violently closed his book, he repeated this manoeuvre,  and ever
6ince, on doing  this—but only on doing this—he regains his poAver of
w*alking.
  One patient could walk whenever he pleased, with the tips of his fingers
merely'on his Avife's arm, but not otherAvise.
  It is essential to  replace  a (unfounded?) conviction  in the  patient's
mind, that  he  is powerless, by another, viz.,  that he really possesses power,
the  circumstances  being  changed.   The prepossession—the depressing
emotion  must be removed, and replaced by an emotion of the  opposite
kind.
  In speaking of emotion as the cause of paralysis agitans, Ave ought to
notice that this emotion is of the painful and agitating kind, and  not unal-
lied to fear and vexation.  The elevating emotions or mental states, as hope,
confidence, energy,  have  a  marked  beneficial effect.   The movements
made  wdth firmness and resolution are  ahvays least attended  by agita-
tion.
  There is, in consequence, a disposition in this  malady, to rapid move-
ment.   The patient is  apt to run instead of Avalking  deliberately.   An
energetic volition overcomes the influence of emotion ; volition of less energy
is more or less defeated by emotion in its turn.
  The paralysis agitans has hitherto made an exceedingly slow, but not the
less fatal, progress.
  Unfortunately, Ave possess no  post-mortem examinations of this disease.
I suspect no morbid lesion Avould be detected.  No  such lesion, hitherto
knoAvn, Avould lead to the peculiar phenomena of this malady, except toAvard
its close, ivhen a sort  of general paralysis takes place, Avhich may be the
effect  of effusion and consequent pressure.
  As emotion is the original  and continued cause of this trying malady, an
important  question arises—What Avould be the effect of a sustained removal
of all sources of emotion, if, and Avhen this may be possible ?
  Seclusion in a cottage, a  judicious  companion, books of quiet interest,
repose in  the  nearly recumbent position (the head especially being sup-
ported), free exposure to the open air, the gentlest exercises, the  farm, the
fields, the  garden—the plants, the corn, the  cattle, the poultry (not his
OAvm).  It  becomes an important  question also, Avhether the shoAver-bath,
douche along the spine, etc., may be  useful; various sedative or narcotic
medicines long given to subdue emotions, as we ivould give them to subdue
pain, in stated forms and doses, regularly and systematically.
  The bichloride of mercury, quinine,  strychnine, etc., should be put to a
cautious trial by competent judges.                    Part xxiii., p. 83.

  Rheumatic and  Local Paralysis, treated  by  Pulvermacher''s  Chain
Battery.—Mr. Vallance highly recommends this chain battery in preference
to the same strength of currents from the ordinary machine, believing that
the  current from the  hydro-electric  chain  of Pulvermacher has a  much
greater effect.                                         Part xxv., p. 51. 
PARAPLEGIA.
313
  Paralysis of the Lower Limbs.—M. Gerard  recommends the ergot of
rye in daily doses of from 8 to 40 grains.               Part xxx., p. 59.
  Lead Palsy.—The state of lead cachexia, according to Dr. Todd, is very
greatly improved by the long continued use of sulphur baths.
                                                      Part xxv., p. 69.
  IncompleteParalysis of the LowerExtremities, connected with Diseases
of the  Urinary Organs.—Mr. Wells, surgeon to Samaritan Hospital,  says :
There is a form of incomplete paraplegia—mere Aveakness and loss of con-
trol  over the muscles of the limbs—the effect of disease of the  bladder,
kidneys, or urinary passages, and only cured by the relief of this  primary
disease.  There may be no  pain in the dorsal region on pressure, but  cases
have occurred Avhere the pain, on pressure  in the dorsal region, led to the
diagnosis of spinal disease,  and after death the spine and its contents  were
found perfectly healthy and. the kidneys diseased.  The intimate  nervous
connection between the urinary organs and the  cord by means of the sym-
pathetic, is  probably the cause.  Some impediment to the discharge of
urine is one  of the earliest symptoms.  There is generally obstinate gastric
derangement. The sensibility of the limbs is not impaired, or very slightly,
and they do not become atrophied or lower  in  temperature than  natural.
The sphincter ani is not paralyzed. The  bladder, to a great extent loses its
contractility, but not entirely.  There is no history of violent neuralgic
symptoms at the commencement of the disease.  Great  amendment -will
often follow catheterism and the removal of any obstruction to the free dis-
charge of urine.  Exercise, Avarm clothing, bathing, and change of air, are
important.  Avoid aloes and saline aperients, as they tend to increase the
urinary irritation.  Gregory's powder is the best aperient.  The patient
may Avear an elastic belt to support the lax abdominal parietes. A mixture
of cantharides and iron tends much to restore the contractile power of the
bladder, and relieve the urinary irritation. Opium relieves irritability very
much.  That Avhich is productive of most good effects is a complete change
of life, as a long sea voyage.   Paraplegia is a common result of frequent
seminal emissions, voluntary or involuntary ; it  is undeniable that the fre-
quent agitation of the nervous  system,  so caused, leads to chronic inflam-
mation  and softening of the cord, Avith paraplegia as a necessary conse-
quence.                                            Part xxxvii., p. 31,
  Paralysis.—Dr. Althaus states that in cerebral paralysis, the excitability
of the muscles in the paralyzed limb is often, but not always, increased. In
lead palsy and traumatic paralysis, the muscular excitability is almost lost.
In hysterical rheumatic, and spontaneous  paralysis, the paralyzed muscles
respond normally to the electric current.                Part xl., p. 314.
                       PARAPLEGIA.
  The Use of Setons in Paraplegia.—Dr. Marshall Hall  strongly recom-
mends the use of setons in preference to issues, on the course of the spine
in paraplegia, and  in acute or  chronic local or limited inflammation of
different parts, as in hepatitis or nephritis.  In cases of diseases of the
spinal  marrow, Avith  paraplegia or  paraplegic  spasm,  setons are  more
especially valuable; but Dr. Hall  looks upon the usual seat of application 
314
PARASITES.
of these setons as improper.  He thinks the great error committed by
medical men is the ap'plying the seton below the seat of the disease.  " The
spinal nerves proceed for softie distance, from above, directly rather than
ooliquely, doAvnward,  and the seat of  the  disease is at or above their
junction (insertion or origin) with the spinal marroAv."     Part iv., p. 46.
  Ergot of Rye.—M. Payan states  that Ave may find ergot of rye very
useful  in  paraplegia.  When  Ave consider its  effects,  not  on the uterus
only, but also on the rectum, bladder, and lower extremities, and, indeed,
occasionally on the Avhole system, causing the  patient to feel universally
benumbed, as she  frequently expresses herself, followed by poAverful  ex-
citement, we must suppose that it  acts primarily and especially on  the
Bpinal cord ; and Ave may consequently believe that in some cases of para-
plegia it will be found  useful.                             Part vi., p. 88.
  Paraplegia from Ascarides.—In the proceedings of the  Ipswich Medi-
cal Society,  there is recorded the case of a child, tAvelve months old, wdiich
was  attacked with sudden  loss of poAver in the  loiver extremities, Avhile
the sensibility of those parts wTas exhausted.  After purgatives had been
given without advantage, the administration of sesquioxide  of iron was
followed by the expulsion of a " firm ball of ascarides,"  and the relief of all
the symptoms.                                          Part xv., p. 68.
  Paraplegia.—The alkaline and phosphatic condition of the urine,  says
Dr. Garrod, may be remedied by  the administration  of benzoic acid in
large doses, two scruples four times a day.               Part xix., p. 28.
  Reflex Paraplegia.—Dr. BroAvn-Sequard remarks, that if strychnia be
administered in the reflex form of paralysis, it will be advantageous. This
is Avell illustrated in a case of paraplegia  produced by exposure to cold and
wet.   But,  given in cases of paraplegia consequent on congestion or actual
inflammation of the cord, strychnia will only aggravate the  affection.
                                                        Part xl., p. 40.
                        PARASITES.
  Benzin or Benzole, as a Remedy for Animal Parasites.—Our readers
are probably aware that benzin or benzole is a clear, colorless fluid, pos-
sessed of a pungent etherial  odor,  which is produced by the decom-
position  of benzoic acid, or  other organic substances, at a light tempe-
rature.   It was long ago ascertained by Milne Edwards  that its vapor Avas
very fatal to insects.  This property has led M.  Reynal, of the veterinary
school at Alfort, to employ  it for the treatment  of pedicular  maladies
among animals.   He has found that it destroys the parasites in these dis-
eases,  more surely, and with  more  safety to the animal, than tobacco-
juice, mercurkti  ointment,  or any other of the  many remedies used. It
destroys the epizoa without at all injuring the skin.
  It is proposed to use this fluid in the parasitical diseases of the human
skin, especially in phtheiriasis or morbus peclicularis, and in scabies,  etc.
                                                    Part xxxi., p. 196. 
PARONYCHIA.
315
                       PARONYCHIA.

  Lotions and Medicated Poultices in Phlegmonous and Erysipelatous
Inflammations, and especially in Paronychia.—In all these cases Dr. F.
J.Brown urgently recommends the employment of astringent and sedative
lotions, and poultices made with these instead of water, for not only, he
says, may the disease by these means be  sometimes  checked  before  sup-
purationtakes place, but Avhen  matter is formed the inflammation is  not
so great, and the parts are much sooner healed.  He says:
  The astringents that I employ are the sulphate of zinc  and burnt alum
mixed wdth acetate  of lead.  This is an unchemical mixture, but its use is
Satisfactory.  I am  indebted to my father, an old staff surgeon, for  the
prescription, which  is, for each ounce of water three grains of burnt alum,
two grains of zinc, and tAvo grains of lead.  The lotion  should be used
warm. It is advisable to omit the lead after the disease has been subdued,
for fear of its  effects on the muscular system, although I have  never  seen
ill effects from perseverance in its application  for many Aveeks.  These in-
gredients, placed in paper as a powrder, in  sufficient  quantity for  a Avine-
bottleful of water,  enable a patient  to  use the lotion  both freely  and
cheaply.
   I have no doubt  but that many surgeons use lotions for the affections
mentioned, and I must therefore apologize for bringing forward this mode
of treatment; but I have seen so many fingers crippled by the  persistence
of inflammation under the  Avater-poultice  treatment, that I consider the
subject Avorthy of  attention.   Surgeons  can see the  improvement  that
occurs in many diseases of the eye, ear  and throat, from  the use of as-
tringent lotions, yet they commonly neglect such applications in phleg-
monous inflammation occuring in the trunk and limbs.
   Nitrate of silver is sometimes  applied over  surfaces affected by erysi-
pelatous inflammation, but  I  am not aware that astringent  lotions are
usually applied by means of cloths laid upon the parts.  I recollect reading
in one of the periodicals of sulphate of iron lotion for erysipelas, and Iha\Te
employed it Avith advantage.
   I presume that the astringents diminish the calibre of the bloodvessels,
and effect some change upon the nutritive process  by which  the profuso
formation of cells is restricted.   Certain it is that the inflamed part be-
comes diminished in size and Avhitened; and suppurating parts yield secre-
tion in  greatly diminished quantity (Avithout becoming hot and dry, as
might be anticipated),  Avhilst their bulk is reduced.
   The internal treatment that exerts most influence on paronychial inflam-
mation is sulphate of quina in Epsom  salts mixture, preceded (in severe
cases) by a few doses of tartrate of antimony in Epsom  salts mixture.
The same internal  treatment  is peculiarly efficacious  in erysipelas  and
phlebitis, and in the unhealthy inflammations generally, as they are termed.
   In concluding these few remarks, I Avould mention that the ancient lapis
divinus (alum, nitre, and sulphate of copper) constitutes a gargle that will
quickly  remove inflammation of the throat;  and  the  same  (with  the
omission of the nitre) forms  a lotion under the use of Avdiich sores on the
penis heal with rapidity.
  The medication of poultices by means  of ointments  is advantageous in
certain eases.   Resinous  ointment  mixed  with a poultice considerably 
316
PEDICULI—PENIS.
hastens the suppuration and cure of a boil, and it Avill cause the skin to
yield much sooner in abscesses of the breast and neck than occurs under
simple poulticing.  Red oxide of mercury ointment mixed Avith a poultice
cleanses foul sores, and expedites their healing.  Medicated fomentations
and poultices Avere in great esteem formerly, but they have fallen into a
neglect which I consider to be unmerited.           Part xxviii.,^. 23f.
Ml
                         PEDICULI.

  Pediculi Pubis.—Dr.  Haural recommends the following treatment;
Wash  the parts  thoroughly, first with  soap and water, then  with pure
water; dry them, then  pour chloroform on drop by  drop, and rub it in:
then cover the parts with a folded handkerchief for  half an  hour, when
another Avashing  Avith  soap and water  should be  performed, in order to
detach the debris of the pediculi.                    Part xxxvii., jo.  182.
  Pediculi Pubis.—Dr. Ryding, of Oakham, uses the  folloAving lotion:
Bichloride of mercury, twelve grains; rectified spirit, two ounces; distilled
Avater, tAvo ounces.  Apply  this carefully for ten  minutes with a flannel,
and immediately afterward well dust the parts with ammonio-chloride of
mercury.   Repeat this night and  morning for  twTo days,  then use  a
Avarm bath and soap.  The ova will be destroyed effectually by this pro-
cess.....
  Apply the folloiving liniment  for forty-eight hours:  Finely levigated
nitric oxide of mercury,  tAAro drachms; olive oil, one ounce ; mix.....
  Apply an ointment containing half a drachm of iodide of potassium to an
ounce of lard.....
  Rub in a large  quantity of calomel at bed-time.  One application will
usually be sufficient.                              Part xxxviii., p.  176.
                             PENIS.

  Amputation of the Penis.—[Mr.  Barnes publishes an account of the
mode in which M. Ricord avails himself of the process of contraction after
amputation of the penis to keep the urethra open.   The principle of most
surgeons in this operation is to counteract contraction.]
  M. Ricord's principle is to avail himself of this process of contraction,
and turn it to account in preserving the orifice of the urethra patent.  The
proceeding is this : having performed the  amputation, with the precaution
of preserving sufficient skin, and no more, to sheathe the corpora cavernosa,
and secured  the vessels, the surgeon seizes  with  the forceps the mucous
membrane of the  urethra, and Avith a pair  of scissors makes four slight in-
cisions, so as to form four equal flaps; then using a  fine  needle, carrying a
silk ligature, he unites each flap to the skin by a suture.  The Avound unites
by the first intention ; adhesion being formed between the  skin and mucous
membrane, Avhich become  continuous, a  condition analogous to what is 
PENIS.
317
observed at the other natural outlets of the body.  The cicatrix then con-
tracting, instead of operating prejudicially, as in the old methods, tends, on
the contrary, constantly to open the urethra, whilst a perfect covering is
provided for the ends of the corpora' cavernosa.  The difficulty of  direct-
in"- the stream of urine, is one which becomes troublesome in proportion to
the shortness of the stump. The patient must provide himself with a funnel-
shaped canula, made of box, ivory, or metal,  the base of which being ap-
plied over the stump, and resting on the pubes, the other end will serve to
carry the urine clear of the person.                     Part xi.,p. 170.

  Penis—Cancer of.—M. Bonnet employs the actual cautery to execute
the amputation.  The patient being put under the influence of chloroform,
and Avet compresses disposed round the penis, the organ is held  by means
of forceps, and the heated iron applied perpendicularly to the back  of the
penis.  When the fibrous structure is divided, the iron is to be passed into
the corpora cavernosa, and so through the penis.  Four or five applications
Avill be wanted in all.   When  the cancer extends to the scrotum or abdo-
men, the operation is more tedious, as the ramifications must be folio Aved by
the cautery,  though  the pubis itself has to be reached.  If the inguinal
glands are affected, they should be removed by a bistoury, and the cautery
applied.   There is generally  far  less reaction than after ordinary amputa-
tions of the penis.  In about a week the  eschars begin to  be detached in
fragments, and they have all  fallen in fifteen or twenty  days.  By this
operation, then, we can much more readily act on healthy tissue, Ave are
enabled to attack cases the knife could not reach, and we  prevent hemor-
rhage.                                               Part xx., p. 165.

   Case of Considerable Sprouting of Warts on the Glans Penis.—[Ricord
believed that warts upon the penis Avere non-syphilitic, other eminent sur-
geons think they are; but there can be no question that these excrescences
may be implanted on the organs of generation in the same  way as they are
present upon the fingers.  From the narrow space in Avhich they grow,
they are liable to produce  great irritation  and inflammation, and their
removal rendered a  matter of anxiety.  The patient in the case of Mr.
Hancock, Avas a married man, aged 35, and stated positively that he had
never had any A-enereal affection Avhatever. He had never noticed anything
the matter Avith the penis until four months  before admission, Avhen the
warts began  to grow.]
  The  patient has congenital phimosis, and noticed at the  time  just men-
tioned, that  some tumor Avas deA-eloping between the glans  and the prepuce
in the neighborhood of the corona.  The pressure from Avdthin soon caused
slight pain in the prepuce, and inflammation ensued, marked with a vivid
redness on its external surface near the corona glandis. The patient applied
poultices; ulceration and perforation  took  place, and the mass of warts,
which had been the exciting cause of all these symptoms, protruded through
the ulcerated opening in the prepuce.
  The  verrucas having thus obtained room, seemed to grow more rapidly  ■
than before;  the aperture just mentioned became larger, and  the warts
greiv to  such an  extent  as  to cover the glans almost completely,  and to
rouble its size.  The extremity of the prepuce ivas, in  the meanAvhile,
almost  separated by ulceration from the rest of that process, abundant sup-
puration had set in, and the  parts looked, to an unpractised eye, as if the 
318
PERICARDITIS.
organ had been suffering from carcinoma.  Very little  or  no pain accom-
panied these changes.
  The patient was brought into  the  operating theatre, and when he  had
been rendered insensible Avith chloroform, Mr. Hancock began  to remove
Avith the scissors the enormous crop of warts Avhich  had sprung up about
the part, as also the thickened semi-detached pieces of prepuce Avhich were
giving to the organ a misshapen  aspect.  When the whole mass of verrucas
had been excised, the  penis was surrounded with lint  dipped in cold
water, and the patient placed in bed.   The progress  has been most satis-
factory since the operation, and the parts are noAV quite cicatrized.
                                                    Part xxix., p. 241.

                              ----»-♦-•----
                    PERICARDITIS.
  Treatment of.—On account of the frequent occurrence of pericarditis, its
dangerous nature, and the numerous important diseases—endocarditis, val-
vular disease,  atrophy, hypertrophy, dilatation—which are  frequently its
consequences, it is highly important that  its detection should be easy, and
its treatment  simple and straightforward.  Although the pericardium is
composed of two distinct kinds of tissue, yet  as they are intimately con-
nected, and supplied by the same vessels, the character and products of
the inflammation depend more upon the condition of the blood than upon
the nature  of the tissue primarily affected.
  Dr. Shearman wrould bleed, first  generally, and then  locally, to such an
extent as to cut off part of the supply of blood to the part, and to decrease
the quantity of fibrin in the blood ;  give opium to diminish irritability and
vascular excitement, and to relieve pain; give purgatives moderately ; and
blister.  But all these remedies combined wdll be inefficient for good, ex-
cept mercury be given.   Get the patient, therefore, as quickly as possible
under the specific action of mercury; and for this purpose the best method
is to give calomel with opium, and  to use frequent frictions with strong
mercurial ointment.  Colchicum, emetic tartar, and aconite may sometimes
be useful in allaying excessive action ;  but must be given with great cau-
tion.                                                 Part xvi., p. 113.
  Ptyalism in Pericarditis.—Dr. Taylor's cases seem  to show that our
opinions on the powers  of mercury in pericarditis require  revision.  In
twelve cases, ptyalism was not followed by any abatement of the disease;
and  in  six cases pericarditis followed upon the ptyalism.
                                                     Part xvi., jo. 116.
  Rheumatic  Pericarditis.—The treatment of pericarditis, says  Dr. 0.
Kidd, has recently undergone considerable modification.  Taking blood by
venesection, which  would  first suggest  itself, though necessary in  some
cases, in others is all but inadmissible.  It  has been recently shown by
Bouchardat, that rheumatism may even be  induced  by the  coagulable
state of the blood, the result of repeated bleedings.   Every particular case,
of course, wdll  require a  different line of action.   Venesection after  the
middle of the first week,  as a general rule, will lengthen the period of re-
covery, and many cases will not require bleeding at all.
  The local abstraction of blood in  rheumatic pericarditis will be ahvays 
PERINEUM.
319
found the most beneficial.   The treatment must vary, as  Ave have to treat
patients ill fed and etiolated in cities, or healthy and full of red blood in
the country.  Antimony, alkalies, nitre,  and colchicum, are A'ery valuable.
The exhibition of mercury has been lately dwelt upon, the general impres-
sion being that its beneficial effect will, in a great measure, depend On the
period at which it is given.  If early in the disease, it will prove much more
satisfactory than later, its action being more properly directed to prevent
thh deposition of organizable matter in the  pericardium than to remove it
afterward.  Indeed, our late statistics would go to prove that salivation
has no very marked effect on the disease at all, the ceasing of the friction
sound, according to Taylor, being more of a coincidence than really brought
about through the agency of the mineral.   As to the use of tartar emetic
to remove inflammation, perhaps there is no difference of opinion; the
dangerous effects of this valuable medicine having little or no  existence
except in the estimate of those who have not studied its effects.
   Case.—Margaret B., aged 20,  single, had suffered formerly from rheu-
matism, and lately very much  from debility, and irregular  menstruation.
She complained, on admission into Guy's Hospital,  of burning hot pains in
the joints, and all the accompanying  symptoms  of rheumatic fever.  The
heart's action Avas found to be  quite normal, as well as the impulse, a very
feeble bruit being perceptible Avith the  first sound,  particularly over the
valves.  The second sound free.   Ordered pills Avith antim. tart,  and calo-
mel,  and a draught for the morning, with senna and vin. colchici, to be kept
very quiet, and to get simple drinks, Avithout food.   As the symptoms of
pericarditis  gradually came on,  Avith acute pain below the  left  nipple,
between the fifth and sixth ribs, a rubbing sound Avas detected Avith the
systole, and  occasionally of a " to  and fro " character.   Cupping glasses
Avere now put on, and §vj. of  blood drawn from the cardiac region, the
former medicines being  continued.  Although the  " rubbing sound " con-
tinued for six days longer,  the general symptoms began  to  improve ;  but
the bruit began  to be traceable along the aorta.  She Avas noAV, in addition
to the same medicines, ordered a blister to the region of the heart.  In a
Aveek after  this, the pericarditic symptoms had entirely disappeared,
although she had suffered some little relapse.         Part xxii., p. 116.

  Pericarditis.—Dr. Stokes says that Avhenever the fever present is of a
typhus character wine is required.                    Part xxix., p. 21.
                        PERINEUM.
  Ruptured Perineum—Operation.—After dwelling on the difficulty of
accomplishing the re-union of the parts in ruptured perineum, Mr. Fergus-
son says, that " it is generally alloAved that in cases Avhich  do not heal up
soon after delivery, the parts being kept in perfect rest, it is better to wait,
before attempting any surgical means, until the primary inflammation has
subsided.   Mr.  Fergusson has  chosen the  interrupted  suture, certain
objections to them being  removed  by precautionary  measures.   This
patient,  18 years of age,  had  been  delivered of her first child  by the  for-
ceps six months previous to  her admission, and  ever  since had been
suffering from the effects of a lacerated  perineum,  extending from the 
320
PERINEUM.
fourchette to the margin of the anus, the fasces involuntarily passing through
the recto-vaginal aperture.
  After this young woman had  been duly prepared for  the operation, by
rest and  opening medicine, she was brought into the  theatre and placed
under  the  influence of chloroform.  The patient being secured in the
position for the operation of lithotomy, Mr. Fergusson began by paring the
whole length of the margins of the perineal gap, from above downward,
and brought them  in exact apposition, by three interrupted sutures.  The
next step of the operation consisted in making a longitudinal incision  on
each side of the line of sutures, in order to take off the tension which the
neighboring  parts  would  naturally  exercise upon the  sutures.  These
lateral Avounds were filled with dry lint, cold compresses applied to the
perineum, and the patient removed to a bed, Avith her  knees kept together
by a roller.
  Much  care was subsequently used in keeping  her quiet and  regulating
the action of the  bowels by  enemata;  and  about eleven days after the
operation Mr. Fergusson Avas enabled to remoA'e the three sutures, as
pretty firm adhesion had  taken  place.  The  bowels noAV became regular,
Avithout  the necessity of the injections which had hitherto been systemati-
cally  administered, and  about one month after  the  operation, both the
perineal  wound and  the  lateral incisions Avere completely healed.  The
further progress of the patient has been satisfactory,  the rectum has
regained the  faculty of retaining  its contents,  and the poor Avoman is
delivered from a very distressing infirmity.           Part xxii., p. 305.
  Rupture of the Perineum.—The plan of Mr.  Brown's operation  is as
folloAvs:  Having made a clean incision into the vagina, so as  to  separate
from each side of the rent any portion of mucous membrane, three or four
sutures were passed deeply through the parts, and attached to a piece of
quill or  elastic bougie on each side.  Three or four smaller sutures might
be  passed also through the edges of the wound,  so as to bring them into
more certain apposition.  To  prevent the inner edges of the Avound  being
draAvn separate by the sphincter, and the lochia  allowed to penetrate into
the wound, Mr. Broivn divides this muscle ;  and this he considers one of
the most essential features of his  operation.   In all cases he administers
opium, which allays the irritability of the nervous system, and exercises a
most salutary influence  over  the patient.  He has never seen any harm
arise from its constipating effects.                     Part xxvii., p. 196.

  Abscesses in the Perineum and Neighborhood of the Anus.—[According
to Prof.  Syme, the explanation of the origin of abscesses in this situation
Avhich is usually given and received, is very erroneous, so  far as the rectum
is concerned.  They are said to be from ulceration hi the mucous membrane,
allowing intestinal matters to enter the  cellular texture. But such an
occurrence never does take place, since ulcers in this  situation are ahvays
attended AAdth an induration of the subjacent texture;  and]—
  It is this firmness of base that renders ulcers at the  rectum recognizable
by  touch, Avhich from long and large experience,  I  may confidently assert,
is sufficient for the diagnosis of all derangements in this  part of the  body,
Avhile speculums are not only painful and useless, but calculated to mislead.
If  further evidence were required to disprove the agency of ulceration in
giving rise to the abscesses in question,  it would be afforded by the effect
of wounds penetrating the mucous membrane, which give  rise to abscesses, 
PERINEUM.
321
it is true, but totally different in their nature and character from those of
the ordinary purulent collections  met with in this situation.   The most
frequent instances of such an  injury are produced in a Avay that would
not readily occur to you, viz., the administration of enemata.  Many years
a^o, on making my daily visit  to this hospital, I Avas told  that  a patient,
who had been admitted with retention, was suffering from extravasation
of urine.  Upon  examination,  I  found much swelling of the nates and
neighboring part of the perineum, but no difficulty in passing a full-sized
catheter, through Avhich a large quantity of healthy urine  was evacuated.
Having then  ascertained that an injection  into  the rectum  had been
employed as  a substitute  for more efficient relief, I suspected the truth,
and introducing my finger into the anus, at once felt an aperture on the
anterior surface  of the bowel, through which the  fluid injected had no
doubt passed, so as to simulate the appearance of urinary extravasation.
In those days, the instrument employed for throwing  injections  into the
rectum, was  the old  metal syringe with  a straight  pipe, wdiich, when
introduced behind  the  patient, as  it generally was, could hardly fail to
encounter resistance from the opposite surface, requiring force which was
sometimes employed so strenuously as to make the fluid escape in a Avrong
direction into the operator's face.   Impressed Avith  the danger of such a
procedure, as manifested by the case just mentioned, and others that came
to my knowledge from the  inquiries Avhich it suggested, I recommended
that  the old  injecting  apparatus  should  be  abolished, and that Read's
syringe should be employed in its stead.   But even  from his more safe
and apparently harmless mode of administration, I have known perforation
of the mucous membrane produced ;  and in order to put you still further
on your guard, I may mention  that a most kind and attentive practitioner
asked me to see a gentleman, in whose case  he felt  so  much interested, as
to administer an injection by the apparently innocuous means of a bag and
pipe, or in other Avords, a bladder,  Avith an ivory tube  attached to it, with
the effect of perforating the boAvels, and distending the hip Avith the usual
mixture of gruel, salt  and oil.
  The fluid  injected  excites inflammation  of a very violent character.
attended Avith a  corresponding degree of constitutional disturbance, the
[ocal  result  being very  speedily a large collection of extremely fetid fluid
and air.  These characters of the abscess may be supposed to depend upon
the peculiar nature of the matters  alloived  to issue from  the boAvel, but
are more probably connected Avith the sort of inflammatory action wdiich is
excited  by the wound.
  The abscesses wdiich, under all ordinary circumstances, occur at the verge
of the anus, differ entirely from those which  we have been considering.
Instead of being large  and diffused,  they are small  and circumscribed ;
instead  of being preceded by  intense inflammation, and  attended  with
Aiolent constitutional  disturbance, they take place without either one or
the other of these conditions ; instead of  being rapidly they are slowly
formed;  and  instead  of dark-colored fetid matter, they contain merely a
little of what  used to be called Avell-conditioned pus.  It is such abscesses
which lay the foundation of fistula in ano.  When alloAved to open sponta-
neously, they  almost  invariably do so on  the external surface—that is,
through the skin ; and if,  when this has happened,  or  the  contents  have
been evacuated  by an  incision, a  finger  is introduced into the rectum,
Avhile a probe is employed to explore the cavity formed by suppuration, it
    VOL. II.—21 
322
PERIOSTEAL  AFFECTIONS.
will be found that the mucous membrane, although to a considerable extent
completely denuded, still remains  entire.   Sooner or later an aperture ia
formed  by ulceration, through  this detached  portion  of the lining mem-
brane, and then the fistula becomes complete or open on both the external
and internal surface with Avhich it is connected.
  Then, as to the urethra, it has long been taught  that abscesses  con-
nected  with  it in general  proceed from  ulceration  of this membrane,
allowing urine to escape into the cellular texture.   But Avhenever urine can
be positively ascertained thus to issue from  its proper channel, the local and
constitutional effects  are so violent  and characteristic as to prevent the
possibility of o\Terlooking them;  while the abscesses that usually precede
the formation of a fistula in perineo take place slowly and insidiously so as
frequently to escape observation until they discharge their contents, Avhich
in the first instance are almost ahvays simply purulent, the urine folding
its  Avay through them only by a secondary process  of ulceration in the
denuded  mucous lining of the urethra, Avhich,  like that of the  rectum,
remains entire for a time.  It is true that strictures frequently give rise to
abscesses of the  perineum, but not by impeding  the Aoav of urine so as  to
cause the extravasation, their real agency in producing this  effect being
through the excitement of irritation, which gradually leads to the result in
question.                                           Part xxxiii., p. 187.
  Ruptured Perineum.—In the Vienna Lying-in Hospital, Vidal's  serres-
fine seem to have superseded every other means  of approximation.  It
may be necessary to pare the edges a little ; then, as soon as the bleeding
has ceased, two or three may be applied according to the extent of lacera-
tion.   Allow them to remain two  hours, keep the parts clean, and, above
all, keep the patient on her side till the termination of the case.
                                                    Part xxxiv., p. 246.
  Perineo-Plastic Operation.—Dr. Savage, of Samaritan Hospital, states
that one great element of success in this operation is to remove the entire
thickness of the vagina as far  as the perineal fascia.    Part xxxvii.,^?. 211.
                 PERIOSTEAL  AFFECTIONS.
   Treatment of Periostitis.—Mr. Ferrall  has tried the  three  principal
modes of treatment usually adopted in  this disease, viz.:  1st, by incision;
2d, by mercury; and thirdly, by hydriodate of potass.  By the first the
cure Avas completed in tAventy-eight days , and by the last in thirteen days:
relief was more immediately procured by incision, that is, by cutting down
upon the bone through the periosteum for the space of about two  inches,
but the cure was, nevertheless, protracted.
  He gives from eight to tAventy grains of hydriodate of potass three times
a day in the  third mode  of treatment, to Avhich he gives the preference,
since the iodine treatment  avoids a painful,  though brief operation, and is
not folloAved by an open sore.
  The second ground of preference, namely, the earlier period at wdiich the
patient can resume his occupation, is  clearly on the side of the iodine, for
the case treated by mercury occupied  thirty-seven  days, that by incision
twenty-eight days, and that by the hydriodate  of potass thirteen days. 
PERIOSTEAL AFFECTION8.
32b
  Sarsaparilla is also spoken of as a medicine of great efficacy in sub-acute
and chronic periostitis.                                   Part i., p. 120.
  Periosteal Disease.—Dr Oke gives the following case:
  J. O, aged 40, a baker by trade, consulted me for an agonizing pain of
a rheumatic character in the right  tibia,  which  was considerably enlarged,
and its periosteum thickened along the upper half of its anterior and inner
surf ice.  This pain had  existed for eight years/  It attacked him every
night as soon as he was Avarm in bed, and had in a great measure long de-
prived him of sleep.  He is a married man ;  and solemnly assures me that
he has contracted no syphilitic disease for the  last twenty years, when he
had a swelling of the groin.  He told me  he had spent in  vain almost all he
possessed in medical advice, and had been once in a hospital with no better
success;  that he could bear his sufferings no longer; and, that in the event
of my treatment being also unsuccessful, he  had decided on submitting to
amputation as a last resource.  I  at once put  him under  the use of the
iodide, of Avhich he took five  grains in solution  three times a day, and con-
tinued the  treatment  for  six  weeks; at  the  end of a Aveek the pains left
him and  never returned; the enlargement  of the tibia diminished, and he
speedily  recovered.                                      Part ix., p. 61.
   Periosteal Thickening  cured by Iodide of Potassium.—Mr. Alexander
Ure relates a case of periosteal inflammation of left ulna, about its middle
third, of tAvo  months' standing,  Avhich, after blisters,  leeching, etc., had
been tried, was cured by taking tAvo grains  of iodide potass, twice daily,
in infus.  gent, co., and a grain of opium  at bedtime,  for a fortnight; bran
poultices applied to the arm.                             Part xi., p. 186.
   Treatment of Periostitis.—In  obstinate cases, says Prof. Miller, where
aggravation and suppuration  seem imminent, direct incision is unAvarrant-
 able, but it may be  done as  folloAvs :  Insert  a fine bistoury or tenotomy
needle, at  a little distance from the  tense part, passing it over, cautiously,
beneath  the integument;  then turning  and pressing its edge, divide the
tense membrane wholly to the desired extent; now cautiously Avithdraw the
instrument, making a valvular, oblique, subintegumental wound; finally,
 close the single puncture immediately, Avith isinglass plaster or collodion.  .
                                                     Part xxiii., p. 215.
   Syphilitic Periostitis.—Iodide  of potassium for this disease,  says Dr.
 Todd, certainly deserves the  name of a specific, the chief dra\Arback to it is,
 that its  effects are so evanescent.   To obviate this, mercury may be given
 with it,  or a short  alternate course of each,  and then using only tonic
 means, resume the mercurial and iodine  treatment if necessary.
                                                      Part xxiii., p. 81.
   Periosteal Disease affecting the Dura Mater.—The dura mater,  says
 Dr. R. II. Goolden, is supposed to be very little liable to disease, except as
 the result  of injury, or in connection with strumous softening of the petrous
 portion  of the temporal  bone, or with abscesses  about the  ear,  or as the
 effect of syphilitic poison; and this poison, supported by some of our best
 authorities, seems to have diverted attention from a very common affection
 of this membrane, of the same character as the periostitis which gives rise
 to nodes on  the tibia or cranial bones.
   This  partial  affection  of the dura mater may or may not coexist AAdth
 general  periosteal disease.  It is part of the same incroid state, and it has 
324                     PERIOSTEAL AFFECTIONS.
no  necessaiy  connection  either with  syphilis  or wdth  mercury, though
these poisons, and especially the latter, greatly favor its development.  In-
deed, the worst cases have been those who, in the tropics, have  taken
large quantities of mercury for fevers or hepatic disease, often many years
previously, and have been afterward exposed to cold and damp in our more
northern latitudes.  They give way, at least for the time, to very simple
treatment, viz.: iodide of potassa, Avith sarsaparilla, blisters or issues to the
head, and full doses  of opium every night, with a good nutritious diet—
in the same way as periosteal  nodes are known to do.   When the pericra-
nium is the seat of the disease, it is at once recognized by the presence of
great tenderness, as Avell as unevenness to the touch ; but when the dura
mater is affected, this morbid  condition is not so palpable; it is, hoAvever,
evinced by unmistakable symptoms.  The patients are often free from pain
during the day, but at eight or nine o'clock at night the pain sets in, and
is so agonizing  that they are willing to submit to any measure for  relief.
It lasts till three or four o'clock in the morning, folloAved by a profuse per-
spiration, when the patient gets some sleep.   The intermittent character,
and the time and  duration of the paroxysms, are very remarkable.  For
some time the  cerebral  functions  are not impaired, but at length  the
sufferer complains of a constant headache, though not so severe as during
the paroxysms;  he holds  his head forward, Avith his broAvs knit; then fol-
low occasionally epileptic  fits,  weakness  of the lower limbs, paralysis, and
the patient becomes greatly emaciated,  despondent, and suffers colliquative
perspirations.
  Some years ago, a sailor, wdio had frequently been a  patient  for such
attacks, Avas accidentally killed.  This  afforded an opportunity of examin-
ing the head, when it was found that the inner table of the  skull ivas
greatly thickened, and also the dura mater.
  Such is the most marked and aggravated form of the disease occurring
in patients debilitated by climate, mercury, purpura, or syphilis, Avhich no
one would fail to recognize as identical (except in situation) Avith periosteal
disease, Avhen it attacks  the  tibia, ulna, cranial bones, crest of the  ilium,
etc., in the form of nodes, and for Avhich the iodide of potassium seems to
be the appropriate, if not specific remedy.
  Although this aggravated form of periosteal disease of the dura mater is
most common in  sea-port hospitals, where the patients have been for the
most part exposed to all the  predisposing causes, yet it occurs  also in a
milder form, and therefore  more  likely to escape  recognition, as the
cause of many  distressing headaches,  ultimately  leading  to epilepsy or
paralysis, or at all events  reducing the sufferer to the most distressing state
of debility.
  These cases are marked by headache, having  its regular nightly parox-
ysms, morning perspirations,  and gradual emaciation.   The  patients have
mostly been treated for  dyspepsia, rheumatism, gout, neuralgia, brow
ague, and often for supposed obscure cases of phthisis, having, in  addition
to the above symptoms, some cough and bronchial murmurs; but by the
peculiar expression of countenance, the pain and Avakefulness  during the
first part of the night, the true nature of the disorder has been recognized.
                                                      Part xxiv., p. 54.

  Periosteal  Disease Affecting the Humerus and Femur.—This disease
often affects the upper end of  the humerus, and the lower end of the femur, 
PERIOSTEAL  AFFECTIONS.
325
and is often  overlooked.  The shoulder is aching, tender, and cannot be
used on account of the pain, the muscles being inserted into the periosteum.
The pain is more severe at night; there is no perceptible swelling.   There
soon folloAVS a state of permanent congestion, or subacute inflammation.
The  hip joint is liable to a similar affection, but is more rare.  In  these
cases the iodide of potassa must be given three times a  day.  If of long
standing, blisters or issues must be employed.  The nitric acid issue is the
best.  A piece  of  lint is to be applied the size required, not too Avet Avith
the acid, to the tender part anterior to the joint, as it is generally  under
the covering of the deltoid and biceps, near the  joint.  It should then be
covered over  Avith  a piece of  lint, dipped in a  solution of carbonate of
soda.   A linseed  poultice should be then  applied.   The slough usually
comes away in five or seven days,' and the discharge will continue till the
pain is removed.
  Periosteal Deposits.—Dr. Goolden also alludes to some painful swellings
of the tarsal and  metatarsal, as well as carpal and metacarpal  bones,
often observed to remain  after attacks  of  gout, when all active signs of
gout have subsided—and sometimes mistaken for gout—and to the known
success  of the iodide of potassa in relieving the pain.  These  SAvellings of
the fingers and Avrists are very different  from chalkstone deposits, though
they disfigure the  hands.  They are very common in advanced life, and
then they rarely subside so as  entirely to restore symmetry of form.  But
the same observation holds good in all other forms  of periosteal deposit;
that  is  to  say, although the  activity of the disease  may be arrested  by
iodide of potassa and blisters, the absorption of earthy matter in old age is
much more difficult; the pain will subside, but the tibia and  frontal bone
still retain the SAvelling and unevenness.
   Another set of periosteal deposits is on the fangs of the teeth, causing
the most agonizing toothache, Avithout any apparent  decay  of the  teeth.
The  fang  of the tooth becomes thickened, too large for the  alveolar cell,
and,  when drawn, the membrane shows unusual vascularity, and there is a
deposit of dentine, softer than the fang of the tooth, and may be cut with
a penknife betAveen the membrane  and the fang, giving it bulbous form,
and rendering it difficult to extract without breaking.  This is not uncom-
mon  after  mercurial salivation;   and in ladies who  have taken metallic
remedies for  a continuance—especially  salts  of iron—given for the relief
of headache,  and remittent pains about the  chest and other  parts—some-
times for neuralgia—all dependent upon this state of the system.
                                                     Part xxiv., p. 57.

  Periosteal Disease affecting the Dura Mater.—[In  previous notices  of
this disease, Dr. Goolden has  shoAvn  some important, but not generally
recognized forms of its development, and its independence of  syphilis.  In
considering its remedial treatment, he says :]
  No more valuable remedy has been introduced into medicine than the
iodide  of potassa,  but its precise value  is scarcely generally recognized.
Some practitioners  give it in eight-grain doses, three times a day; and
give it with calomel or bhie-pill, and colchicum ; others never venture be-
yond  tAvo  grains,  and even then fear the results; yet no one ventures to
dispute its almost general efficacy in  nodal periostitis.
  As far as I can draw any inference from my own  cases, I should say that
smaller doses produce the specific effect quite as soon  as the larger; and I 
326
PERIOSTEAL  AFFECTIONS.
have  often knoAvn two-grain doses act readily on the system, when larger
doses have failed; but I think it necessary to combine the salt Avith liquor
potassa, as any acid on the stomach Avill decompose the  salt, and the lice
iodide Avill thus be very likely to act as an irritant.  I may also observe,
that it is not wTell borne Avhere there is any considerable gastric  irritation,
indicated by a foul tongue, dry skin, precordial pains after food, etc., at-
tended Avith  acid eructations, and especially wheie there is urine  turbid
with lithates or lithic acid; and yet we may have all these, as w-ell as peri-
osteal nodes, to contend Avith ; and I am quite sure, that  during  the active
forms of gout and rheumatism, the medicine is never  Avell borne; yet it is
often A-ery useful in relieving pains which are still existing after all consti-
tutional traces of specific  disease have subsided.  It is therefore necessary
to relieve the dyspeptic  symptoms by appropriate remedies, before using
the iodide of potassa;  or not to set down our failure to the inefticaey of
the salt.   The disagreement of the medicine is soon detected by the exces-
sively nauseous, metallic taste in the  mouth, before the gums are affected,
or the catarrhal  symptoms so severe as to  oblige us to discontinue it; and
when that taste  distressingly prevails, the salt rarely produces  any bene-
ficial effect.
  But I will even go further  in asserting, that in seme instances periosteal
nodes have been the result  of the very medicine Ave are giving for their
cure.
  I have met with cases of periosteal nodes, wdiich haA'e appeared during
a course of iodide of potassium and sarsaparilla, taken for secondary skin
eruptions, and wdiich have subsided on substituting mercurial  medicines
for the iodide.
  It will be  found that  the different preparations of iron with quinine,
sometimes gentian and  ammonia, sometimes nitric acid, and decocticn of
sarsaparilla, may be given wdth advantage; but the relief is very different
in degree and kind from  that produced by the  iodide  of potassa or by
mercury in the  cases to  which  they are  respectively applicable.  I have
occasionally observed some benefit to accrue from the use of the  phosphate
of ammonia, where the iodide of potassa could not  be persevered in.   I
must  first refer to iron as a remedial agent.  I have not lately used iron in
any form as  a remedy  until  satisfied that the patient wras intolerant of
iodide of potassa, or else  as a tonic during such  intervals as  it has been
found desirable to intermit the use of that salt; but amongst those who
have  applied to  me as private  patients,  I have been able to collect facts
relative  to the  effects  of iron which had been previously recommended.
   Of all remedies, next to the iodide of potassa, iron has  certainly been
generally the most serviceable; but  the form in which it is exhibited does
not appear to me at least to be of much consequence. A lady, near Dork-
ing, consulted me for neuralgic pains on  the right side of the  face, from
which she had suffered for six years.  She had at different times consulted
some of our most eminent  physicians and surgeons, and  derived some
benefit from carbonate of iron, prescribed for her by  Sir B. Brodie; but it
never quite relieved her.  The tic occurred in paroxysms in the evening;
and on questioning her, I learned that she had also headache, pains in the
crest of  the ilium, and  tibial nodes.  She had the appearance of one who
had been much  stouter,  but was emaciating and anasmic.  Small feeble
pulse ; clean tongue, and had  no  sleep  for  pain.  She took  iodide  of
potas«ium, five  grains; liquor  potassas, half a drachm;  compound decoc 
PERIOSTEAL AFFECTIONS.
327
tion of sarsaparilla, an ounce and a half; thrice a  day.   An opium pill at
night.
  Under this treatment she gradually lost all pain.  The opium was soon
discontinued, but she slept well, and the medicine was at length omitted,
in consequence of the disagreeable metallic taste.   Her medical attendant,
Mr. Curtis, favored me Avith a favorable report of her since, and she is noAV
taking quinine and iron under his direction.
  The carbonate of iron ivas considered to have a kind of specific action in
such neuralgic cases, and was prescribed in spoonfuls;  but I think  it a
clumsy way of giving medicine; being nearly  an insoluble powder,  and
any quantity of course may be given that will pass off by the bowels.  The
more soluble salts are certainly the most effective, and none more so, or
more agreeable, than the vinum ferri as prepared at Apothecaries' Hall;
but the  sulphate  or hydrochlorate, or the ammoniated tincture, will answer
equally well.  The chalybeate wraters are even more certain in their effects
than any of our  medicinal potions, and this is a fact  not so  generally
recognized as it should be.  It matters not Avhether the Avater be natural
or artificial.   Small doses largely diluted are more  readily absorbed and
diffused than larger and more concentrated doses.
  The anaemic appearance usually observed in periosteal disease would
seem to point naturally to iron preparations, and though  they do not seem
directly to control the morbid action going on during the activity of nodal
deposit, as both  iodide of potassa and mercury, in their appropriate cases,
are observed to do, yet their indirect influence is very decided,  and when
the  acute symptoms are relieved, it is most  desirable to alternate  the"
iodide of potassa with iron preparations;  and there is  one form of iron
which is especially applicable, viz. the iodide, Avhich is  best given in the
form of sirup.
   Quinine is an important agent in the treatment of this disease.  Periosteal
disease  is rife in the  aguish districts of Kent and Essex, and although the
iodide of potassa will control the paroxysms, the relief must be  followed
up by such  remedies as  restore the  constitution to a normal state, which
the iodide will not do, and Avithout wdiich the relief can only be temporary.
  The anasarcous swellings indicate an obstruction in the chylopoietic
vessels,  whether in the liver, spleen, or kidneys, and Bright's disease is no
unfrequent attendant, evinced by albuminous urine.  Without hoping to
restore the kidney to its normal function, when that is evidently degene-
rated, much good accrued from the exhibition of  quinine, either alone,
or in combination  with  sulphate of iron,  dissolved in dilute sulphuric
acid.
  Where a simple tonic is required, quinine is not  the  most efficacious,
and is often  observed rather to oppress than invigorate the digestive func-
tions (I  am acquainted with two persons in whom  severe inflammation of
cellular  tissue is the result of a  grain dose of quinine);  but some of the
simple bitters, Avith ammonia, are often found more useful.  This holds
good mostly in tipplers—I do not mean absolute drunkards, but those who
are constantly drinking small quantities of wine, dilute spirits, or even
beer, at all times  and seasons, and in cases where  constitutions have been
debilitated by residence in the tropics, or by the  exhausting  passions.  I
have not been able to satisfy myself that there is any reason for preferring
one bitter rather  than another.  I have prescribed gentian, quassia, casca-
rilla, cusparia, and simarouba, each  for a  stated  time,  in order to watch 
328
PERITONITIS.
their comparative effects, and I am inclined to think that any preference is
rather a matter of fashion than founded on any carefully and  extensively
watched clinical observation; but taking our Pharmacopoeia preparations,
I think I may safely say that the dose should never exceed half an ounce
in an ounce and a half draught.
   Concerning topical  applications : I have already referred to the efficacy
of issues and blisters, and in the severer forms of cephalalgia arising from
the disease of the dura mater, I  prefer them ; but I may also recommend
the application  of spirit of Avine, the most  convenient  mode of using
which, is, to wet some lint Avith the spirit, and having applied it over the
head or other painful  part, to prevent evaporation by covering it over Avith
oil-silk: it produces  a  copious  swreat in the part,  and with  very great
relief!  I need hardly mention, that  eau  de Cologne, or any strong spirit
most  readily procurable, wdll ansiver the purpose.  Old nodes may be
painted Avith the tincture of iodine, or  rubbed with the iodine ointment,
but these are not convenient applications to the  scalp, and the latter is
objectionable Avhere there is much tenderness.
   There is only one more remedy which I must not omit to mention—that
is, guaiacum.   It is by no means universally applicable, but in some cases
most  decidedly useful,  and  especially Avhere there is a cold, dry surface,
and languid pulse, and Avhere the iodide too readily produces catarrh. Lest
I should confound such cases with  the catarrh rheumatism affecting  the
head  or other parts, I have  been cautious to draw my inferences only from
cases in Avhich tibial or other easily  recognized nodes are seen  and felt.
                                                      Part xxv., p. 59.
   Acute Periostitis.—Mr. Curling says: The chief difficulty in diagnosis
lies in its great resemblance to acute rheumatism.  In both  there  is high
inflammatory fever, wdth swelling  of the limb and great pain, increased by
pressure;  but  the point of difference is here—that in periostitis little or
no pain is caused  by pressure, unless it be made over, or in the course of,
the affected bone.  The swelling is not limited to the larger joints, to the
ankle  or to the knee, but occupies a wider range, and  is cedematous in
character.  The conclusion in favor of  periostitis will be much strength-
ened  if it be found that the attack of inflammation succeeded an injury.
In the treatment,  do  not rely on local depletion, Avith calomel and opium ;
make an early and free incision down to  the inflamed periosteum, not Avait-
ing even for evidence of matter, for the  mischief is  then done, the perios-
teum is already separated from the bone, and the bone will die.
                                                        Part xl.,jo. 95.
                                  , 9 ,----

                        PERITONITIS.
   Opium in Peritonitis.—The pamphlet published by Mr. Bates, of Sud-
bury, some years ago, on the treatment of severe peritonitis by opium, made
a strong impression on the minds of some medical men.   He recommended
opium both by the mouth and rectum ; and insisted on a  rigid adherence
to the horizontal posture, till all pain had subsided.  Mr. Bates's practice,
however, may  be  considered as  chiefly valuable in those severe cases
Avhere, either from ulceration or injury,  perforation  of the  intestine  has
taken place, and which  have been  supposed to be almost  invariably fatal.
Some very striking cases, however, are related by Dr. W. Stokes in  the 
PERITONITIS.
329
second number of the " Dublin Journal of Medical and Chemical Science,"
which strongly confirm the opinions of Mr. Bates in  cases  where perfora-
tion is supposed to have taken place.   Dr.  Stokes truly  remarks,  that  in
many of these cases the  patient  sinks  Avith  awful rapidity, and gives no
time to pursue the active treatment Avhich is adopted in other cases. _ Mer-
cury and purgatives would in such cases probably increase the  evil, by
tearing asunder recent adhesions, and  thereby prei-enting nature  closing
the communications between the mucous and peritoneal cavities.  One of
Dr. Stokes's cases is related as folloAvs:
  " The well-known symptoms of perforation of the  intestines had existed
for two days ; The exhibition of sixty  drops, in the tAventy-four  hours, of
the preparation called the black drop Avas folloAved by the most signal im-
provement.  The pulse regained its fullness and softness, the extremities
became Avarm, and the countenance had lost  the hippocratic expression.
The patient could bear pressure  on the abdomen, Avhich the day  before
Avas exquisitely painful.  The same treatment  was continued  for twenty-
four hours longer; and by the end of that time every symptom of abdominal
inflammation had completely subsided.   The belly felt natural, there  Avas
no tenderness, the pulse Avas good, and the patient declared himself well."
At this period of the case, Dr. Stokes  omitted the opium,  and gave the
mildest possible saline laxative, as  there had been no stool for 48  hours.
Four evacuations took place, folioAved by  the  immediate  return of the
symptoms of peritonitis, under which the patient rapidly sunk.
  Dr. Watson remarks:
  This example puts in a very  strong light the good effects of opium ;
the dangerous effects of purgatives;  and the mode in which recovery
from these frightful accidents may sometimes be brought about.
  Dr. Stokes gives another instance in Avhichthe patient did recover; after
taking 105 grains of opium, besides Avhat Avas administered in injections :
and he alludes to a third case, in  wdiich the  employment of opium Avas
successful, Avhen peritonitis had  supervened upon the bursting of a hepatic
abscess into the cavity of the abdomen.
  Dr. Watson recommends applying the .same  principle of treatment, as
an auxiliary, in all cases of peritonitis.  The  opium is  not to  supersede
the bleeding, nor the mercury;  it is not incompatible with either of those
remedies;  and it may be most advantageously adopted in conjunction with
them both.                                              part v., p. 28.

  Treatment of Peritonitis.—[ The constipation which occurs in cases  of
peritonitis should never be treated by  giving  acrid purgatives.  Dr.  Cor-
rigan observes: ]
  Relieve  the serous inflammation, and permit the peristaltic action of the
intestines to return, but  do not force it; look  upon the constipation as  ef-
fect, not as cause.
  Let the first object be, therefore, to  look upon inflammation as the cause
of the constipation in peritonitis,  and  to endeavor  to remove it by the
application of leeches, by blistering, and putting your patient under the
influence of mercury; and recollect Avhat I told you of the  danger of a
rekpse from the use of stimulants of any kind.
  Where accumulations  occur in the colon, their removal  may be advan-
tageously obtained by the introduction once or twice of  the long  tube, as
recommended by Dr. O'Beirne; but it is worse than useless to repeat this 
330
PERSPIRATION--PESSARIES.
process after, and so attempt to force a discharge  of the  contents  of the
intestine.                                              Part xiv., p. 90.
  Peritonitis.—Apply a layer of collodion over the whole surface  of the
abdomen.  (M. Latour.)                              Part, xxv., p. 325.
  Acute Peritonitis  after Abortion.— Chloroform.— Chloroform,  when
given in full doses, either by inhalation or swalloAving, depresses and brings
doAvn the rate of the pulse from 90 or 80 to 70, 60, or less.  This may  be
taken advantage of in some instances of disease,  especially  acute  seroua
inflammations.   Dr. Simpson relates a case  of acute peritonitis after abor-
tion: the pulse was weak  and scarcely perceptible, ranging above 150, and
there ivas little hope of the patient surviving.  Chloroform was given to
relieve the intense pain, when the pulse w-as  found to sink doAvn to 100, or
less, and became stronger and steadier ; and as long as  the action  of the
chloroform continued, the pulse continued  thus greatly loAvered  in rate
and improAred in poAver.   The patient was kept for sixty consecutive hours
under its influence, and the  great abdominal tenderness and tympanitis
were then almost entirely reduced, the patient being in  a much more satis-
factory state.   The pulse never rose again to any very high rate,  and she
recovered nicely.                                       Part x\.,p. 180.

                              ---»-•-•—


                         PERSPIRATION.
  Pure  Tannin,  a remedy  for  Excessive Perspiration.— Dr.  Charvet
relates several  cases  in support of  the  anti-sudorific property  which he
attributes to tannin.  He  prescribed it in doses of from  half a grain, to
two grains, in the form of pill, in the  evening, wdth  or without  opium,
which neither  checks nor favors  its action.  The cases occurred  among
consumptive patients who had arrived at the last stage of the disease.
  They are additional examples of  the activity Avith  which tannin sup-
presses sweating, eAren when the disease from which it arises  is beyond the
resources of our art.                                   Part, hi., p. 53.
  Night Perspiration of Phthisis.  Dr. T. Thompson recommends four
grains of oxide of zinc, and four grains of  extract of hyoscyamus, made
into tAvo pills, every night for a time.                   Part. xxix. p. 92.
   Colliquative Sweating.— In the " Dublin Hospital Gazette " it is stated
that tannin dissolved in the  aromatic sulphuric acid,  or dilute sulphuric
acid, forms a good  combination!  in cases  of colliquative sweating and
chronic diarrhoea.                                   Part, xxxiv. p. 211.
   Vide Art. " Phthisis Pulmonalis."
                         PESSARIES.
  New kind of Pessary.—The great advantage of a pessary of the kind
described and recommended by Mr. Clay, would no doubt be, as he says,
to support the ivomb, and, at  the same  time, Avould  not so distend the
vagina as to render the evil of  prolapsion even  greater than  ever, the
moment the instrument is Avithdrawn.  It is described  as folloivs: 
PESSARIES.
ool
ool
  It consists of a small shield of wood, ivory, etc., of a peculiar shape,
secured to the vaginal entrance by bandages attached to a belt applied
around the body.   To the inner surface of the shield is fitted a strong coi
of steel wire, plated over  with gold or silver, the  dimensions of the coil
bein<* such, that, when worn, the vaginal canal will not be in the least ex-
tended, but with every facility assume its original dimensions. At the end
of the coil is a caoutchouc ring, a little larger in dimension than the coil on
wdiich the os  uteri rests when applied; when it  is weighed with the ute-
rine mass, it should be about the length of the vaginal canal in a healthy
state.   I think a coil, varying from three and a half to four and a hall
inches, will be found sufficient.  To prevent any folds of the vaginal coats
from getting entangled in the  coil, a thin slip of caoutchouc is  proposed to
stretch along the under and outer surface of the coil.
  Advantages over the old Pessaries.—First, The elasticity  of the coil
allows of the free motion  of the body in every possible direction, Avith per-
fect ease.  Second, The vaginal canal not being obstructed, the; catamenia
can flow through the caoutchouc  ring  and along the  coil Avithout any
hindrance.  Third, The dimensions of the coil and ring being so moderate,
no undue pressure can prevent discharges  either  from the bladder or rec-
tum.  Fourth, The laxity of  the vaginal canal  may be removed, and its -
original dimensions restored (the measurements of the coil being not larger
than the vaginal canal in a healthy condition).  Fifth, Local applications
for improving the tone of the parts are facilitated by the opening in  front
of the shield  through Avhich  injections  can be  thrown, and  retained at
pleasure, by introducing  a small piece of sponge,  or plug, into the  open-
ing ;  and the same plan  might be a  protective to females in heated or
croAvded rooms, for sudden appearances of the catamenia. Part iv., p. 119.

   Medicated Pessaries.—Dr. Simpson has been in  the habit of applying a
variety of substances in  the form of medicated pessaries, particularly zinc
and lead ointment, as simple emollients;  mercury and iodine as discutients
(and  particularly the iodide  of lead); tannin, alum, and catechu,  as  as-
tringents ;  opium, belladonna, etc., as anodynes.  The pessaries Avere made
of the size of" walnuts, and could be easily introduced by the patients them-
selves—one or two in the twenty-four hours.  By their use, for instance,
Ave could keep the cervix uteri, when ulcerated  and indurated, constantly
imbedded in  mercurial or iodine ointment for wreeks, and sometimes with
the most marked benefit  and success.  They fulfilled  another  indication in
cases of irritation and inflammation of the mucous membrane of the cervix
uteri and vagina.  They  kept the opposed diseased surfaces from coming
in contact; and it was Avell knoAvn how  important  a matter this Avas in
the pathology of mucous  and  cutaneous surfaces.  They were composed of
the medicine used, mixed up  in the form of an ointment, and brought to a
requisite degree of consistence with one or two drachms of yelloAv Avax to
the ounce of ointment.  After being  made up  in the proper  form, they
were.usually coated by the druggists with a firmer  covering, by dipping
them into an ointment made up Avith Avax and resin, kept liquid by heat.
About an ounce of the different ointments made four balls.
   1. Zinc Pessaries.—R oxidi zinci, 3j.; ceras  albas, 3j.; axungias, 5vj.;
misce, et divide in pessos quatuor.
   2. Lead Pessaries.—R Acet. plumbi, 5ss.; ceras alba;, 3iss.; axungias, 3vj.;
misce. 
332
PHLEBITIS.
  3. Mercurial Pessaries.—R Unguent, hydrarg. fort., 3ij.; ceras flavas, 3ij.;
axungias, gss.; misce.
  4.^ Iodide of Lead Pessaries.—R Iodidi plumbi, 9j.; ceras flavas, Bv.; ax
ungise 3vj.; misce.
  5. Tannin Pessaries.— R Tanninas, 9ij.; ceras albas, Bv.; axungias, 3yj.
misce.
 < 6. Alum and Catechu Pessaries.—R Sulph. aluminis, 3j.;  pulv. catechu,
3j.; ceras flavas, 3j.; axungias 3vss.; misce.
  1. Belladonna Pessaries.—R Extr. belladonnas, Bij.; ceras  flavae, 5iss.;
axungias, 3v.; misce.                                 Part xviii., p. 302.
  Caoutchouc Air-Bags.—One bag may be used either as a pessary in
displacement of the uterus, as a plug in  uterine hemorrhage, or as a dilator
of the os uteri.  On the  same  principle, M. Gariel treats strictures of the
urethra, oesophagus, cervix uteri, etc.; and similarly the nasal fossas might
be plugged  in epistaxis.   In aU cases the  bags are  introduced  collapsed,
and, Avhen introduced, are inflated either by a bag-insufflator or syringe.
                                                       Part xl, p. 240.
                          PHLEBITIS.
   Actual and Potential Cautery as  Means of Preventing and Curing
Phlebitis.—The cauteries employed by Mr. Bonnet are the potassa cum
calce, the chloride of zinc, and the red-hot iron.  The red-hot iron rapidly
applied produces  a very  superficial eschar;  the potassa  cum  calce acts
much more deeply; the pain  in regard to either is  sharp, but speedily at
an end, and the inflammation  that succeeds is trifling.  The chloride of
zinc produces much deeper eschars than  either the red-hot iron or the
potash and lime.  The author  quotes a case of phlebitis folloAving venesec-
tion, and four cases of severe  constitutional disturbance following Avounds
received in dissection, wdiich Avere treated by the hot-iron with immediate
and complete success.  As many as ten cauterizing irons were used at
once in the case of phlebitis, the  subcutaneous cellular tissue being found
hi a semigangrenous state.  In the dissection wounds, the seat of the injury
alone Avas deeply seared; the iron was elseAvhere carried superficially along
the course of the red lines. The author has applied the same method  to
the treatment of hemmorhoidal  tumors and prolapsus ani.  Of  these dis-
eases existing together, he gives four cases which were successfully treated—
one, in part, by means of the potassa cum calce, the rest by the chloride of"
zinc.  He has also found the caustic an effectual agent in treating varico-
cele.                                                  Part viii., p. 165.
   Treatment of Phlebitis.—The principles of treatment, says Mr. Cooper,
are to promote the secretions Avithout loivering the strength, and to allay
irritation.  For these purposes give a combination of  calomel, antimony,
and opium, and a mixture containing liq. ammon. acet., tinct. of hyoscy-
amus, and camphor mixture.   Keep the limb  elevated,  apply  fomenta-
tions and poultices over the Avhole limb, and make punctures through the
skin Avherever it has become tense from effusion; but do not apply leeches.
When the local irritation has been thus subdued, give bark, mineral acids,
porter and nutritious  food, and continue them without fear so long as the
natural secretions are duly performed.                    Part xx., p. 65. 
PHLEGMASIA DOLENS—PHTHISIS PULMONALIS.          333
                   PHLEGMASIA DOLENS.
  Phlegmasia Dolens.—In the treatment of this  affection, says Professor
Simpson, which depends essentially on a toxasmic state of the blood, the
first and most important indication  of general treatment is, depuration of
blood by exciting the various organs of elimination to increased activity,
by their appropriate stimulants.  An emetic, or a mercurial purgative com-
bined Avith ipecacuanha or antimony, may be  given at first, but not  so as
to produce  debilitating effects.  Perhaps  small  and  repeated doses  of
alkaline salts, are, as a general rule, the safest and most efficient remedies
to fulfill this indication.  Tonics and stimulants are rather required than
any antiphlogistic measures, and of these  iron and quinine are the best.
The best local treatment is, to wrap the limb up in cotton wool, and then
incase the Avhole in oil silk, to prevent the escape of the insensible  perspi-
ration ; the limb should be slightly raised in bed.  Toward the end of the
case, a flannel bandage, neatly applied from the toes upward, wdll  greatly
favor resorption.                                      Part xl.,  p. 198.

                              ---•-•-•---

                 PHTHISIS  PULMONALIS.
  Employment of Sea Salt  (Chloride of Sodium) in  Pulmonary Con-
sumption.—M. Latour relates three cases in the human  subject, in wdiich
the administration of salt appears to have been followed by the happiest
results.  In one of the cases, the disease had  gone so far that there was
distinct cavernous rattle with  pectoriloque,  muco-purulent and purulent
expectoration streaked with blood, great emaciation, hectic fever, etc., and
yet the patient made a perfect recovery at the end of a few months,  the
sea salt having been given uninterruptedly  for sixty days.
  The aliment should consist almost exclusively of beef or mutton  grilled
or roasted, of good rich soups, or animal jellies.   Every fine day,  wdien
the sun shines, and during its warmest period, the patient should take gen-
tle exercise in the open air ; and his chamber should be weU aired twice
or thrice a day.   Flannel is recommended to  be worn next the skin.
  Half a drachm to a drachm of the chloride  of  sodium  is administered
daily, either in a glass of beef-tea or in some  pectoral infusion, or if this
should excite cough, it may  be given in divided doses made up into bread
pills, drinking a little beef-tea  afterward.   It is  best to  commence Avith
small doses.  In general, some thirst is at first caused by the administration
of the sea salt, and for this M.  Latour directs a weak infusion  of gentian
flavored with orange-peel.                                Part  i.,p. 21.
  Inhalation of  Conium  and  Iodine.— Advised in  the treatment of
phthisis, by Sir. C. Scudamore:
  R  Iodinii puri,  iodid. potassii, aa. gr. vj.;  aquas destillat. |v. 3vj.;
Alcoholis, 3ij.  M. fiat mistura, in inhalationem adhibenda.
  " I noAV ahvays prefer to add the conium at the time of mixing the iodine
solution with the water; and it should be  a  saturated  tincture, prepared
Avith the genuine dried leaves.   In  the commencement of the treatment, I
advise irery small proportions of the iodine mixture; for  example, only from
half a drachm to a drachm for an inhaling  of eight or ten minutes, to be
repeated tAvo or three times a day.   Of the soothing tincture, I direct half 
334
PHTHISIS PCKJONALIS.
a drachm—which I usually find sufficient; but it may be increased  if the
cough be very troublesome."                             Part, i., p. 30.
  Prevention  of Tubercles.—M. Coster recommends ferruginous  bread,
containing half an ounce of carbonate of tion, to the pound.
                                                        Part i., p. 32.
  Lime Moxa.—Dr. Osborne of Dublin states that in a case of commencing
softening of tubercles, and in another apparently of purulent infiltration
after  pneumonia the  effect  of lime moxa  in putting  a  stop  to the
ulcerative process Avas most decided.                     Part, v., p. 129.
  Phthisis induced by the inhalation of Gritty and Metallic particles.—
Dr. Holland draAVS  attention  to an  ingenious  contrivance  to  prevent the
inhalation of that large quantity of gritty and metallic particles Avhich cause
so much pulmonary disease among the grinders in Sheffield.   Many years
ago  a magnetic apparatus  was contrived which  attracted  the metallic
particles before entering the  nose and mouth ; but this was of no avail  in
attracting the non-metallic substances, and moreover the  grinders would
not be at the trouble to make use of it.  Since that time another plan has
been  suggested and brought into practice, Avhich seems likely to save the
lives of thousands of these tradesmen not only in Sheffield, but also in all
large toAvns where grinding  or filing is carried on, especially among those
mechanics who prepare the different kinds  of machinery  for cotton, flax
and Avoollen manufactories.  "A wooden funnel, from ten to tAvelve inches
square, Is placed a little above the surface of the revolving stone,  on the
side the furthest from the grinder,  and this funnel terminates in a channel
immediately under the surface of the floor;  or we may consider the chan-
nel simply as  the continuation of the funnel, in order to aA^oid any confusion
in the explanation.  The channel varies in length, according to the situation
of the grinder, in reference to the point Avhere it is most convenient to get
quit of the dust.   If w7e suppose that eight or ten grinders  ivork in the
same room, each has his  OAvn funnel and channel, and they all  terminate
in one common channel, the capacity of which is perhaps twice or three
times as great as each of the subordinate or branch channels.  The point
where they terminate is always close to an  external  Avail.  At  this point,
AAdthin the general channel, a fan is  placed, someAvhat  in form like that
used in winnowdng corn,  and to this is attached a strap Avhich passes under
and over a pulley,  so that whatever puts the puley in motion, causes the fan
also to revolve.  The pulley is placed  in connection Avith the machinery
wdiich turns the stone, so that wdienever the grinder adjusts his machinery
to work, he necessarily sets the pulley and  the fan  in  motion.  The  fan
acting at this point, whatever may be the length of any of the subordinate
channels, causes a strong current to Aoav through the mouth of each fun-
nel, wdiich carries along with it all the  gritty and metallic particles evolved,
 leaving the  room in  which the operations are pursued free  from any
 perceptible dust.—When the whole apparatus is perfect and in excellent
 condition, the atmosphere of the place is almost  as healthy as that of a
 draAving-room.                                         Part, viii., p.  32.
    Vomiting, a cure for Phthisis.—It is stated  that 176  patients under
 consumption, 47 in the incipient, and 129 in the advanced stage, admitted
 during  a period of four  years  into the military hospital at Capua, w'ere
 ultimately discharged perfectly cured, their tieatment having consisted in
 the administration of a tablespoonful,  night and morning, of the following 
PHTHISIS PULMONALIS.
335
mixture :  Tartarized  antimony, three  grains ;  sirup of cloves, an ounce ;
decoction of marsh malloAvs,  six  ounces;  mix.   The dose  was  to be
repeated until vomiting ensued.                        Part, viii., p. 80.

  Miner's Phthisis.—[It is Avell known that, besides the diseases to which
we are all  liable, miner's are, from their  occupation, peculiarly subject to
affections of the respiratory  and circulatory  organs.  From a very in-
structive paper by Dr. Makellar on a peculiar form of lung disease, Avhich
may be termed Black Phthisis, Ave extract as follows ; premising that it
is caused by small particles of  coal inhaled, accumulating in the lungs, and
giving rise to irritation, and finally ulceration.   It is thus closely analogous
to the " grinder's disease," " mason's disease," etc., which commit such
fearful havoc  amongst certain of the operative  classes, and have all a
common origin.]
  The rise and progress  of the malady may be thus sketched:  A robust
young man, engaged as a  miner, after being for a short time so occupied,
becomes affected wdth  cough, inky expectoration, rapidly decreasing pulse,
and  general exhaustion.  In the course of a feAv years, he sinks under the
disease ; and, on examination of the chest  after death, the lungs are
found excavated, and several of the cavities filled wdth a solid  or fluid car-
bonaceous matter.
  [Dr. M.'s remarks are upon the disease as it appears among the colliers
in the Lothians, but we believe that  they will apply to others generally.
In the district above named, the ventilation of  the mines is, on account of
their immunity from explosive gas, very  much  neglected.   Hence a  large
accumulation of carbonic acid and other  pernicious gases.   After working
some time  in these ill-ventilated places,  the  lungs  inspire  more  of the
impure air, in order to make up for the  deficiency of oxygen; and every
iioav and then a deep and  sustained inspiration is taken, during which the
floating particles are draAvn in.  When the mine becomes so impure as to
be actually unable to support  a light,  the men are  necessitated to leave it,
until by the gradual accumulation of  purer air, it again becomes capable
of supporting respiration and combustion.]
  It is now known, that  this disease  originates in two principal causes,
viz., First, The inhalation of lamp smoke with the carbonic acid gas gene-
rated in the pit, and  that expired from  the  lungs ; Second, Carbon, and
the  carburetted gases which float in the heated air after the ever-recurring
explosions of gunpowder, which  the  occurrence of trap-dykes renders
necessary.
   [It was long supposed that  the change in color of the lungs ivas a form
of melanosis, a systemic disease,  properly so called.  It  has been lately
proved, however, that the black color is not from any change in the system,
but  is produced by the infiltration of particles of coal, and chemical analysis
confirms the fact.  The minute bronchial ramifications  are first filled, and
the  disorganization gradually extends until the whole lobe is infiltrated,
softening going on in the  meanwhile, from the irritation produced  by the
foreign substance.]
  The first indication of cure, is change of work, and a lengthened sojourn
in pure air.   The folloAvdng indications should also be attended to : To add
oxygen artificially to the hyper-carbonized blood :  To remove the overplus
of carbon  in  the blood, either  directly  or indirectly.  In regard  to the
former of these, I have never ventured on the direct application of oxygen to 
336
PHTHISIS PULMONALIS.
the lungs, because these organs have generally been in an  irritable condi-
tion, and have contented myself Avith recommending the free use of pure
atmospheric  air, and  bathing.   I have  also endeavored to increase its
amount therapeutically, by the exhibition of oxydized preparations of iron,
wdiich I have found most beneficial  in this complaint;  nor has their use
been folloAved by any bad effects, as frequently happens in other diseases of
the lungs.  I endeavored to accomplish the second  indication, chiefly by
alkalies, especially the  carbonate of soda, but the results  Avere by no means
satisfactory.  Small  doses of calomel had no better effect.  It appeared,
howTever, to  act  beneficially when  combined with  jalap, especially in the
first stage of the disease.  The treatment is modified according to the dif-
ferent stages as  follows: In the first, although the physician is seldom
consulted, I recommend, besides the already mentioned hygienic measures,
especially Avarm or cold baths, according as they are borne, and, under cer-
tain  circumstances,  an emetic, and a purge of calomel  or jalap.  In the
second, the same treatment on a more extensive scale ; and, in addition,
carbonate of soda, and  other  alkaline remedies, but more  especially the
extract, aloes, aquos ; rhubarb, cort. rhamni frangulas (especially extolled);
and in summer, the use, four times a  week, of the artificial Carlsbad water,
in so far as the strength of the patient permits.   In the third, I have seen
the most astonishing effects from the continuous use of warm baths, and
the artificial  Carlsbad  water, and after the  cure, and the continued use of
one of the above-named extracts, chosen according to the  individual pecu-
liarity of the case, I have frequently, after a time, had the felicity to see
before me a renovated man.  Preparations of iron are  often here of the
most decided service.   Bleeding,  and the so-called expectorants, on the
other hand, are never of the least use.  Derivative measures are only useful
in relieving the rheumatic pains of the ohest.  The severe  fits of coughing
sometimes also require palliative measures.  In the last  stage nothing can
be done, but by mild restoratives, and a strict attention to diet, to endeavor
somewhat  to prolong life, and strengthen digestion by bitters.  At this
period iron  is especially useful,  particularly the  ferrum  iodatum.   The
tinct.  ferri pomat.  and  the tinct. nervin. bestusch., are also  of signal
benefit, and prolong life for a considerable period.   The painful symptoms
at this period, often  require  numerous remedies, and the daily use of
opium or morphia.   Anasarca generally disappears speedily under digitalis,
squill and other diuretics, Avhich act by producing smart  diarrhoea.  When
structural  change of  the lungs  occurs along with the  melanosis,  little
relief can be afforded.  All that can be  done, is to alleviate some of the
more  distressing  sympathetic sufferings; the  dyspnosa, however, con-
tinues most obstinate,  and sloiAdy destroys the patient.     Part xii., p. 64.

   Use of Naphtha in Phthisis.—Dr. Hastings ascribes  the failure of those
medical men who have been less successful than himself  in the treatment
of phthisis  by naphtha, to one or all of the following causes.   First,  From
a deleterious agent  being employed for a medicinal one.   Second, From
\ts use in cases where it was contraindicated.  Third, From patients being
treated in unfavorable situations.
   He proceeds to say, that cases are continually occurring  in which oily,
milky, and coal-tar naphtha are administered, and  most prejudicial results
ensue.  The preparation recommended by Dr. Hastings is the pyroacetic
spirit, which is obtained by the destructive distillation of  an acetate gene- 
PHTHISIS PULMONALIS.                     337
rally of lead or time, and in its natural form is scarcely distinguished from
pyroxylic spirit.
  The author's test was its colorless  and transparent  character, and its
agreeable ethereal alcoholic odor;  its increase of temperature consequent
upon admixture Avith Avater ; its preservation of appearance on the addi-
tion of nitric acid ; and its taste being Avarm, Avithout the least  sensation
of burning.  Dr. Ure has  recently suggested an easy method of effecting
this object, which is founded on  the  folloAving facts.   If nitric acid of
specific gravity 1.45 be added to  pyroxylic spirit, the mixture assumes a
red color, but no effervescence takes place.  If the same acid be  added to
pyro-acetic spirit, there  Avill be no  change of color, but an  effervescence
wdll  slowly be formed, accompanied by an elevation of temperature,  and
copious evolution of gas, resembling in appearance the action resulting from
the mixture of alcohol with nitric acid, but with an acetic instead of an
ethereal odor.  Pyro-acetic spirit may  also be generally distinguished from
pyroxylic spirit, by its causing no  appearance of milkiness  on mixing wdth
water, in the state in wdiich it is met Avith in commerce.
  Dr. Hocken states that  "the most ready test is to be found in litmus
paper, wdiich is  reddened by the non-medical,  but is  unaffected by the
medicinal compound."
  In stating the cases in which he recommends the  use of naphtha,  Dr.
Hastings  observes, that  the less phthisis  is complicated with other affec-
tions, the more suitable it is for this treatment,  where the pulse is at the
ordinary standard, or thereabouts, where the hectic is slight,  laryngeal and
peritoneal disease absent, the functions of the stomach and bowrels  not
much impaired,  the constitutional disturbance inconsiderable,   and  the
physical signs denoting only a slight deposit of tubercles in one lung—the
prognosis  is favorable, and a speedy recovery  may be anticipated.   In
many cases this mild character of the  disease is never Avitnessed, however
early they may be seen; at the same  time, for want of close observance,
this period  frequently altogether escapes notice; hence success  often
depends upon an early diagnosis  of disease.  If naphtha is employed in
acute phthisis,  Avhere the cough  is very harassing, Avith  slight frothy
expectoration, respirations thirty to forty per minute, pulse a hundred  and
tAventy to a hundred and forty, hot skin, profuse night sweats, great thirst,
appetite deficient, or altogether Avanting, and the physical signs  denoting
an extensive crop of tubercles  in both lungs, it \vill be  found  injurious
rather than beneficial.  If it be employed in chronic phthisis, coexisting
with disease  in other organs, its value  is diminished, in proportion to  the
extent of the complications and their vitiating  influence on the constitu-
tional powers ; if it be continued in certain cases where  improvement  had
followed its use, after the appearance of intercurrent pneumonia, bronchitis,
or pleurisy, it Avould do great mischief.  Many such cases give way to a
short course of treatment with antimony, digitalis, etc.,  and then the pyro-
acetic spirit may be again employed with the greatest advantage.  Where
hemoptysis  is present,  or Avhere  it  has recently existed, naphtha  is
generally contraindicated.  When complicated with dyspepsia, little or no
benefit will accrue from its use until that affection is removed.  The author
has also found that the  disease is  not  amenable to this plan of treatment
when the patients are in crowded  hospitals, or in other situations Avhere
the atmosphere is impure.
  The dose in AA-hich the author appears generally to administer the naphtha 
338                     PHTHISIS PULMONALIS.
is from  ten  to  twenty drops in a small quantity of water three times n
day.                                                   Part xii., p. 7o

  Treatment of Incipient Phthisis.—[The following remarks were made
by Dr. Graves, in an obscure case of pulmonary disease, subsequent to an
attack of fever, and  are  applicable to numerous cases in general practice.
This fever soon subsided under ordinary treatment, but a troublesome and
increasing cough was left behind, which began to keep the patient awake
at night.  This raised suspicion, and an accurate stethoscopic examination
was made of the chest, when on the right side, below the clavicle, respira-
tion was found  feeble, and  mixed with  crepital and  bronchial  rales.
There was nothing to point out Avhether this was an unexpected deposition
of tubercles, or mere bronchitis, with effusion ; and therefore the safe side
was taken, and the patient treated as if tht former were the case.]
  I immediately ordered leeches  to be  applied under the clavicle, to be
repeated as  the exigency  of the  case might  require, and prescribed the
hydrocyanic acid in the form recommended by M. Magendie.  He recom-
mends a drachm of the  cyanuret  of potash to  be dissolved in an ounce of
distilled water. This solution  is stated by him to be equal in efficacy, and
capable of producing all the advantageous  effects  of hydrocyanic acid,  at
the same time  that it is less volatile, less liable  to undergo change, and can
be ahvays  prescribed of the same strength.   He says that it possesses all
the beneficial  properties of hydrocyanic  acid, in  relieving  the  irritative
cough of phthisis, or the excitement wdiich accompanies gastric derange-
ment.  Of  this solution I ordered the patient to take one drop in half an
ounce of water e\rery fourth hour, to be increased in the course of three or
four days to double the  quantity.  On  making an examination this morn-
ing, I find that his symptoms are improved ; there is  less dullness on per-
cussion, respiration is clearer, and the crepitus  is diminished.  On the
ivhole, his condition authorizes us to entertain  hopes of being able to bring
about a cure.  If phthisis  be  curable, or if tubercular deposition admit  of
being resolved, it is only at the very commencement of the disease, and
before that state of  constitution is established  in which there is a tendency
to the formation of tubercular  productions.  If we happen to be so fortun-
ate as to detect phthisis at this early period, I  think that it is possible for
us not only to  palliate, but  also to remove it.   By free and repeated leech-
ing, the use of blisters, a mild diet, and the insertion of one or two  setons
over  the part  dull on percussion, we shall often be  able to remove any
threatening symptoms, and perhaps save the patient's fife. Part xii., p. 71.

   Use of the Seeds of Phellandrium Aquaticum in Phthisis and Chronic
Bronchitis.—Recommended as a Palliative.—M. Sandras  has  published
the results of a careful investigation into its merits, conducted during eight
years at the Beaujon.  He speaks of it  in the  highest terms of praise as a
palliative of the most distressing  symptoms of phthisis;  and believes that
occasionally it  even  exerts a curative agency, and at all events, indefinitely
postpones the progress of cases which furnish all the symptoms of incipient
tubercle. He  is, hoavever, fully aware Iioav deceptive these symptoms often
are, and speaks w ith due caution on this point.  The important agency of
the seeds, however, in relieving suffering in undoubted and advanced cases
of the disease  seems certain ; the days of the  sufferer not only being con-
siderably prolonged, but his  path  to  the grave  materially smoothened.
The good effects generally manifest themselves in from a wreek to a fort- 
PHTHISIS PULMONALIS.
339
night, by a diminution of fever and  diarrhoea, a  return of appetite and
sleep, less dyspnoea, and an easier cough, so that the patient often supposes
himself nearly Avell.  The strength is  supported in this way for a considera-
ble longer  period than it otherwise Avould be ; and Avhen at last it finally
gives way, the course of the disease  then  becomes very rapid.  Chronic
bronchitis is obviously and speedily modified advantageously by this medi-
cine.  It is especially indicated in that form which comes on in aged per-
sons in cold damp weather, and  persists until this changes; and in young
lymphatic subjects, deficient in reactive power, it cuts short  the tedious
cough left by colds.  M. Sandras has found it of no avail in  emphysema
and nervous asthma, except inasmuch  as these Avere connected wdth chronic
bronchitis.                                            Part xix., p. 89.
   Phthisis Pulmonalis.—Manganese has appeared to M. Hannon to be very
useful.  The sirup of the iodide seems to be the best form of administra-
tion in these cases, but the carbonate, phosphate, or sulphate may also be
given.                                                 Part xx., p. 35.
   Hemoptysis, as a Symptom of  Phthisis.—The diagnostic value of
hemoptysis, as a symptom of tubercle, is estimated  very highly by Dr.
Walshe.   It appears that, with the exception of cancer of the  lung, aortic
aneurism, and disease  of the heart,  there are very few cases in which a
material hemorrhage takes place from the lung independently of tubercles.
Xeither those cases  of apparently simple chronic bronchitis, nor those of
irregular menstruation, in which  blood is voided from the  lungs to  any
extent, appear to be exceptions to this proposition, although the tubercles
may remain for a considerable period latent after the occurrence of the
hemoptysis.                                            Part xx., p. 79.
   Intercostal Neuralgia as a Sign of Phthisis—This symptom is almost
constant in phthisis pulmonalis.  Among fifteen  cases  under M. Beau's
observation at the time of writing, it wras  not  absent  in more than one;
and only one of these cases presented the  symptom of spontaneous pain.
The author, therefore, thinks it Avill  prove a useful  diagnostic  mark in
cases Avhere the physical signs of phthisis are marked by bronchitis.   The
predominance of the pain  in the anterior part of the spaces, where the
alteration of the nerves is least considerable, is ascribed by M. Beau to the
cl cumstance that Avhen  a nerve is  diseased in any part  of its course, the
morbid sensibility is  ahvays referred to its peripheric extremity.
   Another form  of  the intercostal neuralgia of phthisical patients is the
pain between the shoulders Avhich has been  so  frequently described as
characteristic of phthisis.                               Part xx., p. 79.
   Treatment of Phthisis.—According to Prof. Bennett, faulty nutrition is
the first element in the production of  the  disease;  and this faultiness con-
sists in an inability of transforming the carbonaceous constituents of vege-
table food into fat, or of  acting upon the fatty matters introduced into the
system so as to render them easily assimilable.  The first  indication of
treatment, then, is' to cause a large amount of fatty matter to be assimi-
lated, by giving food rich in fat.  In most cases, however, the poAvers of
the stomach and alimentary canal are much enfeebled, and unable to
separate this fat  from the food.  It  therefore becomes necessary to give
the animal oils themselves, Avhich will readily enter the system, and become
assimilated: and this is the  rationale of the good effects of cod-liver oil,
which can be digested when no other  kind  of animal food can be taken in 
840                     PHTHISIS  PULMONALIS.
sufficient quantity to furnish  the requisite amount of fat.  The ordinary
dose of cod-liver oil should be a tablespoonful thrice a day, but  it may be
advantageously increased to four, five, or even six.  The kind of oil is of
no importance except as regards the palate.             Part xxi., p.  127.
   Use of Tannin.—-Dr. Alison, of London, would give tannic acid in any
stage of this disease, but  especially  in the third, Avhen  there  are cavities.
The dose may be one, two, or three  grains, tAvice or thrice a day, dissolved
in wTater  or any simple vehicle, flavored with  sirup, wdiich will  cover  the
taste.   If there is much sweating, add a little dilute nitric acid.  Tannin
may be given at the same time as iron, cod-liver oil, or any such means.
                                                      Part xxi., p. 326.
   Phthisis  Pulmonalis.—Do  not let the patient breathe an atmosphere
Avarmed by stove-heat, even  although equable in its  temperature; it is
stated by Dr. J. Hutchinson,  to be  extremely prejudicial.  If the patient
cannot rest at night for coughing, give gr. iv. of the ext. of hemlock, Avith
gr. ss. of ipecac, and  one-eighth gr. of muriate of morphia, at  bed-time.
Immediately on the first suspicion of pulmonary consumption, give the cod-
liver oil, commencing with 3j. for a dose, three  times  a  day, and seldom
exceeding 3iv.  Counter-irritation is of essential  importance;  employ a
solution of §j. of  iodine and iodide  of potass, to |ij. of spirits of Avine.
Use it first on one side and then on  the other, even if one  lung only
is affected.  By  these  measures  the cough  is_ allayed, the weight is
increased, rest is  procured,  and  counter-irritation  is  set up.   Collateral
symptoms must be met as they arise; if hectic fever or hemoptysis appear,
we must suspend the oil.                             Part xxiii., p. 105.
   Use of Cod Liver Oil.—Thinking it  owing to its  non-absorption, that
the  oil sometimes appeared to  lose  its efficacy, M. Loze, a naval surgeon,
combined it with a mucilage containing pancreatic juice, Avhich thus forms
an artificial chyle.  He states it to be thus completely and readily  absorbed,
and  in phthisis its effect more directly obtained.'       Part xxiii, p. 299.
   Diagnosis of Phthisis.—In speaking of  the diagnosis of phthisis, Dr.
Walshe lays down the following highly practical and useful propositions:
   "  (a.)  A young adult who  has  an obstinate cough, which  commenced
wdthout coryza, and without any obvious cause, a cough at first dry, and sub-
sequently attended for a time Avith Avatery or mucilaginous looking expecto-
ration, and  Avho has wandering pains about the chest,  and loses flesh, even
slightly, is,  in all probability, phthisical,   (b.)  If there be hemoptysis, to
the  amount of a drachm even, the diagnosis becomes, if the patient be a
male, and positively free from  aneurism or mitral disease,  almost positive.
(c.)  If, in addition, there be slight dullness under percussion at one apex,
with jerking, or divided and harsh respiration, while the resonance  of the
sternal notch is natural, the diagnosis of the first stage of phthisis becomes
next to  absolutely certain,   (d.) But not absolutely certain ; for I have
known every one of the conditions in a, b, and c, exist  (except hemoptysis,
the deficiency of Avhich Avas purely  accidental) when  one apex  ivas infil-
trated  Avith  encephaloid cancer, and no cancer had been discovered else-
where to suggest to the physician its presence in the  lung,   (e.) If there
be cough such as described, and permanent weakness and hoarseness of the
voice, the chances are very strong (provided he be non-syphilitic) that the
patient is phthisical. (/.) If decidedly harsh respiration exists at the left apex,
or at the right apex behind : if the rhythm of the act be what I have called 
PHTHISIS PULMONALIS.
341
cogged-wheel, and there be dullness, so slight, even, as to require the dyna-
mic test for its discovery, there  can be little doubt of the existence of
phthisis,  (g.) If, with the same combination of circumstances, deep inspi-
ration  evokes a feAV clicks of dry  crackling rhonchus,  the  diagnosis of
phthisis, as far as I have observed, is absolutely certain, (h.) If these clicks,
on subsequent examination, groAV more liquid, the transition from the first
to the second stage may be positively announced.  (i.) If there be  slight
flattening under one clavicle, with deficiency of expansion movement, harsh
respiration, and slight dullness under percussion, without the local or gene-
ral symptoms of phthisis, the first stage of tuberculization cannot be diag-
nosed with any surety, unless there be incipient signs at the left apex also;
the conditions in question, limited  to one  side, might  depend on chronic
pneumonia or on thick induration matter in the pleura   (k.) The existence
of limited though marked dullness under one clavicle, Avith bronchial respi-
ration and pectoriloquy, so poAverful as to be painful to the ear, the other
apex giving natural results, will not justify the  diagnosis of phthisis.  I
have known this  combination when the apex of the  lung ivas of model
health, and a fibrous mass, the size of a Avalnut, lay between the two
latninas of the pleura.   I would even go further, and say, that the combina-
tion in question is rather hostile than otherAvise to the admission of phthisis,
as, had tuberculous excavation formed at one side, the other lung Avould, in
infinite probability, have been affected in an earlier stage.  (I.) Pneumonia
hunted to the supra  and infra-clavicular region  on one  side, and not ex-
tending backward, is commonly, but not  ahvays tuberculous,  (m.) Sub-
crepitant rhonchus, limited to one base posteriorly, is not, as has been said,
peculiar to tubercle ; it may exist in emphysema, and in mitral disease, (n.)
Chronic peritonitis, in a person aged more than fifteen years, provided cancer
can  be excluded,  involves as a necessity, the existence of tubercles in the
lungs.  To this law of Louis it is necessary to add the qualification, pro-
vided Bright's  disease be also absent,  (o.) Pleurisy with effusion, which
runs a chronic course in spite of ordinary treatment, is, in the majority of
cases, tuberculous or cancerous : the character of the symptoms, previously
to the pleurisy, wdll generally  decide  betAveen the two.  (p.) Double pleu-
risy, with  effusion, is not, as has  been said,  significant of tubercle ; for it
may depend on Bright's disease.  If the latter disease  can be excluded,
carcinoma and pyohajmia remain as other possible  causes, (q.) If a young
adult, free  from secondary syphilis and spermatorrhoea, and not dissolute
in his habits, speedily lose flesh without clear cause, he is, in all probability,
phthisical, even though no subjective  chest-symptoms exist,  (s.)  But he is
not by any means certainly so, for  he may have latent  cancer in some im-
portant organs, or he  may have  chronic pneumonia,  (t.) Nay, more, he
may steadily lose Aveight, have dry  cough, occasional diarrhoea, and night
sweats,  and present dullness under percussion, and bronchial respiration
under both  clavicles, and yet  be non-phthisical.  I have known all  this
occur in  cases,  both Avhen the  lungs  Avere infiltrated superiorly with pri-
mary encephaloid  cancer, and wdien they contained  secondary nodules of
the same kind,  (u.) Failure of weight becomes  less valuable as a sign of
phthhis, the longer the thirtieth year has been passed,   (v.) The discovery
of cardiac disease with  marked symptoms, deposes  against, but does not
exclude the existence of active tuberculization.  (10.) The existence of can-
cer in any organ is unfavorable to the presence of tuberculous disease, but
tubercle and cancer may coexist, even in the same lung." Part xxiv.p., 68. 
342
PHTHISIS TULMONALIS.
  Expectoration as a Means of Diagnosis in Diseases of the  Chest.—If
a person with some severe chest complaint coughs frequently,  and expec-
torates only frothy, salivary-looking fluid, says Dr. Theophilus Thompson,
we  suspect  pleurisy; if a glairy fluid  like the white of egg, Ave suspect
bronchitis; if it has a rusty tinge, and resembles gum Avater colored Avith
blood, Ave are likely to find pneumonia.  If there is a sudden gush of pus
in considerable quantity, w^e expect to find that matter accumulated in the
cavity of the pleura has found its way into the bronchial tubes.  In con-
sumption  the expectoration assumes four  characters :  1st, salivary or
frothy;  2d, mucous;  3d, flocculent;  4th, purulent or porraceous.  The
first may proceed from irritation or slight tubercular  deposit.  The  2d
may proceed from a more confirmed affection of the bronchial tubes.  The
3d is peculiarly characteristic of secretion from a vomica modified by the
absorption of its thinner constituents ; and the 4th is indicative of phthisis far
advanced, and (if mixed Avith froth) usually involving  both lungs. N The
black matter often expectorated is not carbon, as commonly supposed; it
is rather a pigment knowm to be formed under slight or not severe forms
of bronchial inflammation.   On a little heat being applied to this expecto-
ration, and  the  microscope used, crystals of  apparently triple  phosphate
may be seen, the proportion of the salts being in an inverse  ratio to the
degree  of inflammation present.   The  3d form of expectoration  men-
tioned above, viz., the flocculent, is  stated to be almost a pathognomonic
symptom of phthisis.   When spat into water it assumes the form of globu-
lar  masses, like little balls of avooI or cotton.   Some of these masses have
subsided, some are suspended at different depths, others float on the surface,
sustained by bubbles of air, entangled in the  surrounding mucus. If the
process of contraction is  going on  in a vomica, a diminished quantity of
expectoration is a  favorable symptom.  This  is promoted  by the use of
appropriate regimen, the administration of cod-liver oil, and by the inhalation
of turpentine.  When the bronchial tubes contribute much to the supply,
the skin being moist and the appetite defective, naphtha may sometimes be
useful, but generally speaking, tannic  acid vs ill  probably be found a more
appropriate remedy.                                   Part xxiv., p. 78.

  Cod-Liver  Oil.—Combine liq. potassas with the cod-liver oil, especially
in the early stage of phthisis.  Where cod-liver oil cannot be administered
internally, says Dr. T. Thompson, it  may be rubbed into the chest, night
and morning, combined Avith a little oil of lavender. If diarrhoea be pro-
duced, one ounce  and a half of cod-liver oil,  four drops of creasote, two
drachms of compound tragacanth powder, and four  and a half  drachms of
aniseed water, form a  suitable mixture, of which an ounce may be  taken
thrice daily.   If vomiting is produced, the addition of creasote often makes
the stomach  more tolerant of the  remedy.  The taste of the oil may be
covered by eating dried orange peel, or by introducing a little dinner salt
into the mouth before or after taking the oil.            Part xxiv., p. 80.
  Hepatic Congestion attending Cases of Incipient Phthisis.—Dr. T.
Thompson gives a combination of chalybeates  ana  saline aperients.  The
natural springs may be imitated by administering tAvo grains of sulphate of
iron, a drachm of sulphate of soda,  a scruple of carbonate of soda, and ten
grains of dinner salt,  in half a pint or a pint of warm water, every morning.
Use at the same time exercise in the open air, the shoAver-bath  and friction
of the skin.                                          Part xxv.,p. 104. 
PHTHISIS PULMONALIS.
343
   Treatment of Cough in Phthisis.—Perhaps there  is no  symptom of
^hich consumptive patients complain so urgently as of cough, and  there
is scarcely any Avhich so often  baffles  our  efforts  for its relief.  Dr. T.   •
Thompson says : If any degree of bronchial inflammation be present, small
doses of antimony are indicated, and in some  instances the application of a
few leeches over the  Avindpipe-affords much  relief.   In  allaying cough in
irritable subjects, much advantage is often derived from the administration
of four  minim  doses of tincture of aconite  in spermaceti mixture; and
counter-irritation may often be resorted to  with advantage.  When the
urgency of the cough has more relation  to the character of the expectora-
tion than to nervous  irritability, lemon-juice  has sometimes seemed to me
to be a useful remedy.  In other similar  cases the solution of potash does
good, especially in combination Avith squill; although this latter remedy, in
cases complicated Avith any degree of bronchial inflammation, would pro-
bably aggravate the symptoms.
  Anodynes, such as hemlock, henbane, Indian hemp, are occasionally use-
ful, and there can be no doubt of the A'alue of hydrocyanic acid.  A draught
containing an eighth of a grain of cyanide of potassium, an ounce of aniseed
water, and some sirup of lemons, is perhaps more trustworthy than prussic
acid in the usual form of administration.  In  a  great number of instances,
however, we are obliged to place our chief reliance on opium, or on  some
of the  salts of morphia.   An agreeable linctus may be  composed of an
ounce of conserve of roses, half an ounce of lemon-juice, half an ounce of
sirup of poppies; or a drachm of tincture of opium and a drachm of diluted
sulphuric acid may be mixed Avith an ounce and a half of treacle or honey,
and a teaspoonful given occasionally.
   You  have had an opportunity of observing the relief often derived by
inhalation:  an  ounce and a half of the  strobiles of hop in a pint of hot
Avater sometimes proves very soothing.   Some of our patients have derived
still greater advantage from inhaling twro grains of  extract  of opium, by
means of the apparatus introduced by Dr. SnoAA'. On the Avhole, hoAvever,
no remedy has acted so promptly and satisfactorily in  allaying cough, as
the inhalation of fifteen or twenty minims of chloroform.
                                                   Part xxv., p. 106.
  Lungs,  Affections  of—Iodide of Potassium.—Mr. Molloy says  that
when the period of acute inflammation has subsided in broncho-pneumonia,
pneumo-bronchitis,  chronic bronchitis,  pituitous  catarrh,  and  in  dry
asthma,  iodide of potassium is an exceedingly valuable remedy, although
the theory of its beneficial influence is somewhat obscure. Part xxv., p. 108.
   Urate of Ammonia Ointment in Phthisis.— Vide Art. "Ammonia."
  Tannate of Quinine in the Night-Sweats of Phthisis.—M. Delioux has
administered tannate of quinine with the effect of arresting night-sweats in
cases  of pulmonary consumption.   He says that, thought  is sometimes
inferior  to pure tannin, it is superior to disulphate of quinine ; and that it
combines the action of a tonic and antiperiodic. He gives it in powder, the
quantity taken daily  being from half a gramme to a gramme (seven  and a
half to fifteen grains), in three or four doses,  taken at intervals during the
afternoon  or evening, so that the last may  be administered  three oirfour
hours before sleep.                                  part xxviii.? p> 90.
  Creasote Inhalation.—To relieve the  cough, Dr.  Inman,  of Liverpool,
places from four to ten drops  of creasote in  the bottom of an  old teapot 
344                     PHTHISIS PULMONALIS.
and then pours a small quantity of boiling water over it.  rIhe vapor must
be inhaled through the spout, which must be protected by being covered
with a little flannel.                                  Part xxvm., p. 92.
  Appearance  of the  Gums in Consumption.—Dr. Thompson  remarks :
" Considerable attention to this inquiry has impressed me Avith a conviction
of the frequent existence in consumptive subjects, of a mark at the reflected
edge  of the gums, usually deeper in color than  the  adjoining surface, and
producing a festooned appearance; this mark  is in some persons a mere
streak; in others, a margin, sometimes more than a line in breadth.  In
the most decided cases, this margin  is  of a vermilion tint,  inclining  to
lake."
   [This  streak on the gums, Dr. Thompson states, is often among the
earliest signs of pulmonary consumption.   In reference to the value of this
sign as an aid to diagnosis, Dr. T. observes:
   *' When in either sex it coincides Avith a pulse not materially  altered in
frequency by change from the sitting to the standing posture, the presence
of phthisis may, A\tih high probability be assumed, even before having re-
course to auscultation."
   Cocoa-Nut Oil as  a  Substitute for  Cod-Liver  Oil.—Dr. Thompson
says :  " Among the patients to  whom cocoa-nut oil  Avas given, there were
some instances of arrested phthisis, as decided as any I have been accus-
tomed to attribute to the use of cod-liver oil, over which it  possesses  ad-
vantages in reference to economy and palatableness; and it is interesting to
remark that its efficacy was experienced  by some who had previously taken
cod oil uselessly, and by others Avho  had discontinued it on account of
nausea."
   Treatment of the Diarrhea  of Phthisis.—In the diarrhoea of phthisis,
Dr. Thompson employs trisnitrate of bismuth in doses of five grains, com-
bined w tih three grains of gum arabic and tAvo of magnesia, every four or
six hours.
   Night Perspirations  of.—Give four  grains of  oxide of zinc, and four
grains of extract of hyoscyamus, made into two pills, every night for a
time.                                                Part xxix., p. 92.
   Palliative Treatment of Phthisis—Profuse expectoration of.—To check
this give creasote, pyro-acetic  spirit, infusion of pitch, or balsam  of tolu;
but by far the  best remedy, says Dr. T. Thompson, is petroleum or Barba-
does tar, which often moderates the cough and expectoration remarkably.
   Diarrhea of.—Give the trisnitrate of bismuth, combined Avith gum and
 magnesia, or wdth  Dover's powrder.
    Cough of.—Mix  one  part of chloroform with three parts of spirits of
 wine, and let the patient inhale when necessary, but Avith caution, and under
medical direction.  The inhalation of camphorated spirit is often sufficient,
 or even the vapor of hot water, or infusion  of  hops.   Sometimes  frequent
 deglutition, as the swalloAving  of a little  oil, will relieve the cough.  Some-
 times four minims of tincture of aconite is a good palliative.
   Night Sweats of.—Give  gallic or acetic acid.  Dip the night dress in sea-
 water, or salt and wrater, and dry it before  using.  But the best remedy is
> four grains of oxide of zinc at  bed-time, combined with a little  henbane or
 hemlock.                                             Part xxx., p. 45.

    Night Sweats in Phthisis.—Mr. Hutchinson, of the City Hospital for 
THTHISIS PULMONALIS.
345
Chest Diseases, shows that night sweats in this disease may be checked with

^tjiider'the usual treatment of phthisis (full diet, cod-liver oil, and tonics),
the tendency to night perspiration often ceases spontaneously. If it becomes
desirable to expedite the process, it may be done by the sesquichloride of
iron, the mineral acids, or, best of all, by the gallic acid.   The following is
the prescription for a night-draught containing the latter:
  R Acidi gallici, gr. vij.; morph. acet.,  gr. £ ; alcohol q. s. (a few drops);
syr. tolutan., 3ss.; aqua?, §j.
  The night-pill, as we find it in the Pharmacopoeia of the Brompton Hos-
pital for Consumption is:                                      _,....
  R Acid, gallic, gr. v.; morph. hydrochl., g. } ; mist. acac. q. s. Ft.pil. ij.
  It is also of advantage to adopt an  astringent regimen as far as  conve-
nient.  The patient should be directed to sleep  on  a mattress, alone,  and
not heavily clothed; he should Avear no flannel in bed ; as dry a diet  should
be taken as conveniently can be borne, and fluid should be especially avoided
in the latter half of the day, none Avdiatever being allowed later than seve-
ral hours before bed-time.                              Part xxx., p. 49.

   Remedies in Phthisis.—[In a visit to the Brompton Hospital, the writer
notices some of the remedies Avhich are there used.   He  says :]
   Among a few of the medical novelties wTe noticed, and which are found
useful at Brompton,  are divers forms of inhalations:  one an inhalation of
hydrocyanic acid vapors, of course in small quantities ; inhalations  of chlo-
rine and inhalations of the chemical substance chloroformyl, inhalations also
found very useful of conium and creasote.
   A mixture of tannin, nitric  acid, and lupulin is  very valuable in the
night sweats of the Avorst cases; the oxide of zinc also is found to answer
wonderfully in some cases Avhich will even resist acids and tannin;  as prac-
tical facts not generally known, these valuable results cannot be too gene-
rally made public.
   A mixture of decoct, hematoxyli and aqua calcis,  not very chemical but
very valuable, is used in diarrhea.   A solution of iodine as a caustic,  how
general in hospitals,  is also found most useful for painting  the chest;  it is
simply one part each of iodine and the iodide of potassium and two of rec-
tified spirit.   Dr. Quain also finds  a  solution  of nitrate of silver to act
almost "like a charm," wdien applied in some cases wdth a  probang to the
top of the larynx and to the vocal chords.
        ********
   Treatment  of Irritable Stomach  in Phthisis.—Give hydrocyanic acid
and trisnitrate of bismuth, as in the folloAving formula:  Hydrocyanic  acid
three minims ; trisnitrate of bismuth ten grains.  Make this into a draught
with mucilage and green mint tea, and  give it three times a day.
                                                      Part xxxi., p. 84.
   Tubercular Infiltration.'—According  to Dr. C.R. Hall, greyness indicates
that the exudation is chronic ; yelloAvness, that it is acute ; jelly-like con-
sistence, that it is recent.  The grey infiltration  takes place while  there is
yet a fit state of blood to pour out contracted plasma; the yelloAv points to
a deteriorated condition of the blood when the disease has injured  the con-
stitution ; the jelly is a still later exudation, and takes place toAvard the
close of life, when the blood is very poor and unable to furnish a coagulated
lymph.                                                Part xxxii., p. 70. 
346
PHTHISIS PULMONALIS.
  Dyspepsia preceding and attending Phthisis.—Mr. Hutchinson, surgeon
to Metropolitan Free Hospital,  says: The severity of the tubercular dys-
crasia, may be measured by the facility Avith wdiich fats, oils, sugar, etc.,
are  relished and digested.   IT a patient has  acquired a liking for cod-liver-
oil and other kinds of fat, the disease is in abeyance; and the most ominouB
symptom of all is Avhen the patient quickly loses  all relish for such things.
In all cases accustom the patient to oils and other fats ; if the stomach will
not bear them, give tonics, AAdth an alkali or mercury in small doses and
with great caution, until the stomach is improved ; then give freely hydro-
carbons, such as pork  chops,  bacon,  butter, cream,  sugar, dried  fruits,
alcohol in various combinations, etc.                    Part xxxii., p. 94.
  Phthisis.— Vide Selections  from Favorite Prescriptions, Art. " Medi-
cines."
  Phthisis.—Dr. Addison believes it  to be nothing more than the  acute
stage of strumous pneumonia.  Mere tubercles may lie dormant for years,
if inflammation of an active kind be not set up.        Part xxxiii., p. 96.
  Phthisis.—Dr. Bullar states that Ave  may often very materially soothe
the passage to the grave by the cautious administration of small doses of
opium.  If the patient be anxious, restless,  tossing about, and breathing
very bad, etc., by giving a Asav drops of the liquor opii sedativus every ten
minutes, the patient \Arill become calm, tranquil, and Avill die quietly.
                                                   Part xxxiv., p. 272.
  Tuberculosis.—The proximate cause of the tubercular diathesis, accord-
ing to Dr. J. F. Churchill, is the decrease in the system of the  phosphorus
Avhich it contains in an oxygenizable state.   Therefore give some prepara-
tion of phosphorus in the lowTest possible degree of oxidation, and,  at the
same time, one  Avhich may be directly assimilated: such a remedy is the
hypophosphite of soda, or lime, which should be given in doses of from ten
grains to a drachm to adults in the tAventy-four hours.  The general  symp-
toms will rapidly disappear.                           Part xxxvi., p. 55.
   Chronic Phthisis.—Dr. E. Smith,  of Brompton Hospital for Consump-
tion,  says : There are various conditions of the throat met with in phthisis.
In the  earlier stages the  patient  complains of dryness of  the throat  and
cough,  and, on examination, the throat is  found smooth and shining, and
the parts  attenuated.  It is  a state of lessened tonicity without  inflam-
matory action.  A useful means of treatment here is the application  of a
mixture of equal parts of chloroform and olive oil, by means of a large
brush ;  the patient  should also frequently swallow about  a tablespoonful
of a strong solution of suet in milk; great relief is obtained from the ap-
plication  of a strong solution of nitrate of silver to the fauces by means of
a large brush.  When the case is more advanced, an  inflammatory state
appears, wdth distended vessels and enlarged mucous follicles, chiefly upon
the pharynx, but also  on the uvula.   This state, and  also Avhere there is
ulceration and fibrinous exudation, is  best treated by the nitrate of silver.
When the inflammation runs high and  extends down the larynx, the ap-
plication  of nitrate of silver  often causes alarming symptoms  of choking;
the best topical application is then equal parts of oil  and liquor potassa?
well laid  on Avith a large brush.                      Part xxxvii., p. 68.

   Use  of Ergot of Rye.—A case is related by Dr. B. P. Stnats, of Albany, 
PHIMOSIS.
347
New York, in which the expectoration, the diarrhoea, and other symptoms
of relaxed fibre of atonic sympathetic  nervine  system, seemed to be con-
siderably relieved by the administration of small doses of ergot ot lye.
This was continued with small doses of ipecacuanha and morphia.
                                                  Part xxxix., p. 9J.
  Carbonate of Lead—M. Beau observes, that it is  extremely rare that
a ca*e of phthisis is found amongst workers in lead,  and  accordingly re-
commends a trial of this mineral in cases of threatened phthisis.  He ad-
ministers from two to sixteen grains of carbonate each day in pill, sus-
pending the use  of it as soon as the patient  appears to  be sufficiently
impregnated.  The patient must  be supported by nourishing food, wine,
tonics, and causing him to observe all the rules  of a rational hygiene.
                                                      Part xl., p. 55.
  Ozonized Oil.—It is found, says Dr. T. Thompson, that  the administra-
tion of ozonized  oils has a  remarkable tendency to reduce the frequency
of the pulse.  It was administered to  fourteen patients.   In two no such
effect was observed;  but in the larger proportion of the  remainder the
effect was very considerable, in some cases to the amount of tAventy beats.
Oils may be ozonized  by exposure for a considerable time to  the direct
ravs of the sun, after previous saturation with oxygen gas.
                                                     Part xl., p. 294.
                          PHIMOSIS.
  Treatment.—Mr. Key considers it unadvisable to cut away a portion of
prepuce in a state  of active phagedena, or even  Avhen  ulceration has
stopped and has left the surfiice covered with a white slough.
  [In many cases] the excessive action seems to have nothing of a specific
nature : it appears to be a common attack of inflammation,  ending in gan-
grene, the poisoned sore acting merely as  an  exciting cause;  for as soon
as the slough is  cast away, the  sore puts on a healthy appearance, and
heals quickly under the application  of astringent dressings.
  When the inflamed part is under the influence of the specific poison, the
operation  of dividing the prepuce, instead of staying it, as it does  in the
case of simple gangrene, seems for a time to increase it, by adding to the
inflammation.  Exposure of the  sore, however, is indispensable for the
preservation of the glans, and should be performed as soon as the unhealthy
nature of the sore is ascertained."  This can be known by observing the
nature of the  discharge, Avhich changes from the common secretion of
chancre to a dirty reddish or brown fluid, mixed wdth fine  shreds of white
slough.  The nature  of the secretion may of itself determine the propriety
of dividing the prepuce; but more especially will it  be required, if there
be also much inflammation proceeding beneath the skin.  The best dress-
ing for sores of this phagedenic character are the balsams, or turpentine,
with the addition of opium if sev. re pain or extreme irritability demand it.
When they are disposed to bleed, warm olive-oil, mixed Avith an equal part
of turpentine, cheeks  the hemorrhagic tendency, without increasing the
inflammation or irritation of the part.  This application is most efficient
when the specific action does not predominate, and agrees best  Avith  a
sore in Avhich the action approaches to  the black slough.   When the pha- 
348
PHIMOSIS.
gedasnic action is maintained by a high degree of local  and general irrita-
bility, equal parts of Peruvian balsam and the sedative solution of opium
form  a most effective application.  When the part can bear it, lint steeped
in equal parts of port-ivine and tincture of opium Avill sometimes check the
ulceration, and induce a healthy surface.
  The operation for phimosis presents but little choice: the mode of ex-
posing the glans must be regulated by the state of the prepuce, and by the
situation of the sore that is required to be exposed.
  The main point in practising is to extend far enough the division of the
inner  layer of skin ; and, Avhen circumcision is first performed, advantages
va ill be obtained by turning back the angles of the divided inner layer, and
uniting  them by means of very fine sutures to the edge of the outer layer
of skin. This proceeding shortens the process of cicatrization, and lessens
the deformity.                                         Part ii., p. 100.
  Aphorisms of Practical Surgery.—It is not prudent to divide the fras-
num for phimosis  during the existence of a  gonorrhoeal discharge, as the
wound is then apt to degenerate into a troublesome ulcer.  (Dupytren.)
                                                      Part iil, p. 116.
  Belladonna.—In case3 of  phimosis  and  paraphimosis,  it has  been
suggested to use an application of belladonna to the part, before resorting
to the knife.   An ointment, composed of thirty parts of cerate and twelve
parts  of extract of belladonna, should be rubbed hourly on the prepuce in
cases  of phimosis, and  on the glands in cases of paraphimosis.  If  great
inflammation exists, a little opium may be added, and less belladonna.
                                                      Part vii, p. 215.
   Operation for Phimosis.—M. Ricord's plan.   The penis  is  allowed
to remain in its natural position, and no traction is used.  A circular mark
is made Avith ink upon the prepuce, about tAvo lines anterior to  the base
of the  glans, and  parallel to  the  corona: a  long  and strong needle, its
point covered with a wax bead, is then introduced  betAveen the glans and
prepuce, and  made to pierce the whole thickness of  the latter, on  the
mesial line, and a little in front of the circular mark.   The mucous  mem-
brane and skin of the prepuce are thus fixed, and the needle is alloAved to
remain.   Behind it, and in a longitudinal direction, a fenestrated  forceps,
wdth notched edges, is then firmly applied.   The fenestras of  the instru-
ment  correspond to the circular mark  and the glans : at this stage of the
operation  the latter is to be pushed backAvard.  The  next step is to pass
sutures, five  or six in number, through  the  fenestras; and, Avhen all the
threads are applied, the  prepuce is  shaved  off Avith a bistoury made to
glide  between the needle and forceps.  The latter is then withdrawn care-
fully,  so as not to disturb the ligatures.   The assistant should be desired
to press the forceps very tightly when the prepuce is being shaved off: if
this be neglected, the prepuce  will  yield, and the sutures will be cut.
When the forceps is_ removed,  the  arteries  ivhich are noticed  to  bleed
should be  tied or subjected to torsion; the threads which pass above and
below the glans are then divided  in  their centre, and the respective ends
of each  half resulting from this section are tied, to bring the mucous mem-
brane in contact wdth the skin.   Of course there will be twice  as  many
sutures  as there were threads passed.
   Treatment.—We should, after this operation, enforce rest, Ioav diet, as-
persions of cold  water, and  camphorated pills; union by first  intention 
pills.                             349
rarely takes place completely.  The submucous  cellular  tissue will gene-
rally he found infiltrated with serosity on the next day, but it is gradually
re-absorbed.  The sutures ought to be removed on the fourth day ; they
might,  if left longer, lacerate the tissues.  The parts are usually healed up
by the  tenth or fifteenth day, excepting in those cases where the union by
first intention takes  place as early as the fourth or fifth. Part xvii., p. 187.

  Operation of Phimosis.—Mr. Colles'  plan.  I seize the edge of the
prepuce, at its fold forming the narrow band, in the left hand, and holding
the scalpel in the right, and  at right angles with the penis, I remove a cir-
cular portion of skin about a quarter of an inch wdde.  The outer fold of
skin being  loose, is  then drawn back »n the penis, leaving the glans cover-
ed by the inner and  tighter fold.   I then divide this layer about half way
back, more-or less, slitting it up exactly in the centre, by passing a sharp-
pointed bistoury under it.   We have now the outer fold of  skin loose,
Avith a  large circular orifice; the  inner, or more contracted portion, pre-
senting also an orifice, but larger  by double the perpendicular incision,
which forms tAvo angular flaps.  I then turn these flaps outAvard, and by
a suture attach each angle to the  edge  of  the external  skin, at  about a
quarter of its circumference  from  the frasnum; a slight suture  at the fras-
nura completes the operation.  I then  draw all forward so as to cover the
glans.  In tAvo or three days I remove the sutnresj and generally find the
wound healed, leaving a covering for the glans  differing in no respect from
the natural and perfect prepuce.                       Part xix., p. 173.
                             PILLS.
   Pilula Hydrg. Protoxydi.— Vide Art. "Antimony."
   New mode of making a Ferruginated Pill of Mercury.—In Dr. Collier's
second edition of the " London Pharmacopoeia," he gives the outline of a
formula for preparing blue pill Avdth sesqui-oxide of iron.  It is as follows •
   R Ferri  sesqui-oxydi, 3j.; hydrargyri,  5ij.;  confect. rosas Gallic*, 3iii\
Contere donee globuh non ainplius conspiciantur.
   It is made in five  minutes; common  blue pill demands a week   The
globules are not visible,  even  by the microscope.  It  is uniform  in its
appearance and effects.  It makes a smoother pill, retaining its  form more
permanently.  It salivates in a few days in the usual doses.  The presence
of the iron prevents the wear and tear of the human body under the effects
of the mercury.   It is particularly eligible for the strumous, the irritable,
and  for reduced  anemial  constitutions  requiring mercury.  The  powers
of life are  not  so much (scarcely  at all) prostrated under  its use.  Its
resolvent power is greater  than that of mercury  alone, especially with
respect to buboes. Practitioners will at all events  know what they  are
using ; at present they have for blue pill all manner of alloys and sulphurets-
meivunal-zinc pill, m-retinal-sulphur pill, etc.           J part Yn.,p.89.

c^C0J\PlVs °%^tract %Gopaibawith Gelatine.-The process  m!
Garot adopts, is as follows:   Fix the pills on long fine  pins; plunge them
into thick purified glue placed m a hot-Avater bath; then  remove them by
t\^kry motlon'.and1stlGkih.e PfS ™ Paste sPread out on a slab,  so that
the pills may remain  elevated m the air; as soon as  fifty are thus treated. 
350
PLACENTA.
rotate them individually in the heat of  a taper,  to  harden the external
pellicle;  pull out the point of the pin, and the process is complete.
  It is applicable to every substance capable of a pilular consistence ;  such
as balsam, camphor, musk, assafostida, mercurial and  ferruginous  prepar-
ations, etc. Tavo hundred pills can be coated with gelatine in an hour, and
will be ready for use after the lapse of tAvo hours.   The pilular mass so
coated remains soft for a much longer time than according to any other plan.
                                                      Part xiv., p. 138.
  Preparation of Blue Pill.—Mr. Stoddart gives the folloAving directions
for the easy and rapid preparation of blue pill.  By this process, he states,
that a pound of the pill mass  may be obtained in an  hour,  so perfectly
prepared, that no  metallic globules  are  visible, even with a Coddington
lens :  "  Triturate  the  mercury  with the powdered liquorice  (adding a
small quantity of distilled or rose water),  till the  globules are quite im-
perceptible ; the confection of roses  is  next added,  and all  well  mixed.
The  rapidity Avith which  the liquorice ' kills'  the  mercury  is really
astonishing to one accustomed to  the old way of rubbing  the  metal  with
the conserve."                                       Part xxxiii., p. 294.
   Honey as an Excipientfor Pills.—M. Thibault believes that much of
the disappointment following  the employment of pills arises from their, as
ordinarily prepared, acquiring a degree  of induration that prevents  their
solution, and enables them to traverse  the  alimentary canal unchanged.
To prevent this he recommends the employment of honey ; pills prepared
wdth it always remaining soft, however  long they may be kept.
                                                     Part xxxv., p. 307.
   Excipient for  Pills.— Mr. Martin  suggests,  as  preferable to honey,
which has been recently recommended as an excipient for pills, the employ-
ment of treacle, Avhich is far  easier of manipulation,  a much less  quantity
being required.  Pills so prepared last soft and flexible for years.
                                                    Part xxxvii., p. 250.
                               ---•-*-,---

                            PLACENTA.
   Incarcerated Placenta—Incision of the Os Uteri in Cases of.—It  some-
times happens that the placenta is separated from the uterine parietes, but
is confined within its cavity, in consequence of the  os being firmly and
rigidly  contracted.  This state is what is  termed incarcerated placenta,
and differs from the ordinary forms of irregular contraction of the uterus,
in the contraction being more limited to the os and cervix.
   The result of these cases is most generally fatal, the patient dying from
the  effects of  typhoid fever, probably excited  by  the  putrescent mass
retained in the system.  When a portion of the placenta only is retained,
a purulent discharge consequent upon inflammation is sometimes  secreted,
by the living membrane of the uterus, and by wdiich the  particles of the
intruding body are carried off.
   In such cases after all the ordinary means have been tried in vain,  and
death seems certain, as a last  resource, before the poivers of life wrere too
far exhausted, would this operation  be admissible ?
   Mr. Power gives the following directions for  the performance of  this
operation.  The patient should be placed on her left side, close to the edge 
PLASTEES.
351
of the bed, as ;n the ordinary obstetric position, the forefinger of the  left
hand should then be carried to that part of the os  or  cervix  intended to
be cut, and a probe-pointed knife or bistoury conveyed cautiously  along
the finger in the vagina to the point mentioned, at Avhich the os or  cervix
may be divided.  This is done by gently insinuating the point of the  in-
strument Avithin the os, and pressing its cutting edge against the rim  on
each side, in the direction in  which it is intended to be incised, the parts
Avill give way readily before it:  and then cautiously  giving  the blade a
withdrawing motion, the openings may be enlarged as much  as may  be
deemed advisable.   The bladder should be previously  emptied, and  if the
incision be brought forward great care should be taken to avoid  its neck.
The liquor amnii will escape after the first incision,  and if the  uterus  act,
the case may then be left to nature.                      Part ii., p. 151.
   Placenta retained Eleven  Weeks.—This case is interesting in connection
Avith the question Avhich  has been  much debated, of the  occurrence or
non-occurrence  of absorption of the  placenta in cases where it is retained
for a considerable time in the uterus.
   A poor woman, 37 years old, having overexerted herself, was taken in
labor in the fifth month of her second pregnancy.   A midwife  who  was
summoned tore the funis in her endeavor to remove the placenta, and an
accoucheur who was then sent for could not succeed in extracting it.   The
Avoman noAV resumed her usual occupation till she was compelled to seek
medical advice by the occurrence of hemorrhage from the uterus.
   Ten Aveeks after her miscarraige she  applied  to Dr.  Scholler, who on
making a vaginal examination found the cervix uteri thick, the os sufficiently
open to admit the finger, and the uterus itself felt  large and  as  though it
contained a foreign body. The Avoman Avas ordered to remain in bed, and to
take gr. x. of ergot of rye every two hours.  After the administration of
twelve doses, pains like those of labor came on,  and Avere followed  by the
expulsion of coagula  mixed Avith fibrous and membranous  matters, and
having a very offensive odor.
   Dr.  Scholler noAV fancied that the case was at  an end, and supposed that
this was an instance of real absorption of the placenta, but after the lapse
of some  days, having adminsterea a purgative, pains  came on in  the ab-
domen and recurred periodically for some hours,  until  a  thick  mass  was
expelled from the uterus.  This  mass  Avas ascertained to be  the placenta,
wdiich had not undergone the slightest decomposition, was hard, surrounded
by a coating of fibrin, and shrunk to  the size  of half a goose's egg.  On
a section it presented the peculiar structure of the placenta.   The  patient
did well.                                              Part vl, p.  167.
   Placenta Previa.-^- Vide Art. " Labor."

                               —•-*-*—


                            PLASTERS.
   Isinglass Plasters.—Mr. Liston has for many years been in the habit of
using, after operations, and for other surgical purposes, a plaster consisting
of oiled silk covered Avith a coating of isinglass.
   The folloAving is the method of preparing it:   Moisten an ounce of isin-
glass Avith two ounces of Avater, and alloAv it to stand for an hour or two
until quite soft; then add three ounces and a half of rectified  spirit, pre- 
352
PLASTERS.
viously mixed Avith one ounce and a half of Avater.  Plunge the vessel into
a saucepan  of boiling wTater, and the solution will  be complete in a few
minutes.
  Having stretched the oil silk on a board, by nailing it round the edges,
apply the solution of isinglass Avith a brush, taking care to move the brush
evenly, and in the same direction, making it smooth  as you proceed—as in
varnishing a picture.   When quite hard and dry, apply another layer, in
the same manner, but moving the brush in  the opposite direction, in one
case horizontally, and  the.other  perpendicularly. In  this manner apply
four coats of the solution, or e\~en a fifth, if the surface  be  not  entirely
smooth.   The last layer should be reduced in strength by the addition of
a little more water and spirit.  An ounce of isinglass is sufficient for about
a square yard of the plaster.
  The following precautions should be preserved:   The distance between
the nails should not be more than an inch and a half, otherwise the oil silk
will shrink  in festoons, and wdll  not  remain flat. The isinglass must be
Avell soaked in water before the spirit is added, otherAvise it wdll not make
a complete  solution : and the spirit,  Avhen added, must be diluted with a
portion of the Avater, to prevent precipitation of the isinglass.   The brush
must be a flat " hog tool," such as is  used for spirit varnish, and Avell made,
otherwise the hairs wdll be found to come out, and this is an inconveni-
ence,  as the  operation must be performed quickly,  while  the  solution
is ivarm.  The solution, when cold, should be of the consistency of blanc-
mange.
   The oil silk has  been in  a great measure  superseded by the use of a
membrane, consisting  of the peritoneal covering of  the cecum  of the ox.
 rubbed  down, and carefully polished in the manner  in which the  com-
 mon goldbeater's skin is prepared.   The following  is  the report of this
 plaster:
   From the extreme thinness of the plaster, the wounds can be examined
 without its removal.   It adheres much better than plaster made with isin-
glass spread on silk; and in the  first  instance of its application becomes
firmly fixed.  It is difficult to fix the isinglass plaster spread on silk, unless
it is very good.  From the extreme tenuity of the membrane plaster, it is
equally unirritating wdth goldbeater's skin ; and Avhen once applied it re-
mains so accurately adherent, that it does not require to be  changed fo;
many days.  Altogether, after a good deal of  experience in all the dil
ferent plasters, Ave find it the best uniting material that has ever been pro-
duced.
   In applying the isinglass to the membrane plaster, the directions already
mentioned, wdth reference  to the oil  silk, may be observed, but a layer
of drying oil is spread on the other side of the membrane.  Part iv., p. 106.

   India-rubber Court Plaster.—Mr. RoA\dand  submits the  folloAving as
the best method of making india-rubber court plaster^wA^cA does not wash
off:
   A stout frame  of wood  must be made, about three yards long (or any
length that Avould be most convenient), and about one yard and a quarter
Avitle.  Within this frame must be placed tAvo sides  of another frame, run-
ning longitudinally and across, so fixed in the  outer frame that  the tAvo
pieces may slide, independently of each other, backAvard and forAvard about
 six inches.  Tapes of canvas must be tacked around the inside of the inner 
PLASTERS.
353
 frame, and the  corresponding sides of the  outer frame,  so  as to form a
 square for the material to be seWed in;  Avhich, Avhen done, the tAvo loose
 frames must  be draAvn tightly to the outer, by means of a tAvine  passed
 round each, in order to stretch, perfectly free from irregularities, the silk
 or satin previous to laying on the composition.
   To  make india-rubber plaster:  Dissolve india-rubber  in  naphtha, or
 naphtha  and  turpentine, and lay it on with a brush,  on the opposite side
 of that which is intended for the plaster, and Avhen perfectly dry, and the
 smell in a great measure dissipated, it will be ready for the adhesive mate-
 rial ; to make wdiich, take  equal parts of Salisbury glue, or fine Russian
 glue, and the  best isinglass, dissolved in a sufficient quantity of Avater over
 a water-bath,  and laid on with a " flat hog tool " Avhile Avarm.  It is requi-
 site to use great caution in spreading the plaster evenly, and in one direc-
 tion, and a sufficient number of coatings must  be given to form a smooth
 surface, through wdiich the texture of the fabric is not perceptible.  Each
 coating should be perfectly dry before the succeeding one is given, and
 placed in a situation free from dust, and Avhere a draught of air would^ faci-
 litate the drying.  The quantity of water used,  and the Aveight of the two
 materials, must be a little varied according to the season, and the gelatine
 strength they possess.
   Lastly, the plaster being ready to receive the  polishing coat, which gives
 also the balsamic effect to it, a  preparation is  made  in nearly the same
 manner as the tinetura benzoini composita of the pharmacopoeia, with the
 addition  of more gums ; this  preparation must be laid on once  only, and
 Avith a brush kept for the purpose.  For making plasters on colored silk,
 it is only necessary to select the silk a shade deeper than the color required,
 as  the plaster causes it  to  appear a  little lighter.  The process being
 finished, the plaster must be cut out of the frame AAdth a pair of scissors, as
 near to the canvas to  Avhich it is sewed  as it will admit.  For sale, it is  cut
 up in squares, Avhich is best done by means of a compass and rule.  I have
 tried various  solvents for india-rubber, and find none answer so well  as
 those above mentioned.  Ether dissolves it with facility, and possesses the
 advantage of cleanliness, but it is much more expensive, and evaporates so
 rapidly that it is almost impossible to spread the solution smoothly on the
 silk; naphtha  evaporates more slowly, and is, therefore, preferable, but the
 quality requires attention, as it may be obtained  almost  free from that
 creasote smell which is the only objection to its use.  The addition of a
 small quantity of turpentine facilitates the solution  of some specimens of
 india-rubber.  The  Avhite india-rubber  is better than that which has  as-
 sumed a black color.
  The  grand arcanum in making court-plaster is glue and isinglass.  The
 polishing coat  is  not  absolutely necessary, but it improves the appearance
 of the  plaster, and the gums may probably increase its healing property,
 and by giving it a more even surface, cause it to adhere more closely.   It
 has occurred to me, that a similar plaster might be  made for common use,
 with calico instead of silk, Avhich might, in some cases, supersede the use
 of strapping;  and also that the adhesive material might be made the vehi-
 cle  for cantharadine  or other  stimulants.  The isinglass plaster is  apt to
crack in Avarm, dry Aveather, but this does  not occur if it is kept in a cellar
in an earthenware jar.                                  Part vii., p. 169.

  An Elegant Sticking Plaster.—Black silk is strained and brushed over
  vol.  n.—23 
354                           PLASTERS.
ten or tAvelve times Avith the folloAving preparation:  Dissolve |ss. of ben-
zoin in f. §vi. of rectified spirit; in a separate vessel dissolve §j. of isinglass
in water; strain each solution, mix them, and let the mixture rest, so that
the  grosser  parts  may subside; when the  clear liquor is  cold, it Avill
form a jelly, which  must  be warmed before it is applied to  the silk.
When the plaster is quite dry, in order to prevent its cracking, it is finished
off with a solution of terebinth, chia. |iv. in tinct. benzoes f. §vj.
                                                       Part vii.,jo. 169.

   Prestafs Adhesive Plaster.—The following composition is  said never to
crack, and not  to  inflame  the skin:  Empl. diachyl. gum., 400 grs., puri-
fied rosin, 50 grs.,  tereb. venet., 38 grs., are  mixed together at  a gentle
heat, and then\12" grs. of gum  mastic, and 12 grains  of gum ammoniac
incorporated, and  the mass  spread on linen.   In  Avinter it is advisable
to add 10 grs.  more turpentine, and 12 grs. of ol. amygdal.
                                                        Part x., p. 176.
   Adhesive Plaster.—An  excellent  adhesive plaster, unirritating to  the
skin," not acted  on by Avater,  or  the discharges from the Avound, and pos-
sessing all the good properties of collodion except its  Avant of color, with
the additional advantage of being cheaper, is made by dissolving, with  the
 aid of a moderate  heat, gum lac in spirit of wine, in sufficient quantity to
make it of the consistence of jelly.  It can be kept in a wide-mouthed bot-
 tle, and spread  with a spatula as required.               Part xxi, p. 357.

   Addition of Tannate of Lead to Adhesive Plaster.—M. Herpin states,
. that his OAvn experience teaches him that Baynton's  treatment, by strap-
 ping, may be extended to every branch of surface, whether resulting from
 Avound or ulcer ; and the only inconvenience he has found attending it is,
 the production of eczematous  eruptions, or vesications in irritable skins.
 After having tried various  means of  obviating this, he remembered the
 great advantage that accrued from the treatment of  bed-sores, by means
 of plasters poAvdered Avith the tannate of lead.  He caused some  of  this
 substance to be combined Avith adhesive plaster, wdiich  henceforth produced
 no irritation.  As  the addition of the tannate diminishes the adhesiveness,
 the proportion  may vary accordingly, as this quality is desired or not.  It
 is retained Avhen l-20th of the  tannate is added, and when  not much re-
 quired the proportion may be raised to 1-12.           Part xxxi., p. 235.

   ScotPs Plaster.—In some  affections of joints (of the knee particularly)
 it is very useful sometimes to get the part into as quiet a state as possible.
 The best plan yet knoAvn is that called  Scott's plan, much used in London
 hospitals,  viz.:  sponge  the skin of  the part (the knee for instance) with
 spirits of camphor till the skin smarts and looks red.  Then  spread an
 ointment composed of equal parts of the ung. hydrargyri fort,  cum cam-
 phora and plain ceratum saponis, on lint; cut the lint into narrow strips,
 and apply them freely round the knee to the part, fully/our inches above and
 beloAV the condyles of the femur: over this next apply soap plaster, spread
 on calico,  cut also  in strips;  this may be apphed for a fortnight or longer,
 if no pain  ensues in the knee ; while over the whole is rolled a bandage or
 roller, steeped in gum  and chalk.  The effect of this plan in removing  pain
 and SAvelling is sometimes very remarkable.           Part xxxiv., p.  284.

   Improved Adhesive Plaster.—M. Colson, as the result of twenty years' 
PLEURISY.
355
trial, recommends the following plaster in place of the ordinary diachylon,
as it never gives rise to irritation or erythema.
  R Olive oil 500, minium 250, yellow wax 185 parts.
  These are to be heated together and  stirred round with a spatula until
the  mixture assumes a black color, Avhen it is to be taken off the fire, and
stirred until quite  thick.  It  is then to be formed into rolls on a marble
table.                          •                  Part xxxviii., p. 294.
                        PLEURISY.
  Treatment of Chronic Pleurisy with Effusion.—The following was
dictated by Dr. Hope during his last illness, and concluded on his death-
bed :
  " Show that I used mercury in all degrees of intensity, so as to ascertain
Avhat quantity was the most effectual,  but at the same time, least injurious.
Show that I always used opium, in full proportion, with the mercury, and
that I used the milder and the external forms when the others could not be
borne—thus taking especial care to protect the mucous membrane.—Add
that I found prompt and free salivation by calomel and opium, and the use
of one or tAvo drachms of cintment on each groin and axilla, night arid
morning  for  forty-eight hours (in conjunction with the other remedies
presently to be specified), produce the most rapid  and  satisfactory effects
of absorption, in cases where the dyspnoea and faintness seemed to be most
urgent and dangerous.  It was quite common, and, in fact, occurred in the
majority of cases, that the fluid descended  one-third, and still oftener
one-half, doAvn the chest, within the space of forty-eight to sixty hours,
carrying Avith it the extreme dyspnoea and faintness, to  the great relief of
the patient.
  " Say that  blisters were used from the first,  and that the folloAving
became my settled plan of managing them.  One blister  six inches long,
3^ broad, exclusive of margin, Avas placed longitudinally over, and a little
to the outside of the angles of the ribs, leaving space for another of similar
sizebetAveen the first and the spine.  Great care Avas taken to not remove the
cuticle (one means of Avhich w-as to cover the surface of  the blister with
silver paper), as this forms by far the quickest healing plaster; but after
about forty-eight hours, during Avhich the running was absorbed by  dry
napkins, carefully prevented from adhering, it became  necessary to cover
the Avhole Avith the mildest soap plaster,  spread  on soft calico, to  prevent
the cuticle from being accidentaUy  abraded.  In  this  way all irritation
promptly subsided, that  is, in  the course of from two to three days,  and
the patient was ready for the second blister, Avhich was placed between the
first and the spine.   It Avas  similarly treated ;  and, at an equal interval, a
third was placed in front of the original one ; that is, rather forward in the
axilla.  When pain indicated the possibility of a pleuritic stitch in any part
of the side, it is needless to say that  the  first blister was placed over that.
Say that  diuretics are conjoined: viz.,  squill;  sp. asth. nit.;  juniper;
iodide of potassium, and, when there is no irritation of the mucous mem-
brane,  the  various other preparations of potass.   Digitalis, by creating
faintness, is  apt to confuse  the  symptoms ; I do not therefore use it till
later.   Where all  these  remedies had failed for tAvo or  three days,  and 
356
PLEURISY.
dyspnoea continued as urgent as ever, I have occasionally used a powerful
hydragogue, as half a grain to a grain of elaterium, combined Avith calomel
and capsicum to  prevent nausea; or the  pulv. jalap, comp. 5j.; so as to
produce ten or twelve copious watery evacuations per day, stimulants being
at hand in case of any sinking tendency.
   " The patient is better in bed, both because it fiwors geutle transpiration
and obviates faintness.
   "Remind  that, hitherto,  I  have been treating a case in which the
dyspnoea seemed imminently dangerous,  and the  most vigorous use of
remedies consequently indispensable; but now explain that inconvenience
sometimes resulted from  hypersalivation ; for, notwithstanding an imme-
diate suspension of the mercury either on the first appearance of tenderness
of the gums, or of amelioration of the symptoms—especially the dyspnoea
and  obvious  commencement of absorption, untoward* salivation would
occasionally occur and greatly retard the convalescence.  Explain that, on
several times observing this,  and having reason to believe that the patient
could bear the dyspnoea  AAdth  safety for some hours longer, provided he
were prevented from rising, which creates faintness, I used more moderate
quantities of mercury, being content to affect the gums within three or
four days.  In this Avay,  the action of the remedy was easily controlled,
either by  omitting the  mercury  for  two  or three days, if its action
threatened to be considerable, or by merely diminishing it according to
the evidence of the mouth and of the symptoms.   I found, however,  that
:t did not answer to  suspend it altogether, but that  a  continuation of it
iatily in a mild form, as a blue-pill night and morning, or at night only, for
the purpose of maintaining the first impressions for a period of two or three
weeks, or in short, until all  the disagreeable symptoms  had disappeared,
was attended with far better  success.  "Explain,  further,  that  the great
acceleration of pulse, wdiich  rises commonly  to 120 or 130, and  in young
persons, even to  150 or 160,  and Avhich is attended with what the patient
calls  'internal fever,' thirst, craving  for  cold  drinks,  and  dryness  and
heat  of skin,  is  not  necessarily a result  of fever, but it is necessarily
a  result of anaemia, occasioned by  the deficiency of  oxygenation from
the total incapacity of one  lung at least.   Here was the- error made by
Broussais, who supposed this to be fever, and put his patient on the lowest
diet.   On the contrary, acting  on the opposite principle, I always supply
my patients  wdth at  least one or two pints of concentrated beef-tea, or
plain ox-tail soup; and if the state of the tongue and the alimentary canal
fully authorizes it, I permit them tender old mutton or beef for dinner. On
this treatment the pulse and  ' internal  fever' rapidly fall in proportion as
the anasmia disappears.
   "Next proceed to  those cases in wdiich hectic is established, resulting,
for the most  part, I should imagine, from  the  fluids being of a puriform
character—for, after a month or six wreeks, and sometimes much earlier,
if the inflammation have been very intense, it  assumes this character.
Allude to the opinion  pretty prevalent, that  mercury is injurious  in such
cases, and say that I have not found it so, but that its use was still indis-
pensable ; for I have noticed that where it has been omitted, contrary to
my wdshes and instructions, a recurrence of the effusion has taken place,
notAvithstanding  the use of mineral acids and the  various  other remedies
usually considered available against hectic ; Avhereas, on  resuming mercury
with opium, and giving the mineral acids for hectic, I have been enabled 
PNEUMONIA.
357
to restore matters to their former condition, though not without an extra
shake to the patient."
  Dr. Hope suggests that sulphate of iron may be added to the sulphuric
acid mixture, in order to cooperate with the animal food in removing all
remains of anasmia.                                      Part iv.,p. 68.
  Pleuritic Stitch.—Rheumatism of the intercostal muscles may be con-
founded with the genuine pleuritic stitch.  Treatment same as in ordinary
rheumatism.                                             Part v., p. 11.
  Pleurisy.—In young and healthy adults, Mr. Guthrie advises to bleed in
a very " determined manner and with an unsparing hand, until an impres-
sion is made on the system, until the pain and difficulty of breathing are
removed, until  the patient  can  draw a full breath, or faints;" and  repeat
it  every  three  or four hours, according to the symptoms, not placing,
however, much dependence upon the pulse.   And give mercury to affect
the gums ; three grains of  calomel with a third or half a grain of opium,
every two or three hours.  In the later stages, when the pulse is becoming
weak, and there is much dyspnoea, or when the disease is becoming chronic,
apply a blister.                                        Part xvii., p. 90.
  A new Sign of Pleuritic Effusion.—Dr. Roy, of Lyons, mentions, in the
" Revue Medicale." the following sign of pleuritic effusion  Avhen the fluid
has much diminished : Put the left hand on the affected side of the chest,
the patient sitting up in bed; then percuss the ribs Avith the right hand.
This will give rise to fluctuation, which will be easily perceived by the left
hand.  Dullness on  percussion, absence  of vesicular murmur, bronchial
respiration, and asgophony, will of course remain  the characteristic symp-
toms Avhen the  fluid is abundant.                      Part xxv., p. 109.
  Iodine Injections in Pleuritic Effusion.—Dr. Atlee relates the case of
a gentleman (age not given) from whose  side nine pints of pus were dis-
charged on the 16th December, through a trocar passed into the left side
of the chest between  the  seventh and eighth ribs, midAvay between the
spine and the sternum.   No further discharge took place until the  2d of
January, but the closed wound then reopened, and from that time about a
pint of pus continued to be discharged daily, wdth the effect, in spite of
restoratives, of rapidly wasting  the patient's strength.  On February 2d,
5.V of liq. iodin. c. (U. S. Disp.) diluted with §j. of tepid water, was thrown
in  without inducing any ill  effect, no precaution against the admission of
air being taken ; and next day the amount of discharge was diminished by
one-half.   Each day the strength of  injection was increased, and  on the
7th February the iodine Avas used undiluted.  The amount  of matter dis-
charged rapidly decreased, and by the end of February the flow had ceased,
the patient daily recovering strength, and in a few weeks later being able
to go to business.   When seen three  years later he was quite wrell.
                                                    Part xxxi., p. 87.
                              -------»-•-•------«■

                        PNEUMONIA.
  Pneumonia Treated with  Spirits  of Turpentine.—Mr. Martin  relates
the ease in Avhich he was  so successful by means of this remedy, as folloAvs:
I was called to visit M— S----, aged twenty-five.  I found her in an ad-
vanced state of pneumonia,  severe  dyspnoea, respiration  40, pulse 120, 
358                          PNEUMONIA.
a short hard cough  accompanied by dark brick-colored  sputa, tongue
white (loaded), boAvels confined, dull sound on  percussion over the entire
of the thorax (excepting a small space, of two inches in diameter, beneath
each clavicle).   Here  the respiratory murmur,  Avhich Avas elseAvhere ab-
sent, wras  of a loud mucous character.  She had been  attacked, six  days
before, with rigors and pains in her chest; and, having been treated solely
with whisky-punch to drive out the cold, her present state Avas extremely
alarming.   Bleeding and calomel were of no avail in arresting the disease,
the pulse  rose to 140, the tips and cheeks were livid, and eyes sunken, with
slight tracheal rale.  Thinking the patient so near death that it Avould be
fruitless to Avait for the action of mercury, I determined to have recourse
to brisk doses of turpentine, which I had seen used Avith success in cases
of pneumonia which resisted  mercury.  I therefore prescribed the folloAv-
ing mixture :
  R Spt.  terebinthinas rect., |ij.; vitelli ovi dimidium.;  aquas  rosarum,
|vss.;  tinct. opii, 3j-;  Fiat mistura cujus coch. duo magna sumantur 3tia
q.q. hora. Emplast. lyttas sterno.
  Next day I found the patient much easier :  respiration 40, less labored ;
the cheeks have lost their livid hue, but the lips are still of a dark purple;
pulse 118, softer and fuller; tongue still loaded; she had six  copious Ava-
tery stools during the night, with a copious secretion of urine; tAvo inches
beloAV the clavicle there is an audible and distinct crepitating  rale ; sputa
still dark-colored; blister vesicated  well; she has finished the mixture;
complains of slight strangury.  To have  the mixture repeated, camphor
mixture  being  substituted for the  rose-Avater.  The  patient recovered
rapidly, and without relapse.                             Part ii, p. 53.

   Bleeding in  Sthenic Pneumonia.—Dr. Kennedy, in  his Observations
on Blood-Letting, goes  on to say:  In sthenic pneumonia, it frequently
happens,  that in spite  of treatment the lung becomes solid ; or, it may he,
the patient does not present  himself  till this has occurred.  A good deal
of difficulty often exists in deciding  on the propriety  of general bleeding
in such cases:  the extremities may be cold, and the surface covered  with
clammy perspiration; the pulse, too, may be Aveak ;  and yet there are few
cases in which general bleeding will  be found more beneficial.  Reaction
will be found  to establish itself, and the lung wdll become  much more
rapidly clear than if less energetic means  had been used.  There is still
 another case connected Avith pneumonia, and AA'hich presents  itself to the
medical man by no  means  unfrequently.  A  person  gets a slight  cold,
 which is  neglected; after some time he asks  advice, and, on examination,
 a portion of the lung  is found solid.  All fever has subsided: the necessity
 for bringing back the lung to its healthy state need not here be insisted
•on. Noav, this  cannot be better done than by following up a plan of treat-
 ment which has been already spoken of by Dr. Stokes for the cure of em-
 pyema,  only Avith a  little  more vigor.  In place  of  local bleedings, or
 possibly in conjunction with them, one or tAvo general bleedings will be
 folloAved  by the most decisive results.  It may be recollected, among the
 details of the treatment alluded to above, that the loAvest diet is enjoined :
 hence, the modus operandi of this plan appears to me sufficiently obvious,
 by keeping in  mind  the principle I am  endeavoring to  establish.  The
 system is deprived of a quantity of  its blood,  and the food  taken  is not
 sufficient to supply the deficiency. Under these circumstances, the system 
PNEUMONIA.
359
is, I believe, actually forced as it were to take back whatever may have
previously been poured out—such as serum, lymph, or, possibly, even pus.
It is curious to observe, hi some  cases, Avith Avhat great rapidity this may
be effected.                                             Part ii., p. 72.

   Colchicum Autumnale.—Suggested as an auxiliary in the treatment of
pulmonary inflammations, uncomplicated with abdominal affections.
                                                      Part iv., p. 11.

   Treatment of Pneumonia.—[Blood-letting, tartarized  antimony, and
mercury, are stated by Dr. Watson to be the three great remedies in this
dangerous disease; and this opinion accords Avith  that  of  most other
eminent men—for, although  every one may not  use  the tartarized anti-
mony and mercury in the same  Avay, yet the general principles of treat-
ment  will be found nearly to correspond.  However much  we  depend
upon  bleeding in the early stages of the treatment, a time arrives Avhen it
is no longer admissible, and is even positively hurtful.]
   We AArant some remedy, therefore, to  assist the  lancet, or to  employ
alone when  the lancet can do no more; and Ave  have two such, in tartar-
ized antimony and in mercury.   The tartar-emetic plan I believe to be the
best adapted to the first degree of the inflammation—that of engorgement;
and the mercurial plan to the second—to that of hepatization.
   I need not tell you that the tartarized antimony is not given in this dis-
order Avith  the object of producing vomiting.   Dr. Thomas Davis states
that it always acts best ivhen it produces no effect except upon the in-
flammation  itself, i. e., when neither vomiting,  purging, nor  general de-
pression are produced.  The first dose may produce all  these effects; but
the second  and third doses may be tolerated, and it is during this tolerance
of the drug that its beneficial effects are chiefly perceived: if the vomiting
and purging be excessive, it is Avell to combine a small dose of laudanum.
Dr. Thomas Davis first bleeds freely in pneumonia;  he  then begins Avith
one-third of a  grain  of tartarized antimony in a little water, with a feAV
drops of laudanum or sirup of  poppies: he  repeats this dose every hour
for twice ; he then doubles the dose  for the next tAvo hours ;  and goes on
thus, adding one-third of a grain every two hours until he  reaches two
grains every hour.   He has  not  exceeded this last dose, and has occasion-
ally continued  it for many days Avithout injurious effects.  Whatever  be
the modus  operandi of this medicine,  there  can be no doubt that this
treatment is both judicious and safe.
   When the dyspnoea has been put an end to by antimony thus exhibited,
 the medicine may be intermitted ; and  if the inflammation show any dis-
 position to rekindle, it must be  again extinguished by a repetition of the
 tartar emetic.
   When, however, the inflammation  has reached the second stage, that of
 solidification, mercury is more worthy of confidence, in my opinion, than
 tartarized antimony.  The object of giving it is to make the gums tender;
 and it is expedient to do this as  speedily as may be.   Small doses of calo-
 mel repeated at short intervals—a grain every hour, or two grains every
 two hours,  or three grains every three hours—combined Avith so much of
 laudanum or of opium as  may be requisite to prevent it from running off
 by the bowels—offer  the most  certain  Avay of accomplishing our object.
 If the bowels are irritable under the calomel, blue pill, or the hydrargyrum
 cum creta,  may be substituted for it Avith advantage; and if the internal 
360
PNEUMONIA.
use of the mercury be anyhow contra-indicated, or if it appears slow in
occasioning its specific effect, the liuimentum  hydrargyri may be rubbed
in, or the strong mercurial ointment.
  Many  persons, I am persuaded, are  saved by treatment  of this kind,
pushed to slight ptyalism ; the effusion of lymph, tending to spoil the tex-
ture of the lung, is  arrested, and the lymph already effused begins to be
again absorbed; and the ease  and comfort of the patient, as Avell as  the
alteration for the better of the physical sounds, attest the healing qualities
of the remedy.                                          Part iv., p. 45.
   Counter Irritation.—By means of the ung. ipecacuanhas, or ung. erne-
tinas, is  preferred by Dr. Turnbull to other rubefacients in  pulmonary
affections, on account of producing little or no pain, or inconvenience to
the patient.                                            Part  v., p. 84.
  Bloody Expectoration.—Dr. Graves states,  that when Ave find in pneu-
monia that the expectoration is tinged with dark venous instead of arterial
blood, we may conclude that it is of a more dangerous nature (originating
from effusion of blood from branches of the pulmonary artery, which ramify
on  the air-cells,) than when the  bronchial vessels only are  implicated.—
Vide Art. " Hemoptysis."                             Part viii., p. 54.
   Complicated with Cerebral Disturbance.—When pneumonia,  as in cer-
tain constitutions and in  certain epidemics, is accompanied ivith marked
symptoms of cerebral disturbance—a very embarrassing complication—
the use of musk, either alone or in combination with  calomel, has been
found by Recamier to be often of decided advantage.      Part ix., p. 77.
  Lotion  of Tartar  Emetic in  Pulmonary Diseases.—Mr. Duncan
M'Diarmid, an American surgeon, has  found great benefit from a solution
of  emetic tartar applied externally in some  pulmonary and  other com-
plaints.
  Dr. Hannay, in 1823, recommended this form of application, and  in 1843
writes, " I still regard  this lotion as a highly valuable application to the
chest in  pulmonary diseases."  Dr. H. finds that the addition  of gr. v. of
hydr. oxymur. to the ounce of solution increases its power and efficacy.
                                                      Part xii, p. 302.
   Treatment of Pneumonia.—[The indications to be fulfilled in treating
inflammation of the lungs,  are, 1st, To subdue inflammatory action ; 2d,
To prevent deposition ;  and, 3d, To guard against relapse.   With the first
intention, moderate bleeding,  at the commencement  of the attack, Avill be
useful, and if the crepitant rale remains after this, it will be a safer criterion
for the repetition of the bleeding than the  beef-fed appearance of  the
blood.  Dr. A. T. Thomson  considers that the use of tartar  emetic, as a
contra-stimulant, in full doses, is  far more  advantageous than  repeated
bleeding.  He observes:]
  My practice, as soon as I have fully satisfied myself of the existence of
the disease, and if the attack  has not run  on to the second stage, is to
order one bleeding to the amount of sixteen or twenty ounces;  to follow
this, immediately, with  three  or  four grains of calomel and one grain of
opium, with the  vieAV of preventing that nervous irritability which often
succeeds the  use of the  lancet, and of sustaining the beneficial impression
made on the  system by the bloodletting.
  In two hours afterward, I give one grain of potassio-tartrate of antimony 
PNEUMONIA.
361
 in a fluid ounce and a half of emulsion of bitter  almonds, and repeat this
 dose every third or fourth hour, until a decided diminution of inflamma-
 tory action takes place—that is, until the  crepitation has  nearly disap-
 peared, and the sputa are no longer  rusty and  tenacious.  The intervals
 between-the doses of the tartar emetic are then extended  to six hours,
 and afterAvard to eight hours, and so continued until convalescence is con-
 firmed.  I prefer the bitter almond emulsion, on account of  its containing
 hydrocyanic  acid, Avhich has  a sedative quality,  and a more  decided
 influence in quieting the nervous system, and abating the cough, than small
 doses of opium.   When  the pneumonia is uncomplicated, this plan, Avith
 the  occasional aid of some  mild aperient, has, in my hands, seldom failed
 to carry the case to a successful termination.   When the attack has passed
 beyond the first stage, when dullness on percussion indicates hepatization,
 then the object of the  second indication—namely, to excite  the capillaries
 and prevent further depositions—requires attention; and, in order to fulfill
 this indication, I  order four or five grains of mercury Avith chalk, or one
 grain of calomel, to be given hi each interval of the administration of the
 tartar emetic.                         -                Part xiv.,p. 11.

   Treatment of Pneumonia in  Children.—According to  Dr. West, in
 idiopathic pneumonia  Occurring in previously healthy children, depletion
 is as important as in the  adult; and is to be followed up by  tartar emetic,
 given in doses of one-eighth of a grain e\'ery ten minutes (to a child two
 years old), till vomiting is  produced, and continued every hour or  two
 afterward for tiventy-four or thirty-six hours.  Then if the physical condi-
 tion of the lungs, and  the  general  state  of  the  patient, are found greatly
 improved, persevere Avith the medicine at longer intervals; but if the signs of
 inflammation are advancing, give mercury with small doses of  antimony, and
 use larger doses of the latter to combat any sudden increase of fever or dysp-
 noea. If under any circumstances bronchial breathing is distinctly audible, the
 mercurial treatment is indicated; give, to a child two years old, a grain of
 calomel every three or four hours, and a little tartar emetic, except contra-
 indicated by sickness or debility; if the stomach and boAvels are very irritable,
 use mercurial inunction. Do not blister, but employ stimulating liniments, by
 which there is no risk of those unhealthy sores which often follow a breach
 of the surface.   If at the outset, large doses of antimony do not seem to
 be required, give tAvo-thirds of a grain or a grain of calomel Avith two or
 three of James' poivders every six  hours.  It is difficult to knoAV when to
 give  stimulants ; but  they  are plainly  indicated  when  there is  much
 diarrhoea, the  pulse becoming  more  frequent, and above all smaller and
 smaller, and the  respiration, though  slower, more labored,  and irregular.
 Then give wine,  even to a child at the breast, and  ammonia in decoction
 of senega, or dissolved in milk, Avhich conceals its pungency.  If there is
 diarrhoea, let the nutriment be arrow root, or the decoction blanche of the
 French; otherwise, give strong beef tea, or veal broth.  In secondary
 pneumonia, especially if preceded by Avefl marked  bronchitic  symptoms,
 antimony may sometimes be given at once, without bleedino-.
   General Management.—It is desirable, in all cases of pneumonia at all
 severe, that iniimts should be taken  from the breast, and that the mother's
milk should for a time be given them from a spoon.  This is of importance
on twro accounts—partly  because the  thirst  they experience induces them
 to suck overmuch (hence it is well that barley-Avater or some other diluent 
362
PNEUMONIA.
be given  them frequently instead of the milk, in order that they may
quench thirst Avithout overloading their stomach); partly because the act
of sucking is in itself mischievous, since, as must at once be perceived, it
taxes the respiratory functions to the utmost.  A second important point is
never to allow the children to lie flat  in bed or in the nurse's arms, but
to place them in  a semi-recumbent posture in the arms, or propped up iq
bed.
  When pneumonia has reached an advanced stage, or has involved a
considerable extent of the lungs, the children should be moved only with
the greatest care and gentleness, lest convulsions should be brought on.
                                                     Part xvii., p. 88,
   Treatment of Pneumonia.—Dr. Todd asserts that all cases  of pneu-
monia have, independently of this or that mode of treatment, a decided
tendency to depress the general powers of  life—some more, some  less;
and that, -with all, a very decided direct antiphlogistic treatment is hazard-
ous—AAdth some, extremely so—and that in  none is it absolutely necessary;
but, with others, there is no  safety for  the  patient, unless the treatment
from the beginning be of a decidedly supporting and stimulating nature.
   Apply flannels soaked in Avarni spirits of turpentine over the regions of
the  dullness, and  keep them  on for half an hour.  Let  these be applied
three times a day for three or four days.  Give  the liq. ammon. acetatis as
a diaphoretic, in  doses  of six drachms every three or  four  hours.  An
occasional dose of a mild aperient maybe given, and the  patient allowed a
pint of beef tea, Avith a little milk and bread, daily.     Part  xxxi, p. 52.
   Lungs, Inflammatory Affections of.—In a  paper upon the  different
sounds of  the respiratory apparatus,  Dr.  T. Thompson  observes, that in
proportion  as  sounds are confined to inspiration, they afford reason for
depletion;  in proportion  as the rhonchi  become bubbling they indicate
secretion, and suggest a discontinuance of antiphlogistic treatment.
                                                    Part xxviii., p. 79.
   Typhoid Pneumonia.—Take care how  you confound  pneumonia occur-
ring in the  course of typhus, with a pure inflammatory attack.   The symp-
toms may easily lead you astray, but to treat a case of typhoid pneumonia
on  the antiphlogistic plan Avould probably be destructive.  Too  great
weight is placed on physical signs in typhoid pneumonia.  The successive
signs of crepitus, dullness, cessation of vesicular breathing, and its replace-
ment by bronchial respiration,  are too  often mistaken for the  effects of
inflammation, Avhereas the same signs  are seen in  typhus.   They are, in
fact, often symptoms of typhus, and of all other forms  of fever, whether
these  be variola, erysipelas, purulent poisoning  of the blood,  glanders,
scarlatina, or measles.  One of the greatest  modern improvements of
medical practice  consists in treating these  cases on the plan recommended
by Dr. Stokes.  Look attentively to the  antecedents of a case, of this kind
Avhen called upon to treat  it; examine its  .history.  The editor  has  been
guided by one simple index in most of these  cases—viz., the brown tongue.
If the tongue be ever so slightly brown it the back, take care  how you
 deplete ;  on the  contrary, begin in good  time  Avith broth, ammonia, and
 wine or good brandy.  Don't be afraid of the physical signs of pneumonia,
 if the history of the case and the tongue  indicate  coming typhus.  It is
 truly surprising  how these physical signs vanish  by the timely exhibition
 of stimulants.  The blood is decomposing, the coloring matter is acting on 
                             PNEUMONIA.                          363

the tongue, the stimulating properties are disappearing, and the functions
of life will soon cease, unless you  compensate  for a time for this loss of
stimulation,  by an  artificial  one, till the poison has been  exhausted or
eliminated.  These  views are also fully supported in some of Dr. Todd's
late lectures.  ,                                       Part xxxi.j p. 17.
  Pneumonia, Chronic.—Dr.  Cotton,  of Brompton  Hospital,  for  con-
sumption, etc., believes  that counter-irritation  is of the greatest benefit.
Apply one or Iavo  blisters,  and follow these by Croton oil hniment, or
iodine, or a combination of both.   If there be no tubercular tendency, you
may employ merc'ury carefully combined  Avith a more tonic plan of treat-
ment.                                                Part xxx., p. 72.
  Absence of Chlorides from the Urine as Diagnostic of the onward
Progress of Pneumonia.—Dr. Bennett  states that in several cases of
pneumonia, the absence  of chlorides from the urine marked precisely the
onward march of the pneumonia, Avhilst their presence indicated its cessa-
tion, and was generally accompanied  by the returning crepitation and com-
mencing absorption of the  exudation.  It still remains to be determined
whether the absence of these salts is a cause or a result of exudation  into
the lungs—whether the interference  to the respiratory function, by dimin-
ishing the amount of oxygen absorbed, gives rise to those chemical changes
in the blood which react on the urinary secretion.
  Dr. Bennett looks upon this chemical fact as an important diagnostic
sign. Therefore, in cases of pleurisy and pneumonia ahvays test the urine
for chlorides, as follows:  Add a few drops of nitric  acid to a portion of
urine in a. test-tube, and then a feAv drops of a solution of nitrate of silver.
If chlorides be present, a dense white precipitate of chloride of silver, which
is insoluble in acids, wdll fall.  If chloride of sodium be altogether absent,
no precipitate will occur.                              Part xxxi., p. 78.
   Treatment  of Pneumonia.—[There  are  but few diseases  Avhich are
treated  more differently by different practitioners, than pneumonia.   The
methods and remedies vary from the most simple to the most heroic.  In
the General Hospital in Vienna, the treatment is almost entirely dietetic,
they are simply left to nature.  Dr. Todd, of King's College Hospital, dis-
courages blood-letting and even tartar-emetic ; he gives large doses of liq.
ammon. acet. or citrat., and supports the patient from the first with animal
broths,  given frequently in small quantities, with a small amount of stimulus.
From the statistics  Avhich Ave have been able to collect, we find that the
treatment by blood-letting, conjoined Avith tartar-emetic, is in the present
type  of disease, the worst, and the  dietetic the best,  especially in severe
cases.  The indications to be fulfilled are:
   1. To diminish the general fever.
   2. To relieve the local symptoms.
   3. To check the tendency to death by  depression.]
  Dr. Routh says : The surest remedy to reduce the frequency of the pulse is
aconite. The tincture of the P. L. should be avoided as uncertain.  It is most
to be depended upon Avhen made from the alcoholic extract of the root, say
one grain of the extract to tAventy drops of alcohol; the dose of this tincture
would be from half a drop to three minims (one drop is about equivalent to
one grain of opium).   For  children one or two drops may be added  to
eight ounces of  Avater, and  half an  ounce given every two hours; for an
adult, half a  drop  every tAvo  hours Avill very  soon reduce the feverish 
364
PNEUMONIA.
excitement.  Its action must be  carefully Avatchcd lest an overdose he
given.  To relieve local symptoms the patient may be  placed in Avater as
warm as can possibly be borne, until the patient faints, which will usually
be in about tAventy minutes ; or. instead of this, Junod's exhausting appa-
ratus may be used, which will draw the blood from the affected part to the
extremity.  As a  counter-irritant, the acetum lyttas  Avith chloroform
vesicates very speedily, especially if covered with cotton-wadding immedi-
ately after the application.   This produces  comparatively little discomfort
to the patient, and, if repeated occasionally, a vast quantity of serum may
be got rid off.   The next best application to the chest is* flannel dipped in
turpentine.  At the commencement, promote expectoration by small doses
of emetic tartar, and afterward support your patient by mild emollient diet,
broths, and gentle stimulants.                         Part xxxii., p. 80.
   Treatment of Consolidated Lungs from Pneumonia.—One of the most
interesting features. Ave have recently noticed in Dr. Todd's practice at the
King's College Hospital is a plan of treating solidified lungs and  strumous
pneumonia by turpentine—a mode not neAV possibly, but eminently valu-
able,  and  one in Avhich  Dr.  Todd seems  to  gain greater confidence at
every session.
   J. B., aged 21, was admitted into King's College Hospital, October 2d,
suffering under various symptoms of chest disease,  the result of a  severe
attack of pneumonia.   Dr. Todd  pointed out  to his class that the entire
lung of one side was completely solidified.   This lung had, in all probability,
gone through the three stages  of  pneumonia so familiar in practice, but
often so very unmanageable in their results, the first and second, stages of
pneumonic inflammation usually merging into one another, and leaving the
lung quite solid.
   The chief practical point, to Dr. Todd, being,  that the  consolidation
of pneumonia  does not  necessarily destroy the vesicular structure  of
the lung, any  more than  effusion into the iris,  in iritis, removable by
mercury,  destroys the structure of that* delicate part; the inflammatory
effusion,  in pneumonia, occurring  almost  universally through the  lung-
tissue, as  well as into the air-cells and in ter-vesicular tissue.  In a very
advanced stage  of pneumonia, it is true, Ave may have pulmonary abscess.
This was  evidently not the case in the present instance.  The treatment
adopted by Dr. Todd, and which he finds the most effectual, was the fol-
io Aving:  Wine,  six ounces, daily;  a draught every third hour, composed
of julep of acetate of ammonia, ivith aromatic spirits of ammonia in excess ;
and strong turpentine stupes, carefully applied, every night and morning,
over  the  back  of the chest and site of the consolidated lung.  Diet
moderately stimulating.
   25th. This man is quite well.  The right lung, as Avill have been observed,
is most usually that affected.  Dr. Todd has great  faith  in the  stimulant
action of turpentine—a remedy not often used, but which in this and
numerous other cases has proved almost specific in its action.  In  phthisical
cases also it may be used combined ivith strong acetic acid, wdien its action
becomes even still more beneficial.                     Part xxxiii., p. 99.

  Asthenic Pneumonia—Treatment by Quinine.—In the first stage of an
attack in  a healthy constitution, says Dr. Corrigan, the capillaries  of the
lungs become distended, but they preserve their sthenic condition ; in such
a case, of course, you Avould bleed and give tartar  emetic to act upon the 
POISONING.                          365
 whole vascular system.   But if the capillaries have passed from this sthenic
 condition, or if from the state of the constitution, the type of the disease,
 or long-continued depressing influences, they have lost their sthenic powrer
 from the very commencement of  the attack, then we have to deal Avith a
 contrary state of things, in which bleeding would be injurious  and dan-
 gerous.  You must meet these cases by large doses of quinine, five grains
 every three hours.  Quinine appears to possess the same poAver in giving
 contractile action to the capillaries of the lungs Avhich we knoAV it possesses
 in so marked a degree OA-er the capillaries and venous radicles in the spleen.
 The large  proportion of venous  capillaries in both the lungs and spleen
 seems to support this view.                          Part xxxiv., p. 33.

   Pneumonia—Bleeding.—-What are the comparative effects of practising
 or abstaining from bleeding in a case of pneumonia ?   Is one or the other
 practice indiscriminately to be adopted ?  The answer to these questions,
 abstracted from the evidence  of Profs. Alison, Bennett, Drs. Watson,
 Gairdner, Jos. Bell, etc., may be given  thus: The non-bleeding plan has a
 demonstrable advantage over that of indiscriminate and repeated bleedings.
 The judicious practice  of moderate early bleedings, general or local, in
 cases of more or less sthenic pneumonia, and of refraining from it altogether
 in asthenic pneumonia, whether as regards the character of the disease or
 the constitution of the patient, is pressed upon us both by experience and
 science.                                           Part xxxvm., p. 69.
  Pneumonia, Secondary, of Rheumatism.—Opium  and ammonia, says
 Dr. E. L. Ormerod, are preferable to wine for the support of the exhausted
 neiwous  system,  when  this demands especial  attention  in rheumatic
 pneumonia.  Depletion  done judiciously may be  borne,  but it requires
 great judgment—if done Avrongly it  will tend  to produce or increase
 the secondary inflammation.  As a general  rule  you may  use blisters,
 slight cupping, and Avatery evacuations from the bowels and kidneys.
                                                   Part xxxix., p. 88.

  Syphilitic Pneumonia.—There is an inflammatory consolidation of the
 lung which owes its origin to the  poison of syphilis.  A case is recorded,
 under the care of Dr. O'Connor, at the Royal Free Hospital, in which it
 was  associated  with a papular eruption, and enlargement of one  of the
 testicles.   The treatment consisted of blisterings  all  over the chest, five
 grain doses  of iodide of potassium, and four grains mercury ivith chalk,
 and  conium, twice  a week.  Subsequently the  iodide  of mercury with
 chalk, were given, till.the gums became tender.          Part xl., p. 54.

                              —»••


                       POISONING.
  Poisoning by Aconite.—[Mr. Sayle relates the case of a man who died
in consequence of taking decoction of aconite.  He saw him an hour after
 he had taken it, Avhen he was  quite insensible, pupils widely dilated, and
pulse  scarcely perceptible ; he ivas foaming at the mouth, and throwing
his  arms about.  A teacupful of brandy was administered, which, for  a
time revived him, but while the contents of the stomach were being evac
uated by means of the pump, he suddenly expired.] 
366                          POISONING
  The plant was the aconitum napellus, stalks and leaves quite fresh.  Of
these, six Avere cut up and boiled in half a pint of beer doAvn to a quarter,
half of which he drank.
  Remarks.—The case in itself presents nothing remarkable ; but as they
are rarely met Avith, I think it behooves the medical man to publish these
symptoms carefully for the information  of others.  Dr. Fleming,  in his
prize dissertation, speaks of four degrees-of operation in man, and finishes
his remarks on the fourth degree Avith these words :  " When the  action
of the drug is  carried to a fatal extent, the individual becomes entirely
blind,  deaf, and speechless.   He either retains  his  consciousness to the
last, or is affected with slight wandering delirium; the pupils are dilated;
general muscular tremors, or  even slight convulsions supervene ; the pulse
becomes imperceptible both at the wrist and heart;  the temperature of the
surface sinks still  loAver than before, and at length,  after a feAv hurried
gasps, death by syncope takes place."   It will be seen that' this case  and
Dr. Fleming's description admirably agree, and that  death takes place by
syncope is  proved by all the organs examined post-mortem being enor-
mously distended with blood.
  The stimulating plan of treatment will probably succeed, when employed
early after the evacuation of the poison from the stomach.
                                                     Part x\n.,p.  149.
   Poisoning by Aconite Root.—This has not unfrequently been mistaken
and eaten  for  horse-radish ;  it  may be knoivn by the acid taste  of the
aconite parings, and the pinkish color wdiich they assume when exposed to
the air.
   With regard to the treatment of such cases of poisoning, Dr. Headland
recommended the immediate and free administration of animal charcoal,
mixed with water.  This to be followed by a zinc emetic, then by brandy
and ammonia.  The charcoal has the poiver of retaining and separating the
poisonous alkaloid, and if ive have rendered help in time, the patient  may
perhaps be saved.                                   Part xxxiii., p.  308.

                            ACONITINA.
   Recovery from a Large Dose of Aconitina.—[No case of poisoning by
this deadly alkaloid has hitherto been  published,  and consequently the
description given  by Dr. Bird  is  highly, important.  The patient  was  9
highly educated gentleman, and obtained  the aconitina by means of a pre-
scription of his own writing.   It is supposed that almost immediately after
taking the poison he fell, and struck his head a severe blow against a piece
of furniture, and that the poison, or the blow, or both, produced immediate
and violent vomiting; but  hoiv  long it may have been before he was dis-
covered, cannot be stated.]
   An excellent surgeon, and shortly after, a physician, were called to him;
and about two o'clock in the afternoon,  Avhich must at least  have been
eight hours after taking the poison, Dr. G. Bird met these  gentlemen.
The patient Avas then fearfully collapsed ;  the surface cold and  SAveating;
quite  pale ; the heart's action scarcely perceptible; pupils acting to light;
no paralysis Avhatever, either  of sensation or motion.   Notwithstanding the
intense exhaustion, the  intellect Avas  unimpaired.   The most  prominent
symptom Avas the repeated  and terrific vomiting of a broAvnish fluid.  This
vomiting ivas, however, peculiar, and perhaps hardly deserved  that  title, 
POISONING.
367
the patient really being seized with a kind of general spasm, during Avhich
he convulsively turned on his abdomen, and Avith an intense contraction of
the abdominal muscles, he  jerked out, as it  Avere,  the contents of his
stomach, Avith a loud shout, depending, apparently, on the sudden contrac-
tion  of  the diaphragm.  These exhausting and distressing  symptoms had
occurred every minute  or  tAvo.   On  attempting to make him SAvallow any
fluid, a fearful  spasm of the throat took place, producing  the distressing
effects so well known in the hydrophobia from the bites of rabid animals:
this Avas not produced by the sight of water, but the convulsive movements
of the body, and the emptying  of the stomach, ivere excited by abruptly
touching him.   He Avas placed in a hot bath, afterward  removed to  bed,
covered AAdth blankets,  a large mustard poultice applied to the scrobiculus
cordis, and an enema of turpentine  administered.  He remained in much
the same state, the sedative  effects of the  poison  on the heart gradually
lessening, so that at nine o'clock the pulse was easily perceptible, although
weak ; the hydrophobic spasms  Avere, however, then produced by every
attempt to swalk>AV,so  that none of the medicines suggested for him could
be made use of.  It was therefore determined merely to administer enemata
of beef-tea, Avith the yolk of an egg,  and ten grains  of  laudanum, chiefly
wdth the intention of procuring rest and giving support.   He had a fearful
night of exhaustion and spasm; intellect perfect, and even vivid, so  as to
enable him, whenever he recovered a little from his exhaustion, to carry on
a conversation.
  After this hard struggle with death,  this  man  emerged  from the
effects of the  poison ;  and at tw7o  o'clock on the following  day, when
another  consultation was held, he  was regarded as convalescent.   Dr.
Golding Bird drew attention to the fact,  that although at least two grains
and a half of aconitina had been. SAvalloAved, yet that the majority of the
poison must haA*e been got rid of during the vomiting which folloAved the
injury to the head, resulting from the fall.  He also  pointed out the  re-
markable train of symptoms developed, especially the convulsive vomiting
and  imperfect hydrophobia, as possibly being characteristic of the effects
of the poison.   For although they differed importantly from the effects of
aconite  root, Avith the exception of the sedative influence on the heart, still
such a  difference becomes intelligible when it is  recollected that a pure
alkaloid often differs materially in its  physiological action from that of the
plant from which it is an extract, as shown remarkably in the case of the
alkaloid conia.                                       Part xvii., p. 290.

                             ARSENIC.

  Action of the Hydrated Sesqui-oxide of Iron on Arsenic.—Dr. Maclagan
concludes:
  That  the hydrated oxide of iron is  a real chemical antidote to arsenious
acid, and that when it removes arsenic from solution  and soluble combina
tions it  acts by chemically uniting witli it.
  That  it appears much better fitted for removing arsenic, when it has been
precipitated by ammonia than Avhen precipitated by potash ; and that  it an-
swers better Avhen in the state of a moist magma, than when dried at  180°,
even though, Avhen thus dried, it still retains a considerable per  centage of
combined Avater.
  That  thus there appears to be good grounds for believing that in the ex- 
368
POISONING.
pertinents on annuals, and the cases in the human  subject, in AAdiich it has
been  found to, arrest. the action of the poison, that it acted as a chemical
antidote and not as a mechanical protection to the stomach ;  that the large
quantities which have been found necessary are required not to protect the
stomach mechanically, but to render the poison chemically inert.  That, as
far as chemical evidence goes, at least twelve parts  of oxide prepared by
ammonia, and moist, are required for each  part  of arsenic, and that when
the oxide has either been precipitated by potash, or been dried even at a
Ioav temperature, that about three or four times larger quantities are requi-
site.                                                     Part ii., p. 43.
  Antidote to  Arsenic.—Dr. G. Bird recommends the  following ready
preparation of the hydrosesqui-oxide of iron as one of the best antidotes to
arsenic :  Half an ounce of the tincture of the sesqui-oxide of iron ; one oz.
of liquor potassa.  Mix.                                Part vi., p. 149.
  By White Arsenic—Liq. Kali Carbonici.—D. Emsmann, of Eckarts-
berge, Avas called to a young Avoman  who had been poisoned by means of
Avhite arsenic.  She was in great pain, Avas vomiting, purging, and suffering
great thirst, etc.  He gave, every half hour, a spoonful of a  mixture com-
posed of half an ounce of  the  liq. kali carb. in tAvo ounces of sir. altheas.
The effect was immediate, the vomiting ceased, the pain was relieved, and
the other symptoms gradually disappeared.               Part vl,p. 149.
  Arsenic as a Poison—Its Tests and Antidotes.—In order to prove  the
existence of arsenic, in a court of justice, says Dr.  Shearman, we should be
enabled to show the following facts  so satisfactorily, that  a  jury may not
only see, but perfectly understand them.
   1st. The metal should be produced either from the contents of the stom-
ach, intestines, or  urine, if  the  patient should survive; or,  if dead, from
these and some part of the body.
   2d. We should be able to prove that the animal substances  experimented
upon  were the excretions and parts  of the patient's body only, unmixed
Avith any other matter.
  3d. We must also prove that  the tests we use to sIioav the existence of
arsenic  have not a particle  of arsenic in themselves.  And  this requires
great caution, because  a skillful  advocate might make a guilty prisoner ap-
pear innocent, owing to this omission.
  4th. As antimony, bismuth, tin, zinc, lead, tellurium, cadmium, selenium,
and potassium,  sublime in  a somewhat similar manner to arsenic, and
may be mistaken for it, it is absolutely necessary to guard against such  a
mistake.
  The most common mode  of obtaining arsenic from an organic solution,
is that of Dr. Christison, in which he gets rid  of the animal matter by
boiling  for  half an hour in distilled water with strong acetic acid, Avhich
often  precipitates  the   casein, and  renders it sufficiently pure ; if not, the
solution should be neutralized by potash or ammonia, sloAvly evaporated to
dryness, redissolved in distilled water, filtered when cold,  and then evapo-
rated  several times again.   This eventually produces a solution free from
animal matter.   With the ammoniacal nitrate of silver this  gives a lively
yelloAv precipitate, the arsenite of silver; Avith the  ammoniacal sulphate of
copper,  an apple, or grass-green precipitate, the arsenite  of copper; and
Avith sulphureted hydrogen gas (previously acidulated with  acetic acid),
it throAvs down  an  abundant sulphur yelloAv precipitate, the sulphuret of 
POISONING.                           369
arsenic.  This sulphuret should be collected on a filter, dried, mixed with
black flux, or freshly ignited charcoal, introduced into a bulbed tube, and
properly heated by a spirit lamp, when a brilliant polished metallic ring of
metallic arsenic will  be sublimed all round the tube.  This is called the re-
duction test.  This metallic ring of arsenic should then be oxidized by ex-
posure to  the  heat  of a spirit-lamp in atmospheric air, when  octohedral
crystals of arsenious acid, Avith triangular facettes, will be deposited on the
upper'part of  the tube, which may be easily seen with.a tolerably good
micVoscope.
  In Marsh's test, Avhere hydrogen gas is generated from zinc, sulphuric
acid and. water, and  the suspected substance is added hi solution, arsenio
having such an, affinity for hydrogen quickly combines what that gas and
forms arsenietted hydrogen, which  being ignited,  metallic arsenic is de-
posited on porcelain  or glass, and may be seen in rhomboidcd crystals with
a powerful microscope.  The  objection to the test  is,  that Ave are obliged
to use zinc, Avhich often contains arsenic ; and although it showrs the most
minute quantity, how can we swear, after the first layer of zinc is oxidized,
that there may not be arsenic in the next ? for arsenic runs in the veins
of the ore.
  In  Professor Reinsch's test,  modified by Christison, we mix the sus-
pected matter  with  distilled water, add  3ij. of pure hydrochloric acid to
every eight ounces  of fluid, immerse a very thin and bright copper plate,
and boil  for half an our, when the whole  of the copper plate Avill be coated
with arsenic.  By cutting these plates into chips, and, exposing them in a
tube at a low red heat over a spirit lamp, arsenious acid will be sublimed in
octohedral crystcds with triangular facettes, Avhich may be rendered more
distinct by turning out the chips, covering the  tube wdth  the  finger, and
.chasing the oxide up and  down the tube  over the lamp.
  A most  ingenious, scientific, and elegant  method of obtaining  arsensic
has been introduced by Robert Ellis, of University College.  He  has  dis-
covered that the  oxides of copper have such an affinity for arsenic, that by
merely passing arsenietted  hydrogen over them, a double decomposition
takes place :  caloric  is  given out; the oxygen of the copper uniting  with
part of the hydrogen forms.water, ivhich is seen in the process; the arse-
nic of the arsenietted hydrogen uniting with the copper forms arseniuret
of copper—the remaining hydrogen being set free.  This arseniuret of
copper may be  easily sublimed in a glass tube, Avhen the whole of the arse-
nious acid Avill be deposited in thick brilliant clusters of octohedral crys-
tals  on the tube.  The objection urged  against Marsh's  apparatus  Avill
equally apply to this—that of  being obliged to use  zinc for the generation
of hydrogen.  The cleanest and safest mode of detecting arsenic is by de-
composing distilled water by galvanism,  to Avhich is added the suspected
solution,  and pure sulphuric acid : collecting the hydrogen from the nega-
tive pole  or zincode of  Smee's battery, igniting it, and  examining the stain
left in a glass tube, open at both ends.   If there is the smallest particle of
arsenic, the hydrogen will untie with it;  and you then have a stain of me-
tallic  arsenic with rhomboidal  crystals which you may then oxidize into,
octohedral crystals;  collect, dissolve in water,  go through the fluid tests,,
reduce the sulphuret in a tube, and  sublime into  arsenious  acid again.
This is the most  delicate test knoAvn, and  perfectly free from the charge
of using any substance  in which  arsenic can exist/
  The most likely substance to  be mistaken for arsenic by any of these
    VOL. n.—24 
3T0
POISONING.
tests is antimony, because antimony sublimes  into the same kind of crys-
tals as arsenic.   But by attending to the following rules the tAvo substances
may easily be distinguished.  Metallic arsenic sublimes into rhomboidal
crystals at a heat of 356° Avithout liquefying.  Arsenious acid sublimes at
380° into octohedral crystals.  Metallic antimony sublimes not  under
810°, and on cooling, acquires a highly lamellated texture, and yields octo-
hedral crystals  like arsenic,  which are insoluble  in water; Avhereas the
octohedral crystals of arsenious acid are very soluble, and which  solution
may be  tested by the three  fluid tests.   In the reduction tests Avith-sul-
phureted  hydrogen gas, it should be carefully remembered that the sul-
phurets of antimony, tin, selenium, cadmium, and  tellurium, have* nearly
the same yellow color, and are deposited in the  same manner as arsenic,
and when reduced to their metallic state with black flux, they not only
give an  appearance so much  like arsenic, that it requires a very practised
eye to distinguish each, if even that be possible; and tellurium and cad-
mium also exhale a garlic odor like arsenic.
  The question then comes—Iioav can a Avitness swear most positively, that
a substance is arsenic and nothing else; and how can he convince an un-
scientific jury of that fact ?  I think  only in the folloAving manner:
  1st. By producing the metal, and shoAving its crystals.
  2nd.  Reducing it to oxide, and showing its crystals.
  3rd. From these crystals going through all the fluid tests.
  4th. Reducing the sulphuret again to its metallic state, then to the oxide
and again going through the fluid tests.
  If this be shown clearly wdth all the before-mentioned tests, it will be
impossible for any advocate to mislead a jury. The only antidotes which
have been discovered for arsenic are the moist hydrated peroxide of iron,
and the moist hydrated  persulphuret of iron.  I have lately given dogs
and rabbits large doses of arsenious acid in solution  and powder, and imme-"
diately  afterAvard large doses of the moist hydrated peroxide  of iron, and
then killed them within a short time.  The  stomachs  have shown minute
patches of inflammation, but no arsenious acid  could be  detected  by
Reinsch's method, the copper plates having merely a scaly deposit of iron
upon them; nor could arsenious acid be detected in any other way. . This
is a strong presumption  that the whole of the arsenic was reduced  to its
metallic state.
  Dr. Golding  Bird  suggests that hydrated per-oxide of iron may be ex-
temporaneously prepared by adding one ounce of liquor potassas to half an
ounce of tincture of sesquichloride of iron.                 Part ix., p. 55.

  Magnesia in the  Treatment of Poison  by Arsenic. — Magnesia, not
strongly calcined, is  recommended by M. Bussy as an excellent antidote to
arsenious acid ; it removes it entirely from a state of solution in water, and
forms an insoluble compound.  Magnesia  in a  gelatinous state answers
best. Magnesia decomposes emetic tartar,  the salts of copper, and corro-
sive sublimate, also the organic alkalies, morphia and strychnia.
  Dr. Christison recommends the light pure magnesia, Avhich may be ob-
tained in a gelatinous pulpy state, by adding a solution of caustic potash to
a cold saturated solution of sulphate of magnesia, and w ashed afterward
with cold water.  The dense magnesia  has  very  little action on arsenic in
solution.   When the gelatinous cannot be obtained, then use the light cal-
cined, in proportion of between thirty and fifty parts to one of arsenic taken. 
POISONING.
371
  As  in the hurry of these cases it is  frequently difficult to  know what
quantity of arsenic has been taken, it must be left to the discretion of each
practitioner to judge Avhat quantity of the magnesia he shall administer as
the antidote.                                          Part x\v.,p. 117.
  Poisoning  by Hingis Yellow.—King's Yellow, according to Dr. Chris-
tison,  contains sulphuret of arsenic, caustic lime, and free sulphur, and in
all probability, the lime exists in the form of a triple sulphuret of lime and
arsenic
  The hydrated peroxide of iron acts as the best chemical antidote, com-
bining with the arsenic in the stomach to form an arsenite of iron Avhich
has little solubility, and  therefore little  energy as a poison.   As the
arsenic may be again set free by the secretions  of the stomach, take care
to give the peroxide in excess, and repeatedly until all effects subside.
                                                    Part xiv.,  p. 119.
  Poisoning  by Arsenic.—[In  a paper read before  Guy's Hospital Phy-
sical Society, Mr. Odling states it as his  opinion that the only plan of treat-
ment to be depended upon is the removal of the poison physically from the
stomach, and  that this is best effected by using the double-action stomach-
pump. He next considers  the  remedies to be  used  in cases of arsenical
poisoning, and first, of the  hydrated ferric oxide, or  sesqui-oxide of iron.
This, by being administered in  the state of a moist magma, suspends the
poison, but its power is extremely weak, and the compound formed wdth it
is perfectly soluble in the gastric juice, and has been  found to possess poi-
sonous properties.  Magnesia,  so much vaunted  at one time, is even less
fitted  to act as a chemical antidote.]
  Mr. O. would at once wash out the stomach by means of the double  ac-
tion stomach-pump, Avith a solution of chromate  of iron or alumina, or a
mixture of permanganate of potassa solution, or wdth hydrate and  acetate
of ferric oxide, or with  hydrate  and acetate of alumina.   By  these  com-
pounds the soluble arsenious acid is immediately converted into insoluble
arsenic acid  or into the insoluble  sesqui-arseniate  of alumina, iron,  or
chrome.  Ten grains of the permanganate of potassa may be mixed Avith
half a pint of the aluminous  emulsion, under  Avhich circumstances,  its
irritant action would be very trifling, riot more than that of an ordinary sul-
phate  of zinc emetic.                                 Part xxiii., p. 317.
  Arsenic—Test for.—Give magnesia mixed to the consistence of cream,
in doses of two or three tablespoonfuls.  In a case reported by Dr.  Mac-
lagan, the  patient took  four ounces  in three quarters of an hour,  and, no
doubt, vomited it nearly all up again.  Reinsch's  test is  a most valuable
and convenient one in cases of poisoning by arsenic.  All that is required
is a little muriatic acid,  a bit of copper Avire, and some vessel as a test tube,
in which they can be heated together.  These articles are  so common that
it must be  rare Avhen they cannot be supplied.   If the piece of copper be
crusted black during the boiling, and Avhen heated in a candle-flame loses
its crust, and  gives off  alliaceous fumes, the evidence will be  sufficiently
precise.                                             part xxv., p. 322,
  Electro-Chemical Mode of Testing for Arsenic.—Dr. Davy's process is
adapted to detect arsenic in all its  states of combination, and in  various
organic mixtures ; and it is a strong recommendation of it, that it obviates
in many instances, any troublesome or tedious manipulations. It essentially
consists in depositing the arsenic in a metallic state upon  a surface of  pla- 
372
POISONING.
tinum (as a platinum capsule or a sheet of that metal), by touching the spot
with a  rod or thin slip of zinc, and maintaining  the contact for a few
geconds, when the metal arsenic falls as a film, more or less thick in pro-
portion to its amount, and adhering firmly to the platinum, whence it can
be removed by heat or acids, and  subjected  to  any further tests that are
desirable.
  To prepare the  solution  for  testing,  some pure muriatic acid must be
previously added ; and when the fluid is very dilute it is then concentrated
by boiling before using the electro-chemical test.  After the concentration,
which may be carried to a considerable extent with  advantage, it is Avell to
add some more muriatic acid before testing.  Sulphuric acid appears, from
some experiments, not to  interfere  with the result, but nitric  acid did.
" There was some  difficulty in exhibiting the arsenic."
  In testing such arsenical compounds as realgar and  orpiment, arsenical
pyrites, etc., they  require first  to be acted on by nitric acid  to dissohre
them, and then all excess of this acid, either exhaled by heat or neutralized
previous to adding muriatic acid and testing, as  a minute quantity of nitric
acid  retards the reduction of the arsenic or redissolves it.
                                                  Part xxxiv., p. 299.

                          BELLADONNA.
  Belladonna Poisoning.—Dr. Jenner, of University Col. Hospital, re-
commends to apply a blister to  the back of the neck, and give an aperient
with five grains of the sesquicarbonate of ammonia every hour or half-hour,
according to the severity of the symptoms.            Part xxxv., p. 279.
  Animal Charcoal an Antidote to  Vegetable Alkaloids.—Dr. Garrod, of
University Col. Hospital, says that if to the solutions of the poisons of hen-
bane, belladonna,  stramonium,  or morphia,  a  little animal charcoal be
added, the poison is completely  neutralized.  This property makes animal
charcoal of the greatest use as an  antidote  to these substances ; common
black bone will do very well; vegetable charcoal  does not possess these
properties.                                        Part  xxxvii, p. 259.
  Poisoning'  by  Belladonna. —Use of Opium  recommended.    Vide
" Poisoning by Opium."

                            COLCHCUM.
  Poisoning by— Case.—The subject of the  following case was ordered
in a public institution six drachms of tincture of colchicum in  a  half pint
mixture of Epsom salts, of Avhich  he took one ounce every six hours.  It
was ascertained that a larger quantity (six ounces) of the colchicum had
been put into the bottle than Avas prescribed.  Vomiting soon commenced
after the first dose, and after the third the nose began to bleed profusely,
accompanied wdth  violent purging.  NotAvithstanding these violent symp-
toms, the  medicine was continued.  His  medical  attendant found  him
sitting up in bed, with his back reclined against  the Avail, his arms hanging
hstlessly beside him, his head bent forward upon his breast, and his shirt
drenched Avith blood from  his  nostrils.  His mouth was  open, his eyes
wTere staring, full,  and turgid ;  the vessels  of the  adnata  congested and
the pupils dilated ;  pulse 170, full, bounding, and incompressible, and respi-
Mfltion short and hurried.   Thirty  ounces of blood  Avere taken  from the 
POISONING.
373
 arm and a mixture containing potass, carb. and liq. opii sed. was prescribed,
 followed by port Avine and cinchona bark.  This treatment seemed to rally
 the patient, but he ultimately relapsed and died.
  Dr. Thompson makes the folloAving practical remarks :
  On reviewing the treatment of this important case, I have  little to  re-
 mark, except that it is probable, had my assistance been sooner demanded,
 I should have opened the temporal artery, instead of bleeding from the arm.
 I am of opinion, that in the early stage  of poisoning by an  acrid,  or a
 narcotico-acrid poison,  the  poison is circulating in the brain,  and  that
 much benefit Avould result from rapidly abstracting a large portion  of it
 from the vicinity of that organ, upon Avhich much of its energy is exerted.
 By such a  practice,  also, the sympathetic  irritation would  have  been
 srreatly lessened, and time would have been  thus afforded for providing
 against the collapse, which, in all these cases, is the result to be dreaded.
                                                     Part viii., p. 48.

                             COPPER.
  By  the  salts  of  Copper— Treatment by  Solution  of  Carbonate of
 Soda.—Liquid albumen is generally administered  as an  antidote  in cases
 of poisoning with the salts of copper, but it  has  this disadvantage, that
 as we are unacquainted  A\dth the  exact quantity necessary to neutralize the
 copper, if Ave employ too great a quantity, the poison is dissolved in the
 excess of albumen.   To remedy  this inconvenience M. Benoist  proposes
 to substitute for albumen, a solution of carbonate of soda, which forms
 with the salts of  copper an insoluble carbonate, having no  deleterious
 action  on the economy.                                  Part, v., p. 84.
  Hydrated  Protosulphuret  of Iron—Suggested as  an antidote in poi-
 soning  by the Salts of Copper.   Vide Art. "Poisoning by Corrosive
 Sublimate."

                    CORROSIVE SUBLIMATE.
  Gold Leaf and Iron-filings, as a Galvanic Antidote to  Corrosive  Sub-
 limate.—All the compounds of mercury  are more or less poisonous, but
 none more likely to be so than the corrosive  sublimate  or bichloride,  on
 account of its being introduced so much in the process of tanning and  to
 prevent the decay of timber, as well as in the destruction of insects ;  thus
 exposing individuals to the danger of introducing it accidentally  into the
 stomach.  Gluten and albumen ha\Te hitherto been our chief antidotes,
 especially albumen, ivhich changes  the  corrosive  sublimate into  calomel,
 and thus renders the patient  liable to very severe  salivation, which,  of
 itself, is attended  Avith inconvenience and  even danger.  Dr.  Buckler,
 amongst other experiments, found, " that by  throwing gold  dust into a
 solution of mercury, no  action took place till iron-filings were added, when
 the metallic mercury was at once revived, and Avas seen  to precipitate in
 a state  of amalgam with the gold ;  at the same time, the oxygen  from the
 corrosive sublimate goes over to  the  iron, and  forms  an  oxide of  that
 metal with Avhich the chlorine combines, leaving  a hydrochlorate of iron
 in solution."
  The result is a complete decomposition of the  poison.   Two grains  of
gold and two of iron are sufficient  to decompose  five grains of  corrosive
sublimate. 
374
POISONING.
  The proposed antidote should be kept by the druggists in papers con-
taining each,
  Finely-divided gold, ditto iron, aa. 9ij ;  gum acacia, 5ss. M.
free from dampness, to prevent oxidation to .the  iron.  In poisoning with
any compound of mercury, one powder is  to  be stirred  in  a tumbler of
water, and SAvalloAved; if any of it is rejected, another poAvder should be
given.  If  a solution  of mercury  were swalloived, Ave could not expect
much benefit to arise from the use of gold and iron, in any other state than
that of dust.  In case of poisoning with the insoluble compounds of mer-
cury, if the dust cannot be obtained, then use  the metals in the form ot
heads, fine  chains, or any  other shape in  which  they can be swalloAved.
Dr. B believes that they Avould decompose the soluble salt with as much
rapidity, at least, as it could be formed in the  stomach.
  Mr. Barry thinks that  Dr.  Buckler's discovery may prove exceedingly
important; but seems to disagree -with him on some parts of the question.
He is of opinion that the  decomposition is owing " to the thin stratum of
fluid immediately enveloping the tAvo  contiguous  particles of iron and
gold;" and, therefore, that " it is essential that these metals should be in
a state of division so  exceedingly minute, as  to remain  a  short time in
suspension throughout the xohole fluid of the stomach.  Every drop of
that fluid must be made to contain a multitude of these particles, and yet
the entire  weight administered be very small."  The chief difficulty in this
case will be, not in the minute division of the gold, but in that of the iron.
It is probable, however, that in this  combination of gold and iron, we shall
possess, when properly managed, a complete antidote to one  of our com-
monest and strongest poisons.                            Part, v., p. 34.
   Hydrated Protosulphuret of Iron  as an Antidote to Corrosive Sublimate.
—M. Mialhe has discovered that hydrated protosulphuret of iron, a perfectly
inert substance, instantly decomposes corrosive sublimate ; protochloride of
iron and bisulphuret of mercury, tAvo inert substances are  formed.  This
preparation will  probably also be found equally efficacious as an antidote
to other poisonous salts, as those of copper and lead.
   The following is the mode of preparing the hydrated protosulphuret of
iron: Dissolve  any quantity of  pure  protosulphate  of iron in at least
twenty times its Aveight of distilled  water, deprived of air by boiling, and
precipitate the iron with a sufficient  quantity  of sulphuret of sodium, dis-
solved also in distilled water, deprived  of air.  Wash the  protosulphuret
thus obtained, with distilled Avater, and preserve it  in stoppered bottles,
filled wdth boiled distilled water.
   Although the preparation of this sulphuret  of iron is very simple, and
may be effected in a few  minutes, yet  it would be  desirable to keep it
always prepared, that no time may be unnecessarily  lost in any case of
poisoning.
   The precaution of preserving this sulphuret out of contact of the  air,
must be strictly observed, as it has a great tendency to pass into the state
of sulphate.                                            Part, vii, p. 83.

   Antidotes of  Corrosive Sublimate,  Copper, Lead and  Arsenic.—By
means of  numerous  experiments, first made in the laboratory and then
repeated on dogs, MM. Bouchardat  and Sandras have arrived at many inte-
resting results relative  to  the antidotes of  corrosive sublimate,  copper,
lead and arsenic. 
POISONING.
375
  Their conclusions were, that the following substances may be regarded
as antidotes, and employed as such in medicine :
  As Antidotes for Corrosive Sublimate.—A mixture of zinc and iron fil-
ings ; or powder of iron reduced by hydrogen; or the moist persulphuret
of the hydrated peroxide of iron.
  As Antidotes for Copper.—A mixture of zinc and iron filings; iron re-
duced by hydrogen; porphyrized iron;  zinc filings; or the persulphuret of
the hydrated peroxide of iron.
  As an Antidote for Lead.—The moist persulphuret of the hydrated per-
oxide of iron.
  As Antidotes for Arsenic.—The moist hydrated peroxide of iron;  the
dry hydrated peroxide of iron ;  and the moist persulphuret of the hydrated
peroxide of iron.
  These experienced chemists  add  the following reflections: This  last
preparation, the persulphuret of the hydrated  peroxide  of iron, possesses
this superior advantage over all the rest, that it changes  the  nature of all
the four poisons above noticed,  and is especially applicable in those cases
Avhere we have not had time to  find Avhich of the poisons has been taken.
As to the  manner of administering these  antidotes, and the doses wdiich
it is necessary to administer, the. simplest means appear the best.   The
powders of zinc and iron may be suspended  in any electuary, or they may
be swallowed in wafer paper.  The magma of the hydrated preparations
of iron may be swallowed in the form of jelly,  in ivhich they are procured
from the druggists.   Several draughts of lukeAvarm Avater ought to follow
the antidote, and the fauces be  tickled Avith a  feather, to excite vomiting
and  the expulsion of the poison.  The efforts at vomiting  scatter  more
effectually over the stomach the antidote which  is  administered.  As to
dose, the experiments proved that 10O grains of the powder  of iron or of
zinc sufficed to prevent any bad effects from 15 grains  of the acetate of
copper.   Fifteen drachms of the moist magma of the persulphuret Avere
required to produce the same effect Avith the same dose (15 grains) of the
acetate of copper.   To act as an antidote  to 4| grains of arsenious acid,
15 drachms of the moist magma of the persulphuret, or 30 drachms of the
moist hydrated peroxide of iron, or 20  drachms of the dry hydrated per-
oxide of iron,  were  required.  With  regard  to the time Avhen  these  anti-
dotes can  be administered with adArantage, in so far as the acetate of cop-
per is concerned, the lapse of 40 minutes from  the time of swalloAving the
poison ought not to be regarded as a sufficient reason for not administering
the antidote; but arsenic is more quickly absorbed.  Nevertheless,  the
antidote should ahvays be  administered, because,  though it will not  neu-
tralize Avhat is  absorbed, it Avdll  prevent its further absorption, by decom-
posing Avhat remains in the stomach.                    Part ix., p. 78.

  Mineral Poisons.—MM. Sandras  and   Bouchardat recommend  a uni-
versal antidote for the mineral  poisons, the  persulphuret of iron in  such
quantities  as to be always  in excess in the  intestines, to  prevent the reab-
sorption of the poisonous matter. They administer first a purgative, and
order a soap-bath, then give the patient a mixture of sirup and persulphu-
ret of iron night and morning.   Opium, strychnia, or belladonna may be
employed  at the same time.  Two cases only proved fatal out of 122  Avith
lead colic  thus treated, and the  others were rapidly cured.
                                                     Part xiv., p. 324. 
376
POISONING.
   Ne-uy Process for the Detection of Metals in Medico-Legal Researches.—
M. H. Gaultier de Claubry gives the following:  "Process  by Avhich all
Metals can be obtained by a single operation, in chemico-legal researches."
His objects are,—1, to obtain in all cases a  solution of the  metal; 2, to
collect the metal from the solution ; and 3, to present it in solution, in aa
concentrated a form as possible,  to the action of chemical reagents.  He
6ays:
   With this intention (that of obtaining a perfect solution of the metallic
substances), hydrochloric acid or chlorine have been employed, Avith more
or less advantage.   Without stopping to discuss the advantages or incon-
veniences arising from their employment, we  may say, that the alteration
desired to be affected by them is always more or less difficult, and  that a
great proportion of the organic matter resists their action.   We  know,
from numerous facts, how much more readily a body enters into a neAV
combination Avhen in a nascent state, than when in the form  under which
we see it; and it is precisely in this state that chlorine may be made avail-
able for the object  which occupies our  attention.  If Ave introduce any
organic matter into fuming hydrochloric acid, and, after having removed
the fatty matters, Avhich are altered Avith difficulty, gradually add concen-
trated nitric acid to the fluid, either cold  or slightly Avarmed, a complete
solution is  obtained  of everything, Avith  the exception  of fatty matters.
The solution is almost colorless, transparent, and can be afterward  tested
with the greatest facility.
   The stomach, intestines, liver, products of vomiting, excrements, blood,
urine, wine, milk, earth from burying-grounds, etc., can all be  treated after
this method, Avhich requires no particular care,  so that  the  operation is
performed as easily as the solution of a metal in  an acid.  Where the poi-.
sonous agent is arsenic, if the operation be  conducted slowdy,  the metal
does not  pass  off by evaporation; hoAvever,  as  a portion of chloride of
arsenic  may be volatilized, and as the chlorine and  acid  require some
means to  prevent them from passing off, and incommoding the operator
by filling the laboratory with their vapors, it is ahvays best to use a retort
furnished Avith a tubular  receiver.  When the operation is  finished, the
condensed liquor is to be  treated in the manner to  be presently described.
A tubular retort, into. Avhich are introduced in succession, first, the hydro-
chloric acid, then the suspected materials, and  finally the nitric acid, is
thus sufficient for the operation.  If it be known that arsenic  do not exist,
and there be no necessity for guarding against the escape of acid vapors
and of chlorine, the operation  maybe  performed  in  a matrass.  By this
process the  difficulties are prevented Avhich arise  from the employment of
sulphuric  acid for the destruction of the organic  materials, and a perfectly
liquid product is obtained.
   When the materials are much disorganized, the nitric acid is to be intro-
duced gradually, and gentle heat is to be applied.  When, after successive
additions  of the acid, the organic matters have disappeared, leaving only
fatty matters, the hquor is to be decanted, and the residuum washed several
times in distilled Avater.  This is to be poured off, and mixed with the acid
solution.   After this, the  detection of  the metals becomes extremely easy,
and may be effected in various ways.
  If it be desired  to use hydrosulphuric acid,  the  nitric acid must be
driven off, by boiling the hquor with an excess of hydrochloric acid, until
chlorine ceases to escape;  after this, the liquor will only have to be tested 
POISONING.
377
for zinc, which may be present accidentally, or for those  metals wdiich are
not precipitable by hydrosulphuric  acid.  If Marsh's test is  to be em-
ployed, the liquor must be saturated  with pure potash; and, after decom-
position has taken place, sulphuric acid must be added, till the last traces
of nitric acid are removed.   The operation may then proceed in  the ordi-
nary manner.                                          .        •
  I have employed another process, which seems to offer important advan-
tages, and is easy to be performed; it depends on the precipitation by a
galvanic current, of the metals in solution.  After having concentrated the
liquors, as far as experience may determine to be  necessary for driving off
an excess of acid, there are to be'placed in the solution two plates of pla-
tinum, or a single plate of that metal, forming the cathode of a permanent
battery; and another  of zinc (if that metal be not sought for), of tin,  or
platinum, forming the anode.  After an interval of greater or  less dura-
tion, according to circumstances, but never exceeding, in the most unfa-
vorable conditions, eight or ten hours, the platinum is covered by a  de-
posit of the metal, or  metals, which Avere in solution.  This deposit is  to
be Avashed,  and  treated Avith hot  or cold nitric  acid; a solution of the
metal or metals is thus obtained, which, from the small quantity of liquid,
can be operated on with the greatest facility.  In this way, almost infini-
tesimal quantities of the various metals may be detected, and it is obvious
that the same proceeding is applicable to all,  with the exception of silver,
which is rarely to be tested for in  cases of poisoning, and zinc, which
necessitates the employment of tin or platinum, as the anode of  the  pile.
  Although sparingly soluble, chloride  of lead dissolves  in an  excess of
hydrochloric acid easily enough for all the lead to be detected in the liquor.
  If the presence of arsenic be suspected in the matters to be examined,
the liquid procured by the treatment Avith nitric  acid, must be  saturated
with potash and after the solution has been  conveniently concentrated, it
must be mixed with the  solution of the organic products.  In no  other
case have volatile products to be dealt with.
  It is wrell known that bakers  have sometimes fraudulently introduced
extremely small proportions of sulphate of copper into paste.  The com-
bustion of the charcoal from bread is very tedious, but an examination is
performed with ease and rapidity by the process A\diich I  have  described.
It permits a large quantity of bread  to be operated on, and a repetition of
the experiments, with a degree of exactitude, which leaves notliing to be
desired.
  When, in testing for zinc in bread, or in other organic  matters, recourse
Is had to carbonization, there is always danger of a portion of the metal
Deing volatilized; by treating it with aqua regia, the operation is rendered
easy, and no part of the metal is lost.  It is  not  necessary to mention all
the other circumstances to  Avhich this  neAV  method may be applied.  I
have met Avith no case in which I have  not been able to employ it; and
hence I may consider  its adoption will render great  services to chemists,
when  called on to make researches of the kind under consideration.
  It may be objected  to this method, as  to many others in which hydro-
chloric acid has been  used, that this acid may contain arsenic.   There is
but one answer to  this objection, viz., that  as hydrochloric acid can be
obtained free from  arsenic,  such must be procured, and alone employed.
Sulphuric acid, also, often contains a greater or less quantity of this metal;
that only Avhich is free from it is tc be used.            Part xix., p. 215. 
378
POISONING.
  Animal Charcoal  an Antidote  tj.  Poisons.—Fresh  animal  charcoal,
when used in sufficient quantity, has the property of- Avithdrawing  from
their solutions most,  if not all, known vegetable  and animal poisonous
principles, and some mineral poisons.  It should therefore be immediately
administered in all cases; whilst, in the case of mineral poisons,  the usual
antidotes should also be given.                         Part xx., p. 298.

                              CUBEBS.
   Use of Electro-Magnetism.—Dr. Page, of Valparaiso, has used this
means in a case of poisoning by a large, dose of powdered cubebs.  The
patient took half an ounce  of this drug on going  to  bed, and Avas found
next morning with his face  red and SAVollen,  lips dark purple, veins of the
forehead and temples turgid, eyes rolling upward and  injected, Avith the
pupils contracted to  a  point, respiration very  slow, short, and gasping,.
and  Avith all the other symptoms of comatose  sleep.  Every method that
could be thought of to rouse him Avas  tried in vain;  he soon  returned to
the same state of insensibility, and death  seemed to be inevitable.   In this
case, Dr. Page tried  the electro-magnetic battery with success.  With an
assistant rapidly rotating the wheel, he applied the balls at first to  each
side of the neck, and  ran them  doAvn behind the clavicles.  The arms anq"
body now moved convulsively, but the patient lay as unconsciously as
before: but on  applying one ball over the  region of the heart, and the
other to a corresponding point on the right side, the patient opened his
eyes Avidely, his head and body were thrown convulsively  forward, and he
groaned.  He again sank back iuto  his former state ;  but on applying the
balls to the same regions, he became conscious,  and ultimately recovered.
Dr. Page in  this  case used a large horse-shoe  magnet mounted upon a
stand, in a vertical position, with an armature, fixed upon an axis between
the poles, so as to revolve in front by means of a wheel; but a much more
portable machine is  now made by most surgical-instrument makers, and
wdiich ought to be in the possession of every general practitioner.
                                                       Part vii., p. 32.

                          PRUSSIC ACID.
   The Liquor Oxysulphatis Ferri—Thought to be an antidote to poison-
ing by prussic (hydrocyanic) acid.                        Part v., p. 68.
   Cold Douche.—In cases  where prussic acid has been administered, and
the frame is influenced by that deadly poison,, a valuable auxiliary will be
found  in  cold  affusion,  to chlorine, ammonia,  artificial  respiration,  etc
Herbst, Orfila,  and others, speak highly of its powers.  It  occasionall)
happens that a sudden alternation from cold to hot  appfications,  and from
hot to cold, Avill be more beneficial  than  a  continuance in the one or the
other, exemplifying what Dr. Marshall Hall says, " that  it is not  the mere
application of cold, but the sudden application of cold to a warm surface,
AA'hich is the effectual means  of exciting respiration.  It is  the sudden
alternation."  In the cases of persons to all  appearance dead, heat and
cold are powerful measures in arousing the respiratory system;  but  they
are not to be regarded as substitutes for other  methods of resuscitation,
so much as allies to them. The value of temperature in congenital asphyxia
is admitted universally: one dash of cold water will  suffice sometimes to
excite breathing Avhere it is delayed.                    Part viii., p. 45, 
POISONING.
379
   Sulphate of Iron, with an Alkaline Carbonate, an Antidote for Prussic
 Acid.—[Messrs. Smith recommend, that in cases of poisoning by prussic
 acid, the first thing to  be done should be to give a large dose of either
 caustic or  carbonated magnesia, in  order to  neutralize the effects of the
 free acid,  Avhich is almost  invariably to be found in the stomach,  and
 which interferes wdth the action of the remedy they propose.   This con-
 sists of two substances: the first, a salt of iron, of the same constitution as
 Prussian blue, and  which is  readily prepared by the following process:]
   Seven parts of proto-sulphate  of  iron, say  seven half-drachms are re-
 quired, four of which  are to  be formed into persulphate.  This is done by
 adding to the solution a quantity of sulphuric acid equal  to  the half of
 what it already  contains ; Avhich, for two drachms, Avould be twenty-three
 grains of acid of the density of 1.845,  and at a boiling heat;  adding, at
 short intervals, small quantities of nitric  acid, till red nitrous fumes cease
 to be given off.  The liquid is then to be evaporated in a porcelain basin
 of perfect  dryness,  by the heat of  a water-bath, stirring constantly Avith a
 glass rod, till the excess of acid is thoroughly driven off.  The operations
 will be -more quickly  finished  in  a bath of a saturated solution  of salt.
 The perfectly dry salt is then to be dissolved in distilled Avater, along Avith
 one and a half drachms of proto-sulphate of iron, so that the solution may
 amount to  two ounces.  This solution wdll not of itself precipitate prussic
 acid, but if a solution of an alkaline carbonate be previously added, con-
 taining a quantity just  sufficient  to  take all the sulphuric acid from  the
 iron salt, the prussic acid combines instantaneously Avith the iron-, forming
 the very permanent and insoluble  compound Prussian  blue.  As the solu-
 tion of the sulphate of iron contains in all nine equivalents of sulphuric
 acid, the same number of equivalents of carbonate of  potash—the alkaline
 carbonate we use—will be required to seize upon these and produce com-
 plete  decomposition.   The  relative  quantities are 910 grains of proto-'
 sulphate of iron, and 623.43  grains of carbonate of potash.  Noav,  as  the
 quantity of sulphate of iron  given  in our formula was seven half drachms,
 or 210  grains,  the  correct  quantity of  carbonated alkali can be found
 by  the  following  proportion — 910  :  622.43  : : 210 : :  144.   There-
 fore 144 grains is the proper quantity for the exact decomposition  of  the
 iron  salt;  and for  the  sake of simplicity, Ave dissolve this in the same
 quantity of water as the sulphate of iron.  As each of the solutions contains
 exactly 961 minims, which, by calculation, should throw down 56.8 grains
 of red prussic acid, between  17 and 18 minims  of each should separate  the
grain ; and as the hydrocyanic acid of the London Pharmacopoeia contains
two per cent,  of  real acid, 35  minims of each would  be required to pre-
 cipitate 100 grains of such an acid.  The acid of the Edinburgh Pharma-
 copoeia, on  the other hand, containing about three  per cent., a third more
 or about 52 minims  of each of the solutions, would be necessary to sepa-
 rate all the prussic acid from  100  grains.  It  is probably unnecessary to
carry the calculation higher, as we suspect, that if a larger quantity than
100 grains  should  be taken, the  fatal effect would be  so rapid, as com-
pletely to  exclude  the  possibility of rendering any available assistance.
these are the quantities theoretically necessary, and, when pure materials
are used, will be found very nearly correct, as  tested  in an open vessel;
but when give:, as an  antidote for the poison, we would recommend  not
less than three  times the theoretical quantity to be  given, as from  the
presence of  food, mucus, etc., in  the stomach, it is  improbable that the 
380                          POISONING.
antidote would mix immediately with the poison at  every point, so that,
to render the action more  certain, a large excess is advisable, more espe-
cially as this can be attended with no evil consequences, as the only effect
that could follow an excess would be the formation of sulphate of potash
and an  insoluble mixture of proto-carbonate and peroxide of iron, Avhich,
if active in any way, would, by producing sickness and vomiting, be really
in the direction most to be desired.                       Part xi., p. 99.

  Poisoning by Prussic Acid.— What ought a practitioner to do in so
fearful an emergency ?
  According to Dr. Christison, he ought, in  the first place, to dash cold
water on the face, the naked anterior part of the chest, and dorsal spine.
Care must be taken not to soak the clothes of the patient.   The object is
not to  chill the patient, but to produce a sudden shock on the external
respiratory nerves, for the purpose of inducing a sudden expansion of the
thoracic Avails, and the full  inflation of the lungs as a consequence thereof:
and further, by getting the lungs thus expanded, Ave enable the  right side
of the heart to  unload itself.  2.  Diffusible stimuli maybe given.  3. A
small, but sudden  abstraction of blood, pleno rivo, from the  jugular vein,
must be practised if the  heart has ceased to beat, or beats very feebly,
4. If the cold affusion, diffusible  stimuli, and bleeding from the jugular,
are not sufficient to restore the action of the heart and lungs, then artificial
respiration must be resorted  to.  We  need say nothing in  favor  of the
cold affusion, as every one believes its employment in poisoning wdth
prussic acid to be  orthodox.  The same remark will  apply to the exhibi-
tion of diffusible stimuli and trying artificial respiration.
                                                      Part xii, p. 118.
  Poisoning by Prussic  Acid—Treatment.—Of all remedies, says Mr.
Hicks,  chlorine,  ammonia, and  the cold effusion,  appear  to  be most
generally relied on ; and as ammonia is most readily to be obtained, this is
resorted to in  the greater number of instances.  Should I be called to a
case, I would on no account lose time by endeavoring to pour fluids into
the stomach, but Avould' at once put in practice a suggestion, for which I
have to thank Mr. Taylor, which,  he states,  is  of much service in many
cases of asphyxia.   It  is merely to saturate a handkerchief with the liquid
ammonia, and then to wave it.over the face of the patient, by which means
the individual being as it  were enveloped in  an atmosphere  of ammonia,
there is every chance of its vapor passing into the lungs ; and this has been
found even of more service than Avhere the ammonia has been given inter-
nally.  There is, however, another  remedy  mentioned by  authors, but
wdiich I think has been spoken  of too lightly; I allude to venesection.  I
would  by no means neglect to adopt venesection in any  future  case, in
combination  with   cold affusion, ammonia and artificial  respiration.  I
would, hoAvever, observe, that  in advocating bleeding, I do  not mean to
say that it is to be performed  indiscriminately, but merely in those cases
AA'here congestion of the brain  and lungs is evident from the bloated and
livid appearance of the face.  With respect to the treatment, I cannot  do
better than conclude Avith the words of Dr. Christison, who says, it is right
to remember that on account of the dreadful rapidity of this poison, it will
rarely be in the physician's poAver to  resort to any treatment soon  enough
for  success;  and further,  that his chance of success  must  generally be
feeble,  even when the  case is  taken  in  time, because, when hydrocyanic 
POISONING.                          381
 acid is  swallowed by man, the dose is  generally so large as not to be
 counteracted by any remedies.                         Part xii., p. 121.

   Poisoning by Prussic Acid.—[Mr. Bishop wa«  sent for to a man wdio
 Avas stated to have taken  poison.  He found him  in bed, senseless, with
 ghastly  pale countenance ;  face SAvollen and covered  Avith perspiration ;
 breathing sIoav, labored, and accompanied by a hissing sound ; the corner
 of the sheet Avas betAveen his teeth;  along  the sides of wdiich quantities
 of thick Avhite foam issued  at each expiration ; the eyes were wide open,
 fixed  and glazed,  and the  pupils widely  dilated; the  pulse sIoav and
 scarcely perceptible, heart's action wreak, and the  Avhole body in a rigid
 state,  Avith the respiration becoming at each instant more laborious.  His
 wife thought he had taken  prussic acid, from finding a bottle so labelled,
 and Mr. B. accordingly  decided  on  instantly  trying  the effects  of cold
 water dashed on the body.}
   I then prepared him for the cold douche,  by tearing away his shirt and
 flannel Avaistcoat, and directing two assistants to hold him off  the  side of
 the bed.  A bucket of cold water was soon brought, and with a vessel
 holding  about a quart, I commenced pouring the water upon him,  so that
 it might floAV over his  face,  chest, and. abdomen.  It produced a decided
 shock; he gave a start, after Avhich the muscular system became relaxed ;
 the sheet dropped from his teeth, and the hands opened ; respiration was
 more quickly performed, and he sobbed violently.   I applied  it a second
 time ;  he again started, sobbed, began to roll his eyes about and utter the
 most  agonizing cries.   He  evidently kneAV me, and in a second  or two
 begged of me  not to douche him  again ; but as respiration was still slow,
 and the  pulse Aveak, I continued, and found that after each application of the
 water he breathed quicker, and the pulse also became quicker and stronger.
 I now dissolved two scruples of the sulphate of zinc in a tea-cupful of warm
 water, and asked him to drink it, which he did very well.  As soon as he
 had SAvalloAved the emetic, ammonia, which I had sent for, on ascertaining
 that hydrocyanic acid had been taken, Avas brought  to me;  it was very
 strong, and  I applied  it to the nostrils, and rubbed the temples and the
 palms  of the hands  ivith it.  The pulse rose, and the face became red, and
 at  each  inspiration  of the ammonia, the  patient said, " Oh, I am better
 noAV; this has  done me good;" indeed, he became very loquacious, and it
 Avas Avith difficulty he could-be restrained.  In about ten minutes, vomiting
 took place, and the ejected matter smelt so strongly  of prussic acid, that it
 was almost impossible to remain near it.  The pulse was now 90, and full;
 the countenance bloated,  Avith redness of face; and he occasionally com-
 plained Avith crampy pain in his arms and  legs, and said, " It is coming on
 again."  I continued the application of the ammonia, and every minute or
 two caused him to inhale it.  A vein wras next opened in the arm, and sixteen
 or eighteen ounces of blood extracted, pleno rivo.  It was of a dark color,
 and I thought at the time emitted the odor of prussic acid.  Afterward I
 was convinced that it was an error, and that it arose fromi the room bein<*
 so impregnate with  the  smell from the vomited matter.   He occasionally
 complained of cramp in different  parts of his  body, but no  other  unfa-
 vorable symptoms followed.   The  patient  had  taken about 40 minims  of
 prussic acid.                      .                    Part xii, p. 124.
  Poisoning by Prussic Acid.—[From an account of a case of poisoning'
by prussic acid. Ave  extract the folloAving, as being most interesting to the 
382                           POISONING.
toxicologist.]  A Jewess, aged 22, of generally good health, was ordered
a mixture, to take a fourth part tAvice a day, for a pain in her side: and a
lotion for chilblains was  also given to her at  the same time, Avhich con-
tained nearly four grains  of anhydrous prussic acid.   By mistake the labels
Avere reversed, and a quarter of the lotion, containing little less than one
grain  of the pure poison, was taken.   Death ensued in from  fifteen  to
twenty minutes.   Mr. Letheby obtained from the remainder of  the lotion,
amounting to about two ounces, 9.2 grains of cyanide of silver ;  this Avould
indicate 1.85 grains of anhydrous prussic acid ;  and as half this quantity
was taken, a dose equal to 45 or 50 drops of the medicinal acid, or 23  to
25 drops of  Scheele's strength,  were swalloAved.
  The principal  points for consideration are the folloAving: The Dose.—
Here a little less than one grain of absolute hydrocyanic acid, diluted Avith
one ounce of water,  occasioned death  in from fifteen to  twrenty minutes.
It is  the smallest fatal  dose upon record;  for  although the Parisian
epileptics are reported,-in most of our works upon medical jurisprudence,
to have been killed by about tAvo-thirds of a grain of prussic acid, yet it
is now proved beyond all doubt that they are in error, and that the quantity
of anhydrous acid which each patient took wras five and a half troy grains.
We learn this from a letter recently received from Professor Guibort, and
published in the "Pharmaceutical Journal" for May.  How so  egregious
an error could have  crept into  our  English works is past my comprehen-
sion.  In reasoning, hoAA^ever, upon the present case, it does not appear to-
me that we are warranted in supposing that one grain of pure hydrocyanic
acid would, under all circumstances, be  sufficient to cause death ;  on the
contrary, the experience of almost every one, to say nothing of the  cases
which are upon  record against this conclusion, would suggest that, in this
instance, it  Avas  an unusually small dose for such a fatal  event;  and  I am
led to think that its potency was increased by the empty condition  of
deceased's stomach.  All that we  can say, therefore, upon this case, is,
that one grain of hydrocyanic acid may occasion death ; we go beyond our
warrant when we say it will.
   [The immediate cause  of  death seems to be stoppage of respiration by
the spasmodic condition  of the muscles concerned in that act.  The  sIoav,
laborious breathing, turgescence of the face and venous system generally,
as Avell  as .the foaming  at the mouth, support this opinion;  and  these
symptoms so simulated  epilepsy in the  above  that it Avas at first supposed
she ivas laboring under such an attack.]                 Part xii., p. 125.

  Poisoning by Hydrocyanic Acid.—Dash cold water  on the patient;
apply ammonia to the nostrils, and heat to the spine and- feet;  give  an in-
jection containing tincture of assafoetida, use friction with a flesh-brush to
the skin; and as soon as the jaws become relaxed, and  the patient can
swallow, give an emetic,  and afterwTard  some wreak brandy and  wrater, and
strong coffee.  Mr. Gray would also cause the patient to inhale the fumes
of ammonia, when he has ceased to be able to  swallow.
                                                     Part xiii., p. 145.
  Poisoning by  Prussic Acid.—The rapidity of death does not ahvays  ap-
pear to be in proportion  to the  largeness of the  dose, but modified by cir-
cumstances, such as idiosyncrasy, bodily strength, and the quantity of food
in the stomach.  There are some grounds even for thinking that beyond a
certain dose the  effects are not  increased, that is to say, a dose  far greater 
POISONING.                          383
than a merely  fatal  dose does not  produce more violent symptoms  or
speedy death than  the  exact  poisonous  dose.  The medico-legal question
of how long a  person, after a poisonous dose, may have power  and con-
sciousness to perform acts of volition  and motion, is of the highest import-
ance, as from these acts principally can it be inferred whether death has
been the result of suicide or murder.   In the case of the trial of Belany for
the murder  of  his Avife, the medical  opinions Avere strong that all volition
would cease after the scream Avhich has been considered as characteristic
of poisoning by this substance.  This  may be quite  correct where a scream
does take place, but it is by no means so  frequent a symptom as is com-
monly supposed.  It  does not appear to have been heard in the case of
Harah Hart; it did not occur in  two cases reported by Mr. Hicks (Med.
Gaz., 1845);  nor in a case given by Mr. Nunneley  (Prov. Med. and Surg.
Jour., 1845).
  A sufficient number of cases, however, are now on record, to prove that
after large doses, viz.:  from two drachms to four ounces of the medicinal
acid of different countries, and consequently of a variety of strengths, re-
levant remarks may be made, and acts of volition and motion deliberately
performed.
  A gentleman  at Bristol (1843), after swallowing half an  ounce (Lon.
Phar.)=five grains anhydrous acid, walked about  sixty yards, articulated
to an acquaintance several words distinctly and  relevantly, and did not
die for ten  or  twelve  minutes.   He gave no scream.  A case is reported
by Sobernheim of a young  gentleman aaIio took  four ounces from two
vials.  He  Avas  found  dead in bed,  the clothes drawn up to his breast,
his arms beneath the clothes, and-on each  side an empty two-ounce vial.
In Mr. Nunneley's case, already referred to, a gentleman, after taking  an
ounce, appears  to have Avalked or rather ran up a stair, was quite sensible,
and spoke rationally for about five minutes, and lived- three quarters of an
hour.
   There are no post-mortem appearances universally found after poisoning
with prussic acid.  The odor of the  acid should be sought for both exter-
nally  and internally; but it is not  ahvays appreciable externally as  is
shown by Sarah Hart's case.  Internally, hoavever, it can  generally be de-
tected Avithin three  or four days;  occasionally it is altogether wanting,
but these cases are rare.   Among the most characteristic signs xff poison-
ing by this drug should also be noticed, the calm and life-like appearance
of the countenance,  and the  bright  state of the  eyes.  There is also ex-
treme  fluidity of the blood, the veins being full  and  the arteries empty.
The left auricle and ventricle of the  heart are generally found empty, and
sometimes  all its  cavities;  but, in  cases recorded by Mr. Nunneley, of
Leeds, the  heart was completely distended with dark  fluid  blood. The
action of this powerful poison seems now generally acknowledged to be
directly on the nervous  system, to Avhat tissue  soever it  be applied.
Dr. Lonsdale's  experiments  have led him to  conclude that, the  imme-
diate effects of the  poison are  exerted on  the brain and  spinal cord,
and that the contractility of the heart is  indirectly enfeebled, according
to .the dose, or  Avhether the acid be in a pure or diluted state.
                                                      Part xxv., p. 115.

   New Test for Prussic Acid.—The following method of testing for  hy-  ^
drocyunic acid is proposed by Mr. Austin,  of Dublin.  The precipitate  of 
384:                           Poisoning.
cyanide of silver, say half a grain, obtained in the usual manner, is mixed
with a small  quantity of oxide of iron and carbonate of potash, and the
whole  fused  together in an iron or  plantinum capsule.  The fused mass is
then dissolved in half an ounce  of distilled water, filtered, and rendered
slightly acid by the addition of a feAv drops of hydrochloric  acid.  The
liquid  thus treated is next divided into tAvo portions, to one  of which a
few drops of a solution of sulphate  of copper is added, which immediately
causes the  evolution of the chocolate-broAvn color, so  characteristic of the
ferrocyanide  of copper;  and to the other a few drops of the muriate tinc-
ture of iron,  or any persalt of iron, when the  solution becomes intensely
blue by the formation of the ferrocyanide  of iron, the ordinary prussian
blue.
  In Mr. Austin's opinion, " these two tests, with the well-knoivn odor of
prussic acid,  are, independent of all others, sufficient to convince the medi-
cal jurist of the presence of free prussic acid." •
  The precipitates above mentioned are very distinctly  obtained with half
a grain of cyanide of silver.                            Part xiv., p. 117.

                              LEAD.
  By  Salts of Lead.—Hydrated Proto-Sulphuret of Iron—suggested aa
an antidote in poisoning by the  salts of lead.   Vide Art. " Poisoning by
Corrosive Sublimate."
  Lead Poisoning.—In addition to the acid,  sulph. aromat., mercury ia
exceedingly  valuable in controlling the  effects of, or  removing this and
other latent poisons from the body.                    Part xxvi., p. 348.
  Poisoningby Lead.—Dr. Goolden states that iodide of potassium in doses
of 10 grains  acts as a curative agent in lead poisoning, by converting the
lead into a more soluble form, which can be readily taken up by the blood.
It acts more  rapidly in conjunction  with  galvanism.
  In a case of aggravated paralysis from lead poisoning, but in wdiich there
Was absence  of colic, the following prescription  was completely successful;
Iodide-of potassium, 5 grains;  liquor of potassium, \  drachm ;  peppermint
water, 1\ ounces; three times a day.  As the recovery progressed,  it waa
observed that the blue margin of the gums  gradually disappeared.
                                                    Part xxix., p. 326.
  Poisoning by Lead,  Mercury, Gold, Silver, or any other Metal—MM.
Poey  and Vergnes"* Electro-Chemical  Bath.—Place  the patient on a
wooden bench, in a metallic  bathing-tub, isolated from the ground, and
filled wdth  Avater up to his  neck.  The wrater is made  slightly acid' with
nitric or hydrochloric acid, if mercury, silver, or gold  is  in the system; and
with sulphuric acid, if lead is suspected.   The  negative pole  of a pile is
then brought into contact with the  sides of the bathing-tub, and the posi-
tive pole placed  in the hands of the patient.  The work of purification is
now in full activity.  The electrical current precipitates itself through the
body of the sufferer, penetrates into the depth of his bones, pursues in all
the tissues every particle of metal, seizes it, restores its primitive form, and
chasing it out of the organism, deposits it on the sides  of the  tub,  where
it becomes apparent to the naked eye.                 Part xxxi., p. 227,
  Lead Poisoning.—Dr. Tunstall states, that when Ave have loss of power
of the  superior extremities, with  corresponding loss of  substance, Avithout 
POISONING.
385
diminished sensation, if there he no eAddence of cerebral mischief, we should
suspect lead as the cause of the disease.  The term paralysis should be re-
stricted to those cases Avhich have their origin in the brain or spinal cord;
in lead atrophy the  loss of power is dependent on loss of muscular sub-
stance, and differs from true paralysis in being gradual instead  of sudden
in its invasion.  The treatment should consist of warm  baths, electricity
and friction.                                       Part xxxiv., p. 298.

  Drop- Wrist from Lead-Poisoning.—A case lately occurred at Charing-
Cross Hospital, of a printer who had been the subject of  this affection for
only two days, resulting from absorption of lead, owing to the tips of the
fingers being denuded by constantly handling new type.  This case ivas
cured completely in a week, by the patient sitting ivith his hand in a solution
of sulphuret  of potassium (|j. to %x.) for  three hours three  times a day.
This acted from the great chemical affinities of sulphur and lead.
                                                   Part xxxvi., p. 46.
  Lead Poisoning—Disease of the Sheffield  File-Cutters.—During the
process of cutlery,  the file is placed upon  a bed of lead, which rests upon
an anvil.   This lead is gradually lvorn away, and may be collected in con-
siderable quantities  in  the  form of fine black powder.  The file-cutters'
disease results from the absorption of a portion of this lead, as is common to
file-cutters, painters, lead smelters, shot manufacturers, sheet-lead rollers,
sugar-of-lead, red-lead, wdiite-lead and  litharge  workers,  compositors,
plumbers, potters, sealing-wax makers,  enamellers of German cards, color
grinders, lead miners, etc.
  Dr. J.  C. Hall, says, that persons who work much in lead should use the
bath daily, or if this  be not obtainable, they should Avash thoroughly the
Avhole of the upper part of the body.  The addition of about four ounces
of sulphide of potassium to thirty gallons of water much  increases the effi-
ciency of the warm bath, causing a formation of sulphuret of lead.  The
habitual costiveness must be overcome by attention to diet, by the frequent
use of injections, and by the administration of doses of sulphate  of mag-
nesia  in infusion of roses.  Iodide of potassium  exerts  a most poAverful
influence on the poison of lead ; it should be taken fasting, that it may not
be decomposed by  acids, and it should be largely diluted.   There is  no
evidence to show that sulphuric acid is an antidote to  slow lead poisoning.
The best means of  purifying Avater from the contamination of lead, is by
filtering it through sand and animal charcoal.          Part xxxvi., p. 56.


                             OPIUM.
  Poisoning by Laudanum—Novel Treatment.—A young  female, aged
22, SAvallowed an ounce of laudanum.  The ordinaiy symptoms soon suc-
ceeded.  There was a state of almost  perfect insensibility, the face livid
and swollen, pulse sIoav, not exceeding 45 in a minute, and the jaws firmly
shut.   Dr.  Buck saw her  in  about half  an hour, and prying the mouth
open, put into it 40  grains of ipecac, and  as much of sulphate of zinc, in
half a  gill  of water.  He  repeated this dose at intervals of ten or fifteen
minutes, five  times, using 200 grains of ipecac, and as much sulphate of
zinc.  It  is doubtful, hoAvever, whether any was swallowed.  In half an
hour, as no change had occurred, he injected into the stomach, through an
elastic catheter, tAvelve grains of tartar emetic dissolved  in half a gill of
    VOL. II.—25 
3S6
POISONING.
water.  After waiting half an hour, and perceiving no symptoms of an
operation, he threw doAvn 24 grains of tartar emetic.  This in a short time
induced a very feeble effort to  vomit, and  about half  a gill of  fluid Avas
thrown up.  But  the symptoms became more alarming ; the pulse was
slower, and the face extremely livid, ivhile  respiration ivas  nearly extinct.
He noAV threw down sixty grains of sulphate of zinc dissolved in half a pint
of water, but without any sensible effect.
   " Under these circumstances, seeing that there was no prospect of mak-
ing her vomit by any ordinary means, I was resolved  to make an experi-
ment.  I injected a pint of vinegar into the stomach, and immediately after
it, a large teaspoon four  times heaped full of salasratus, dissolved in half a
pint of warm water.   The effect was instantaneous.   It broke forth foam-
ing from the mouth in a  stream of  the full size of that orifice, Avith such a
force as to be projected a yard or more.  The quantity throAvn up I judged
to be at least a quart, in  a state of complete effervescence.   In about fifteen
minutes, as there was no further vomiting, I repeated the operation, using
but half the quantity of vinegar with the same quantity of salasratus and
water, wdth the same immediate effect, and then left her for the night, Avith
directions to give her freely strong green tea, if she should recover suffi-
ciently to drink.
   "Next morning found her much prostrated, had vomited several times
during the night,  but was perfectly rational.  She gradually recovered."
                                                         Part v., p. 75.
   Poisoning by Morphia.— Coffee as  an Antidote.—To  relieve  himself
 of a severe attack of toothache, Dr. Fosgate swallowed in solution one and
 a quarter grain of the sulphate  of morphia, equal to about seven and a
 half  grains of solid opium.  In about half an hour, a sensation of thicken-
 ing and  rigidity of the muscles of the back of the neck came  on, and
 gradually extended  itself to .all the flexors of the limbs.  In about five
 hours severe nausea  succeeded, accompanied by efforts to vomit.  Tea and
 sour cider increased the efforts to vomit so much that the stomach rejected
 fluids the moment they reached it, so that the second mouthful could not
 be SAvallowed  before the first was rejected.  Prostration of strength and
 apathy, Avith full slow pulse, and pricking sensation of the skin, were added
 to the other symptoms which Avere continually increasing in severity, when
 coffee was proposed. One gill of cold  strong infusion of  coffee was swal-
 lowed, and  was retained  about  five minutes ; the distressing  symptoms,
 how:ever, Avere by it abated, the nausea  in part subdued, as was also the
 sensation of rigidity of the muscles; and the occasional repetition of this
 simple remedy during the course of the night completely removed all the
 distressing  symptoms.  Dr. Fosgate  states, that wdiilst suffering from the
 severe nausea, but previous to the exhibition of the coffee, his mind was
 depressed, and he felt  considerable anxiety, no  pleasurable sensations or
 reveries  having been felt.  But after the draughts of coffee, the depression
 of mind and all  anxiety vanished, and there  succeeded that  exquisite
 revelling of the  imagination  so  much sought  after  by the opium  eater.
 This state continued for  five or six  hours, and wras succeeded by  sound
 sleep, on aAvaking from which he experienced a few hours of lassitude.
 The morphia had been taken after eighteen hours' fasting.  Part v., p. 62.

    Poisoning by Opium or Belladonna.—Opium and belladonna are mu-
 tually remedial, when either  has  entered the circulation  in a poisonous 
POISONING.
387
dose.  From this cause, if both be prescribed together, as wdth a view to
lull cerebral excitement, the effect desired Avill not be produced, whilst if
either be given separately it wdll.   In cases of poisoning by opium, give a
solution of belladonna—say a drachm of the tincture eiTery half-hour, or,
if it cannot be swallowed,  inject it subcutaneously.  Conversely, in a case
of poisoning by belladonna, opium may  be used.   Several  cases  are
recorded in a paper by Benjamin Bell, illustrating this subject.
                                                 Part xxxviii, p. 244.
  Narcotic Poisoning— Cold Douche.—In narcotic poisoning, this appli-
cation is indicated  urgently, but here it must be perseveringfy repeated,
not relinquished  on  a little trial.  The great source of danger clearly con-
sists hi the blood being no longer duly oxygenated, through deficient or
temporarily suspended  breathing.  The brain, therefore, becomes doubly
influenced—primarily, by the narcotic, secondly, by venous blood.  In an
instance witnessed under the care of Mr. West, of Turnbridge, occurring
in an infant avIio had accidentally swallowed a large quantity of opium, and
was so affected by it that there  wras the completest coma, a pallid counte-
nance, livid lips, and fearful pauses in the respiration and circulation, this
remedy Avas given  a fair  trial.  No  sooner  Avas it used  than inspiration
folloAved, and scarcely Avas  it desisted from ere it became needful to resort
to it again.  Friction was had  recourse  to at intervals, that the wrarmth
of the surface  might be  preserved.  A sort of artificial respiration Avas
kept up until natural breathing returned, and the cerebrum awoke from its
lethargy.  The  nerves of  the  skin were made  to play that part,  which
under, ordinary circumstances the vagi nerves perform (through the stimulus
of carbonic acid), and so life was continued, and a perfect recovery ensued.
                                                       Part viii., p. 45.
   Electricity in Poisoning by Laudanum.—A case of this description is
recorded by Mr. Corfe.  The patient had  taken an ounce and a half of
laudanum the preceding evening, and on his admittance into the Middlesex
Hospital, Avas to all appearance  a lifeless corpse; and after all the more
ordinary remedies had been tried in ATain, Mr. Corfe thought of the electro-
magnetic battery, conjointly Avith electricity.  After this had been acting
upon him for a time the pulse became more steady, firm, and frequent, and
the respirations more  indicative  of resuscitation.  A powerful electrical
machine was also got into full play before a large fire :  brilliant sparks and
strong shocks wrere occasionally passed  through the head, spine, thorax,
and  abdomen.   By these  means  the Avhole body Avas  thrown into violent
and convulsive succussions and muscular contortions. The patient recovered.
                                                       Part ix., p. 78.
   By Opium.—Dr. Lancaster  advises, after the use of the stomach-pump,
to give  coffee,  and pass  currents from the electro-magnetic  apparatus
through the shoulders, chest,  abdomen, arms, and legs.  In some cases,
cold affusion will be beneficial.  Such remedies as ammonia should not be
given but under the most urgent circumstances.        Part xix., p. 218.
   laudanum, Poisoning by.—In a case of poisoning by laudanum, in an
infant, Dr. Herapath excited respiration by galvanism, by placing the zinc or
positive Avire on the mucous membrane of the mouth,  and the negative or
copper Avire just below the ensiform cartilage.  The current seemed to enter
by the fifth nerve, from this to the medulla oblongata, then along the phrenic
and external respiratory and spinal nerves to the diaphragm, and the inter- 
388
POISONING.
 costal and other accessory muscles of the respiratory apparatus.   If the posi-
 tive or zinc Avire slipped from the cheek to the tongue, the movements  be-
 came more  gasping and  convulsive—another set  of  nerves becoming
 influenced.                                          Part xxv., p. 317.
   Poisoning  by Laudanum.—To  evacuate the stomach speedily and
 effectually, introduce into it a quantity of carbonate of soda, followed  by
 vinegar.  The effervescence is  so powerful that all the contents of the
 viscus are discharged.  If emetics have before been taken ineffectually, they
 begin now to act.                                   Part xxvi, p. 348.
   Poisoning by Opium— Use of Belladonna.—Belladonna has been found
 useful in poisoning by opium.  When the patient is comatose and other
 remedies fail,  try the folloAving: tincture of belladonna, six drachms in five
 and a half  ounces of water.  Take  an ounce of this  every half hour,  till
 the coma begins to disappear, or till the pupils dilate.  In  another severe
 case, one ounce of the tincture of belladonna was given at  once, in three
 ounces of water; in half an hour two drachms more were given.
                                                   Part xxix., p. 326.
   Use of  Belladonna in  Poisoning by Opium.—Dr. Graves first sug-
 gested, that in continued  fever, with  contracted pupils and coma, if an
 agent administered  internally would  occasion dilatation of the  pupils, it
 might also relieve the other symptoms of cerebral derangement.
   For cases of Poisoning by Opium.—Always have ready the following
 preparation of belladonna: takerfour ounces of the leaves of belladonna
 and two pints of rectified spirit, and percolate.  Of this give six drachms
 in doses of about one drachm every half hour.
   In one case, ten drachms of the^bove tincture of belladonna  were given
 in the course of one hour wdth success.                Part xxx., p. 301.
   Narcotic Poisoning.—Dr. Marshall HalVs " Ready Method:''—When
 from the degree of narcotism all ordinary remedies fail in inducing vomit-
 ing, and the stomach pump is not at hand, place  the patient on a table,
 with the head projecting beyond its edge, if possible; if not, on the floor;
 and being placed on  the side, the finger of one person is to be  introduced
 into the fauces, whilst the  body is briskly and repeatedly rolled into the
 prone position by another; thus mechanical vomiting will be produced,
 and the poison expelled.  But supposing the narcotism is too deep for the
 success of this manoeuvre, volition has ceased, and that the patient can no
 longer be made to move or walk about—that all  physiological  respiration
 has ceased—we must long and perseveringly employ the " Ready Method "
 to continue respiratory movements till the poison is eliminated  from the
 blood.— Vide  Art. " Drowning."                     part Xxxv., p.  49.


                      GENANTHE CROCATA.
  [Several  melancholy cases of poisoning by this plant (hemlock dropwort)
 are related by Mr. Bossey.  Several convicts Avere at work in the Royal Ar-
senal at Woolwich, and mistook the plant for celery. They ate a considerable
quantity, and were soon attacked with the most violent symptoms, strong con-
vulsions in paroxysms, with insensibility.   In the more violent cases the face
was bloated and livid, the foam about the mouth Avas sanguineous  the breath-
ing stertorous and convulsive, pupils dilated  and  insensible, with most of
 the other symptoms  of apoplexy.  These cases died.   In others, the symp 
POISONING.
389
   toms wtere milder, and recovery took place.  These were able to swallow
   emetics of salt and mustard with warm water, by means of which  they
   vomited freely and ejected a large quantity of imperfectly masticated  root,
   and were thereby greatly relieved.  The convulsions ceased, sensation and
   reason Avere restored,  but there  remained giddiness, pallor of the  face,
   dilated pupils, coldness of the extremities, much Aveakness, severe  rigors,
   and a slow feeble pulse.]
    Further  vomiting was promoted, and  more  of the  root discharged.
   Frietion and Avarmth Avere applied to the extremities, whilst ammonia and
   rum, Avith thin  gruel and other drinks, Avere administered internally, till
   reaction Avas more fully established.
    Emetic  doses of the  sulphate of zinc and copper, and also mustard and
   water, Avere given Avithout effect to  the patients lying on the deck of the
   vessel.  They Avere  also bled very largely both from the arms and jugular
   veins.   The introduction into and removal of warm Avater from the stomach
   by the pump, brought  aivay small portions of the noxious roots.   Cold
•   affusions upon the head being perseveringly used, lessened the struggling,
   and produced some exhaustion.  In three cases the subsequent fits became
   less violent; they passed into  a  state of maniacal delirium, Avith much
   jactitation of the limbs, and after some hours  were removed into the hos-
   pital.  But in one more  patient all these remedies were ineffectual: he
   died convulsed, at  a quarter before  one o'clock.  As  a last effort, the
   trachea Avas carefully opened  by an incision, and artificial respiration kept
   up, but life was quite extinct.
    Several of the men Avho had eaten the root, seeing the others suffer, took
   the salt water emetic Avith success, and had no symptoms of being poisoned.
    The first indication of treatment Avas doubtless to evacuate the stomach;
   but,  as its sensibility Avas destroyed, and the poison was  taken in the  solid
   form, this could not readily be accomplished.  Large and immediate de-
   pletion seemed to be essentially useful, by removing the imminent danger
   of extravasation  from  over-distention of the vessels; the  cold affusion
   was also beneficial in rousing the patient, so  as to make him sensible to
   the emetics, and so were purgathes during the after-treatment.
    Called thus  in  a  moment to so many urgent cases of poisoning, it be-
   came needful to use such remedies as were at  hand; but, upon reflection,
   it seems to me proper,  in similar circumstances, to rely chiefly on emetics
   given early, on large blood-letting immediately employed,  and  the  cold
   affusion.                                               Part x., p. 90.


                             STRYCHNIA.
    Tannin, as  an Antidote. — In a case where  strychnia  had been in-
   cautiously  taken by  the patient to  the  amount  of half a grain in six
   hours, and where  the  symptoms  Avere  becoming exceedingly  dan-
   gerous,  Dr. Ludicke ordered ice to be  applied to the head, and half a grain
   of tannic acid to be given every hour, either in an effervescing draught or
   in distilled water.  After twelve grains had been taken, he substituted for
   it a decoction of two dunces of oak bark  in six ounces  of water, with an
   ounce of sirup of cinnamon and a scruple of sulphuric ether.  The symp-
   toms of poisoning entirely disappeared.  Mesner, in Dresden, recommends
   as an antidote for strychnine, decoction of galls or of oak bark; five ounces
   of which precipitate tAvo grains of nitrate of strychnine.    Part vl, p. 85, 
390
POISONING.
  Electricity in Poisoning by  Strychnine.—The following statement is
deserving of further investigation: M. Duclos has instituted  a  series of
experiments on rabbits, dogs, and guinea-pigs. He poisoned these animals
with strychnine and brucine, and then electrified them, and found that, on
application of the negative electricity excited  by means of an electrical
machine, the symptoms of poisoning subsided, and the animals Avere saved ;
the positive electricity, on the contrary, increased the muscular contraction
produced by the poison, and hastened, death.  Animals Avhich  had been
poisoned Avith arsenious acid could not only not be  saved by electrifying
them, but were killed sooner, wdiether positive or negative electricity Avas
employed.                                             Part ix., p. 83.
  Purified Animal Charcoal as an Antidote to all  Vegetable and some
Mineral Poisons.—This substance,  says Dr.  Garrod, may be used as an
antidote to opium and its active principles, morphia, etc.; nux vomica and
its  active principles,  strychnia and  brucia; heubane, deadly nightshade,
bitter sweet, thorn apple, tobacco, hemlock, bitter almonds, prussic acid,
the aconites, etc.; in fact, to all vegetable poisons—to animal  also, as can-
tharides.   The carbo animalis purificatus of the pharmacopoeia  should be
used, and in the proportion of half an ounce to a grain of morphia, strych-
nia, etc.  It combines with.and renders inert vegetable and  animal  sub-
stances, and absorbs some mineral poisons, especially arsenic,  and renders
them harmless, and exerts no injurious effects on the body.
   It should be rubbed in lukeAvarm water, so as to  form a fluid of slight
consistency,  and  thus given  in quantities of from  one to four ounces.
Emetics also should be given : ipecacuanha, hoAvever, will not do, as the
charcoal renders it inert.   Give sulphate of zinc in scruple or  half drachm
doses, or use the stomach-pump, and then give  more of the charcoal.
   Might not this substance  be tried to  prevent the injurious effects of
animal poisons,  such as  rabies, syphilis, poison of serpents,  etc., applied
in the form of poultice to the parts?                   Part  xiii., p. 142.

   Chloroform in Poisoning by Strychnine.—A case, under  the  care of
Dr. Munson, in which all the symptoms of poisoning by strychnine were
present, was very successfully  treated by the inhalation of chloroform.
                                                     Part xxii.,  p. 329.
   Poisoning by Strychnine.—In a  case of poisonous symptoms being in-
duced  from an  over-dose of strychnine given  in mistake, the following
prescription gave immediate relief:  Twenty-four grains of camphor  were
dissolved in six ounces of almond mixture, one-fourth to be taken every
two hours.                                           Part xxvi., p. 348.
   Test for Strychnia.—Mr. Maxwell Simpson, in a  note to the editor of
the " Dublin Hospital Gazette," says: I think it right to make  it publicly
known that strychnia is not the only substance  that will produce a purple
color when brought into contact Avith a  mixture of bichromate of potash
and oil of vitriol, the test usually relied on for the detection of this poison.
I have found that naphthalidam, an  organic base derived from naphthalin,
will produce, as might have been expected, an  exactly similar color Avhen
tested with the same mixture.   The color is best brought out by making
a mixture of equal volumes of  oil of vitriol and a cold saturated solution
of bichromate of potash, and bringing it, while still Avarm, into momentary
contact with a particle of the naphthalidam.         Part xxxiiiv  p. 309. 
                              POISONING.                          391

  Strychnia and Woorali.—These two poisons,  according to Dr. Pavy,
of Guy's Hospital, ha\'e the effect of reciprocally neutralizing the action of
each other, according as the one or the other is in excess.  Frogs poisoned
Avith woorali, Avhen flaccid  and insensible, very  soon become tetanic if
strychnia be injected;  and on the other hand, if poisoned with strychnia
and  afterward punctured Avith  woorali, the tetanus speedily  disappears.
When treated in this way, they will recover from a larger dose of  each
than Avould be sufficient to destroy life,  if either were given alone.  Thus
it Avould appear that the one might be used as an antidote for the other.
                                                   Part xxxiv., p. 301.

  Strychnia, Tests for.—Dr. Harley, of University College, London, says:
The  physiological  test is the most reliable.  If  l-8000th  of  a  grain  be
injected into the thoracic cavity of a frog, it will become tetanic in ten or
fifteen minutes.  In order to apply any of the tests, we must first have the
strychnia in a pure state.  Suppose an animal has  been poisoned with the
smallest possible quantity, take the blood from the heart and large vessels,
mix  it Avith tAvice its bulk of  Avater,  coagulate  by boiling, acidify Avith
acetic acid, decolorize by filtering through crystals of sulphate of soda or
animal charcoal, concentrate  the filtrate, add potash  to  precipitate the
strychnia, purify and apply the  tests.   Strychnia  seems to produce death
by destroying muscular irritability,  and rendering the tissues unable to
absorb oxygen and exhale carbonic acid......One part of bi-
chromate of potash  dissolved in fourteen parts  of wTater, to which two
parts of sulphuric acid are afterAvard added, is the  most dehcate and
certain  test  for  strychnia.  When  added to a  suspected solution, if
strychnia be present,  it will be precipitated  in the form of  a  beautiful
golden-colored insoluble chromate.  The crystals are immediately formed.
A single half grain of strychnia, although divided into millions of atoms
of crystals each, will demonstrate the presence of strychnia as  well as if a
pound weight of it were operated upon.  (Mr. Horsley.)
  To do away with all possible sources  of fallacy  from the  action of  ex-
ternal re-agents, you must put a little strychnia, with sulphuric acid, on a
piece of platinum foil, and then connect the foil Avith the positive pole of
a single cell of a Grove's or Smee's battery,  and, by  touching  the acid
with the negative pole terminating in a piece of platinum wire,  the  char-
acteristic violet color is instantly produced.  In operating on the  contents
of the stomach, acidify them  with  acetic acid, dilute if  necessary with
Avater, and filter ;  evaporate this on a water-bath to  the consistence of  a
thin paste, add eight or ten  times its bulk of cold alcohol, filter and distill
so that the spirit may not be lost.  The residue, after the  evaporation of
all the spirit, must be diluted with water, filtered again, and super-saturated
with liq. potassas.  Shake this Avith its OAvn bulk  of ether,  and allow  the
two  solutions to separate, decant the clear ethereal solution, and treat  the
aqueous residue  with a fresh quantity  of ether,  and so  a third time, if
necessary.  The ethereal solution must  be distilled  to  remove the ether,
and  the residue dissolved  out of the retort Avith a small quantity of diluted
acetic acid and filtered; treat again with potash and ether, and  after the
spontaneous evaporation of  the  ether, the alkaloid ivill be  sufficiently pure
to be identified.   (Prof. Letheby.)               Part xxxiv. p. 305-315,
  Poisoning by Strychnine.—-Professor Haughton of Dublin,  is of opinion
that nicotine and strychnine are mutually antidotes to each other's action. 
*   392
POISONING.
He has performed some very interesting experiments on this subject.  The
nicotine is always easily procurable in the form of tobacco leaf infusion.
                                                   Part xxxv., p. 277.
   Tests for Strychnine.—It is known  that peroxide  of  lead, peroxide of
manganese and chromate of potassa will each of them produce a red color
when added to a mixture of strychnine and sulphuric acid.
  Mr. Lindo considers the red color  produced  by these three tests is in
every instance referable to the same cause—namely,  the separation  of the
hydrogen from the strychnine ;  that, Avhen the metallic peroxides are used,
they  are converted into protoxides,  which combine Avith sulphuric acid
when the chromate of potassa is employed;  that the chromic  acid is
converted into oxide of chrome, Avhich combines Avith sulphuric acid; and
that the oxygen liberated in each case takes hydrogen from the strychnine,
forming Avater, the  reaction being partly induced by the affinity of sul-
phuric acid for water.                               Part xxxv., p. 280.
   Camphor, in poisoning by Strychnine.—Give two grains  of powdered
camphor, with half  a teaspoonful of tincture of camphor, every quarter of
an hour,  if necessary, a little morphia may be  added.  Two  cases  are  re-
ported by Dr. Rochester, which were successfully treated in this Avay.
       J)C       2j<      3JC      If;       3JC       JJC      3JC       5f!
  A case of poisoning by strychnia, is related by Dr. Pritchard of Filey,
Yorkshire, in which from three  to five grain lumps of camphor were suc-
cessfully administered.  Emetics and  the stomach pump  Avere employed,
and artificial respiration by Dr. Marshall Hall's ready method was necessary
at one part of the tetanic spasms.   Toward the decline of the tetanic
movements, which lasted about twenty minutes, the camphor was continued
with  opium.           *                            Part xxxv., p. 342.
   Strychnine— Dectection of.—Messrs.  Rodgers and  Gbxhvood, from a
carefully conducted series of experiments, have  come to the  following
conclusions: That strychnine can be detected even Avhen it has not been
given in excess ;  that it is not decomposed in the  body ; that it is found
unchanged in the urine; and can be  detected in the blood, organs, and
tissues of the body, quite independently  of the  contents  of  the stomach.
It is more easily detected than  any other poison, from the delicacy  of its
reactions, and from its extraordinary stable qualities.
   The process itself is as folloAvs: The substance  to be operated  upon is
digested with dilute hydrochloric acid, 1 to 10, until it is apparently fluid ;
the liquid is then filtered and evaporated to dryness over a water-bath;
what remains, treated with spirit as long as anything can be dissolved, and
the filtered  tincture evaporated as before.  The residue must now be  dis-
solved in water and filtered.
   This aqueous solution is to be rendered alkaline by ammonia and agitated
in a bottle,  or  long tube, with about \ an ounce  of chloroform.   After
subsidence, the chloroform is drawn off by means of a pipette, transferred
to an evaporating basin, and expelled over a Avater-bath; the residue left
on the basin must then  be moistened with concentrated sulphuric acid,
and exposed for some hours to the temperature of a water-bath, by Avhich
proceeding, all organic matter  except the strychnine is  destroyed.  The
charred mass is then treated Avith water, and the solution  filtered to sepa-
rate  the carbon; excess of  ammonia is  added  and  the solution again
agitated with about 1 drachm of chloroform.   If, on evaporating a small 
                             POISONING.                           3yo

oortion of this chloroform solution,  and acting upon  the residue Avith
concentrated sulphuric acid, any charring takes place, the foregoing process
must be repeated.                          #        .
  The  chloroform solution will afford strychnine sufficiently pure  for con-
clusive testing.  For this purpose, a small quantity is taken up in a capillary
tube, and evaporated by adding successive drops, on the smallest possible
space of a warm porcelain capsule.  If the quantity of strychnine in the
solution is large, say the l-2000th of a grain or more, the method pursued
in using the reagent is similar to  that adopted by others, viz.  moistening
the spot", AAdien the capsule is quite  cold, Avith concentrated sulphuric acid,
and then  adding a minute fragment of bichromate of potash.   When,
however, the quantity is very small,  no color  will be  perceived by this
mode  of testing.  Under  such  circumstances, sulphuric acid,  rendered
slightly yellow by chromic acid, is said to be found successful.
  We mav, in  conclusion, enjoin a caution against  two  sources of failure
in conducting this  test.   The common recommendation to stir the spot
moistened Avith sulphuric acid, Avith  a  glass rod  before the addition  of
bichromate is to be avoided, because the acid sulphate of strychnine may
so be removed altogether ;  and the operator must be careful not to expose
the matter under examination to  an intense light, as in his anxiety to watch
the color changes he is too apt to do, the effect  of light,  in  more than
moderate amount, being to suspend the chemical reactions.
                                                  Part xxxvi., p. 282.
  Poisoning by Strychnia—Inhalation of Chloroform.—A case  occurred
lately in Boston in Avhich violent tetanic spasms, produced by  swalloAving
two grains of strychnia, were completely subdued in ten minutes by Dr.
Jewett, by  the administration  of chloroform.  The  patient recovered
rapidly.         .                                  Part xxxvii, p. 257.
  Poisoning by Strychnia.—-The poison of strychnia  is completely neu-
tralized by nicotine.   In a case of poisoning by the former, Dr.  O'Reilly
of St. Louis, U. S. recommends to take a cigar and infuse it in half a pint of
water,  wdiich give in doses of one tablespoonful e\Tery five  minutes.  Pro-
bably, when half the quantity is taken a favorable change will 'be noticed
the muscles will have  become  relaxed,  the  spasms less severe,  and the
intervals betAveen them longer.  The infusion may then be  given less fre-
quently. Of course, in a healthy person, such quantities of tobacco internally
administered would produce serious effects; but in this  case its effects are
antagonized.                                      Part xxxviii., p. 238.
  Antidote  to.—Dr. BeAvley,  Avishing to  kill  a  mangy cur,  and having
read in Magendie's " Report on Strychnia," that the sixteenth of a grain
will kill the largest dog, determined to make sure of this very  little animal
by giving it about half a grain.   But either Magendie's  statement ivas in-
correct, or the drug was adulterated, for at the end of ten minutes the dog,
though suffering frightfully, Avas  not  dead.   Dr. Bewley resolved to put
him out of his  misery at once,  and accordingly mixed half a drachm of
prussic acid wdth a little milk, and put it under the dog's snout. He lapped
the  milk with avidity, and in less than a minute vomited, got upon his legs,
ran  aAvay, and  recovered.                               Part x\.,p. 278.

  Poisoning by  Strychnine.—Action  of  wourali poison.    Vide Art.
" Tetanus." 
394
POISONING.
  Poisoning by Strychnine.—A case of poisoning by strychnine is related
by Dr. Bennett, of Sydney, in which apparently iodine  conduced  toward
recovery.  He explains its action by its forming an insoluble hydriodate
of strychnine.                                         Part xl., p. 315.
                           UPAS  ANTIAR.

    Poison of the.—[This energetic poison has not been examined since the
. beginning of the present century.   It is obtained from Borneo and Java.]
    The following are the principal results obtained by Professor  Albert
 Kolliker, in his experiments with frogs.
    1. That antiar is a paralyzing poison.
    2. It acts in the first instance and with great rapidity (in 5 to 10 minutes)
 upon the heart,  and stops its action.
    3. The consequences of this paralysis of the heart are the cessation of
 the voluntary and reflex movements in the first and second hour after the
 introduction of the poison.
    4. The antiar paralyzes in the second place the voluntary  muscles.
    5. In the third place it causes the loss of excitability of the great nervous
 trunks.
    6. The heart  and muscles of frogs poisoned with urali may be paralyzed
 by antiar.
    7.  From all this it may be deduced, that the "antiar principally acts upon
 the muscular fibre and causes paralysis of it.         Part xxxvii., p. 256.
                          YEW-BERRIES.

  Poisoning by.—[As cases of poisoning by the berries of the yew (taxus
baccata) are rare, and as some ivriters have denied the poisonous nature
of the tree altogether, the following case by Dr. James Taylor, of Castle
Cary, becomes interesting.]
  October 28th, 1838.   Mary Baker, a fine healthy  child, between five and
six years of age, ate freely of yeAV-berries just before going into  church.
About an hour after, during divine service, she fell from her seat and was
instantly removed in an insensible state to her home.  I saAv her immedi-
ately ; the surface of the body Avas cold ; the countenance pale ; breathing
laborious and  frequent; pupils very dilated; pulse feeble ; convulsions and
vomiting.  Having carefully examined the head, and  finding that it was
not injured by the fall, I gave an emetic, and from what Avas ejected it was
evident she had  eaten a considerable  quantity of  the berries; not the
mucous part only, but  the seeds, wdierein I believe is the most active prin-
ciple of the berry, for  the mucous or fleshy part of the berry has been fre-
quently eaten  Avith impunity.  As  soon  as it appeared the stomach had
been  freed of its  contents, a purgative was  given, and had  the  desired
effect, hut the child never rallied from the first.  She continued in a coma-
tose  state,  and died in four hours after eating the berries. An inquest was
held, but no post-mortem examination alloAved.   I stated, in my evidence,
I considered yew-berries poisonous, and that the child's death had been oc-
casioned by them, but  I remember several of the jury  were very skeptical
on the point.                                          Part xix., p. 218. 
POLYPI.                           395
                             ZINC.

  Poisoning with Chloride of.-Dr. Thomas Stratton relates two cases of
poisoning wdth chloride of zinc.  In both cases  a wine-glassful of solution
was swallowed, containing in one case about twelve grains of the salt, and
in the other about two hundred grains.  In the latter case, burning pam
in the gullet, burning and griping pain in the stomach great nausea,  and
sense of coldness were instantly felt.  Vomiting  followed in a few minutes.
Dr. Stratton saw this patient twenty minutes after the accident, and in-
stantly made a strong solution of home-made brownish soap, of which ne
made the patient swallow at intervals, three or four pints. Afterward olive
oil was given, and the patient recovered. The other case was not seen by
any medical man; but it also terminated favorably.  Dr. Stratton suggests
either soap or carbonate of soda or  of  potash, as antidotes to chloride ot
 •       r                                          Part xix., #.218.
zinc.
POLYPI.
OF THE  EAR
  Mr. Wilde,  in  his treatise on the " Causes and Treatment  of Otor-
rhea," observes:
  The last cause  and complication of otorrhasa is  what I have through-
out  this paper denominated  polypus.   Fleshy,  pedunculated,  morbid
growths in the ear, nearly colorless, having a thin cuticular covering, unat-
tended by pain, not appearing as the result of inflammation, and unaccom-
panied by discharge, I  have  seen,  but such cases, in comparison with
those to  Avhich I have so frequently alluded, and now refer, are  ex-
tremely rare.   Throughout this essay I have constantly employed  the
terms  fungus  and polypus as  indicative  of these  morbid  growths,
the product  of inflammatory action,  and long-continued  otorrhasa.   By
fungus, however,  I particularly allude  to those vascular  and granular
masses Avhich generally groAV either from diseased bone, or upon  the  de-
struction, hi the Avhole or in part, of the  membrana tympani, and Avhose
attachments are to be found principally in the very bottom of the auditory
passage; while polypi are,  for the most part, confined to the glandulo-
ceruminous portion of the tube, and are  attached by narroAver roots than
the fungi.  It  is stated in books that polypi are smooth on their  surface,
while fungi are lobulated.  Here, however, is a very good  specimen of  a
polypus removed  from the  posterior wall of the glandular portion of the
meatus, presenting  such  characters.   In many instances polypi  may be
coexisting with granular tympani or fungous  masses proceeding from the
middle ear. Generally the polypus grows more externally, that is, appears
at the external orifice, Avhile the  fungus  is mostly confined to the bottom
of the tube.  The latter may, however, appear externally.
  The instrument of greatest value for the removal of  aural polypus from
any portion of the meatus, is the small snare-like apparatus consisting of a
fine steel stem, five inches  in length, with a  movable  bar sliding on tht 
396
POLYPI.
square portion toward the handle;  in a  properly-constructed instrument
the small upper extremity, flattened out and perforated wdth holes running
parallel wdth the stem, should not exceed the fourteenth of an inch in its
greatest diameter.   A fine silver, or Avhat is much better, from its greater
flexibility and  strength, a fine platina wire,  ivith its extremities fastened to
the cross bar at  the handle, passes through the holes in the flattened end
of the small extremity of the instrument, and allo\A'ed to be of such a length
as, that Avhen the bar is drawn back close to the handle, this ligature is put
fully on the stretch, and drawn tight through the holes at the small  extre-
mity.  In using  it, the cross bar is pushed forward and a  noose made of
the wire  at the  small extremity, of sufficient  size to include  the morbid
growth, AAdiich it is then made to surround,  and toward the root of which it
is pressed by means of the stem; the cross bar is then drawn up smartly
to the handle,  and it never fails of either cutting across, or of drawing with
it Avhatever was included in the noose.   Some bleeding generally follows,
which should be allowed to subside, then syringe the parts Avith slightly
tepid Avater, and again examine the ear, and if possible discover what por-
tion of the polypus may remain, which, Avhether it may be  the mere point
of attachment, or a portion unaccessible to instruments, should  be invari-
ably touched with the armed port-caustic, and the same application applied
from day to day, until all traces of the morbid growth are vanished. Unless
this latter point of practice be strictly and perseveringly adhered to, it is
in vain that Ave can expect a total eradication  of the disease;  no more,
hoAvever, of the auditory apparatus should be submitted to the action of
the caustic than the actually vascular, granulating, or fungous surface.  I
have frequently witnessed the whole canal in a state of ulceration, and an
erysipelatous inflammation extending over  the entire auricle, from a large
stick of lunar  caustic  having been inserted into, and rolled round  in the
meatus to remove a  polypus  or fungus growth, the  eradication of Avhich
had already been frequently attemped by instruments; a practice as cruel
as it Avas ineffectual.                                   Part ix.,p. 162.

   Ear Polypi.—For the removal  of these growths  Mr. Toyribee uses  a
kind of  ringed  forceps, each  blade  of the forceps  having a  ring at the
extremity instead  of teeth.  By this the structure  is not  broken up, and
the growth has a better chance of being removed by the roots.
                                                    Part xxix., p. 257

   Polypus of the External Meatus.—In all cases of discharge  occurring
from the external meatus, says Dr. Toynbee, the first step  is to use  a
syringe so as thoroughly to cleanse the meatus.  When this has been done,
there is  no  difficulty in determining  Avhether a  polypus  be present,
although it may be  situated  close  to  the membrana tympani.  Polypi
occurring in the external meatus may be  divided into three classes.
   1. The one  of  most frequent occurrence,  Avhich may  be called  the
raspberry polypus.
  2. That Avhich has been termed the gelatinous polypus.
  3. The globular  polypus.
  The cellular raspberry polypus is most frequently  met wdth,  and con-
sists of numbers of round beads, someAvhat similar in appearance to the
free surface of the raspberry.  These beads are attached by means of small
filaments, to  a central  stem, Avhich  forms  the root.  It is frequently 
POLYPI.
397
 covered by ciliated epithelium,  and when examined microscopical y its
 interior is found to be composed of small rounded cells.  It is usually so
 soft that,  upon being taken hold of by the ordinary dressing  forceps, it
 breaks up and bleeds freely.   The raspberry polypus varies much in size ;
 sometimes it is not larger than a grain or tAvo  of mustard seed, at others
 it fills the  Avhole of the meatus and projects from the orifice.  The parts of
 the meatus to which this kind of polypus is attached are very various;  as
 a general  rule they are attached to  the inner half of the tube, and fre-
 quently close  to  the  membrana tympani.   When small, their color is
 usually a deep red ; but when they increase in size they become more pale,
 and the rounded masses considerably increase in size.  The formation of
 these polypi is often  attended wdth considerable  pain and by a discharge
 of blood.  It is not  uncommon  for this  polypus to  remain  undisturbed
 during several years, the Avhole of which time it throivs offa most offensive
 secretion  without producing  symptoms sufficiently urgent to induce the
 patient to apply for relief;  in  other cases  the head symptoms are so dis-
 tressing as to cause serious alarm.  These polypi are usually the result of
 irritation  in the tympanic  cavity and they are frequently symptomatic ot
 obstruction of the eustachian tube.
  The treatment of polypi  by astringent applications, has no beneficia*
 effect; the same remark applies to the use of the nitrate of silver, whether
 solid or in solution.  The potassa cum calce answers the  best of anything,
 and if made to contain a small quantity of iron, it is firmer, much less  de-
 liquescent, and may be more  readily applied than the usual  form.   The
 first step in the proceeding is, to syringe out the meatus  with tepid water,
 and dry it Avith cotton avooI ;  then place the patient in a  strong light, pass
 a glass tube down to the polypus to protect the meatus, and press the end
 gently against the polypus, so that it may fully occupy the distal part of
 the tube, the potass cum calce must then be introduced  and  kept in con-
 tact Avith the polypus  for half a minute; this will scarcely give any pain,
 but if it should happen to touch the surface of the meatus, the pain will be
 very acute, the tube must therefore  be allowed to remain for a few min-
 utes, the meatus must then be syringed out, to wash away the little oozing
 of blood, etc.  On inspecting the polypus, it will be seen to  present a
 pulpy, uneven mass of a dark livid color.   As a general rule, the  potass
 may be applied daily in the same manner  until the whole of the mass is
 destroyed.                                        Part xxxv., p. 147.

                         OF  THE NOSE.

  Gelatinous Polypus.—If Dr. Lewis Shaw's method  of removing the
 gelatinous polypus from the  nose be found efficacious, it will certainly be
 an improvement  on the more ordinary methods of excision, extraction,
 ligature and caustics.  He powders very finely the sanguinaria canadensis,
 and causes it to be snuffed up the nostril, and the throat to  be gargled
 with a strong infusion.  In one case, by repeatedly using these means, the
polypus broke in twenty-four hours, and discharged a considerable quantity
of gelatinous fluid. The remedy was continued till the whole inner surface of
the  nose Avas made raiv, and occasionally afterward.   As the case, hoAvever,
has  not been Avatched a sufficient time, we could  not  depend upon the
treatment.  The sanguinaria  canadensis is one  of the  best knoAvn acro-
narcotics of the poppy tribe.                            Part vii., p. 215. 
398
POLYPI.
  Polypus of the Nose.—In the higher classes of society polypus of the
nose is not an uncommon affection.  It is frequently nothing more  than a
peculiar excrescence of the Schneiderian membrane, which is not malignant.
It is a tumor connected generally by a thin neck to this  membrane, or by
a narrow pedicle, or a long thin membrane continuous with Schneiderian,
but less vascular.
  The polypus is very smooth, and but little vascular, though sometimes
vessels burrow into it.  It is gelatinous in density, and appears to  consist
of coagulated albumen.  In a few instances there is but one polypus ; but
commonly there are two or three, and frequently clusters, so that  we can
scarcely count them. The color, which it is essential to notice, is pearl-like or
wdiite, mixed Avith brown, of an opal appearance.  Soft polypi of this kind,
Sir  B. Brodie has  never seen  attached  to the septum  nasi, the inferior
turbinated bone, or any part of the nostril, but almost always to the cells
of the ethmoid bone, though occasionally to the superior turbinated bone.
  There is at first merely an unnatural secretion of mucus, often w ithout
pain—the smell is  affected or even  disappears, and even the taste may be-
come considerably impaired.   The symptoms may go on for  years, while
the polypus may go on increasing and become more solid, the base being
at last almost cartilaginous.  It may increase even to come down outside
the nostril, or may descend down to the pharynx, behind the soft palate,
of the size of the fist.
  What is the best way of removing a polypus from the nose ?  A ligature
can seldom be applied  properly ; neither can the operation be safely done
with the knife, and seldom with the  scissors.   The forceps, made for this
purpose, is no doubt the best instrument.  The whole of the opposite
surfaces of the blades ought to be  quite rough, convex above, concave be-
low, opening laterally; sometimes opening from  above  downward.  The
forceps should be  oiled and warmed, the polypus caught by the base, and
the instrument cautiously closed.  The part should then  be not only pulled
forAvard, but twisted a little  to each side and then pushed backward—
again twisted a few times, first in one direction and  then another, and  at
last it.should be  pulled forward with some force, when it will  generally
come  away entire.  It is too often  the case  that when the neck of the
polypus is laid  hold  of by the forceps,  the  surgeon suddenly extracts,
Avithout the repeated twistings in all  directions so strongly recommended
by Sir B. Brodie.  It is owdng to the  neglect of this simple procedure that
a great portion of the polypus is often left behind.   When  the diseased
part has been removed, Sir B. Brodie recommends that the parts should be
painted over every day,  by means of a camel's hair  brush, with white
precipitate ointment.   The  unguent,  hydrarg. nitrat. diluted may also be
used, but this causes more irritation than the Avhite  precipitate, and does
not answer  so well.  The white precipitate  ointment should be  applied
regularly, not for a few days or weeks, but for  years.   This should be
done effectually;  not by just brushing over the parts which  are most
external, but by smearing the whole  surface of the  nostril both upward
and backward, even as far as the pharynx.  Astringent  lotions may also
be  used, as  zinc  or alum.  Sometimes  the polypus is of a more fleshy
nature and attached to the nose by a narrow neck, like those of the uterus
and rectum.   When this  is the case it may be snipped off Avith a pair  of
probe-pointed scissors, slightly curved.   Nitrate of silver may be  applied
to the part, and it is probable that it  may never reappear.  Some  polypi, 
POLYPI.
399
however, it is absolutely necessary to remove by ligature; as in a case
related by  Sir B. Brodie, in which there Avas an enormous tumor projecting
the velum pendulum palati forward to the mouth, so that the  finger could
only just reach its lower margin.
  In such a case there Avould be great difficulty in applying a ligature, and
it Avould be evident at once  that it would be almost impossible to remove
the mass either by the forceps or the scissors.  Sir Benjamin Brodie re-
commends  that a  bougie be  passed into  that  nostril  from which the
polypus  is  supposed to rise, and pushed forAvard into  the pharynx.  The
finger is then to be passed to the back of the throat, and the bougie bent
so as to bring one end out at the mouth, to  which  is to be fastened  a
double ligature.  The bougie is then Avithdrawn from the  nose, and of
course the  ligature  follows its course.  The ligature is then cut  off from
the bougie, and  the tAvo cut ends hang out of the anterior nostril over the
upper lip, the loop at the opposite end  hanging out of the mouth.  The
next  step  is to  get the ligature over the tumor.   " For  this  purpose you
cut through the loop  hanging from the mouth, so that there are noAV two
single ligatures.   One end of the single  ligature is to be  passed through
a silver tube, and putting the tube into the mouth and pharynx, you carry
one end  of the ligature under the base of the tumor on one side of it.
You leave  that out of the mouth, and your assistant holds both ends of the
ligature, to prevent it from slipping ; then Avith the same silver tube you
are to take hold of the other loose ligature at the mouth, and carry that on
the other side of the polypus, and there your  assistant is to hold it.  A
knotrthat will not slip must then be made of the two ends of the ligature
that hang from  the mouth.  You have noAV a ligature on each side of the
polypus, and then, by carefully drawing the ligatures out at the end of the
nose, you have got hold of the polypus  at its  base.  A silver tube is then
to be introduced into the nostril, and you  tighten the ligature  upon the
shoulder of the tube in the same manner  as  you tighten a ligature on
the polypus of the uterus.  It must  be  tightened every day till you have
completely cut through the polypus."   The polypus,  hoivever, should be
secured  by a ligature, so that when loose, the patient may draAV it out,
instead  of being in  danger of choking.   But the  method adopted by
Dessault is perhaps still more convenient.   " You require a silver tube by
which the ligature is to be directed into the mouth, a short silver tube to be
introduced into  the nostril for tightening the ligature, and two pretty long
ligatures.  You introduce a bougie into the nostril, and bring out one end
at the mouth.  To this you fasten  a single and a double  ligature; the
single one  must be very long.  This being done, the  bougie  is  to be
drawn out at the nose, and of course the  ligatures  follow it.  You then cut
off the bougie, and you have the two ends of the double ligature hanging
out of the  nose, and  the loop hanging out  of  the mouth; one end of the
single ligature also hangs out  of the nose and  one end out of the mouth.
The single and the  double ligature always pass on one side of the polypus ;
but by means of a silver canula you draw the single Ugature to the  other
side of the polypus.  The ligature being held  in  its place by an assistant,
the end of the single ligature projecting from the mouth is passed through
the loop of the double ligature, and the ends of the double ligature being
drawn out of the nose, the single end follows, and you make a ligature
which you fasten by means of a canula introduced into  the nose."  This
method of Dessault is certainly preferable to the one first described. 
400
POLYPI.
  Other tumors  of a malignant  nature may grow from the nostrils
which may be confounded with the two kinds of polypus just referred to,
No good has hitherto resulted  from interfering wdth  them,  and there-
fore Sir B.  Brodie thinks  it better to let  them  alone,  as " they have
generally so broad a base that any operation for their removal is out of the
question."
  There are some non-malignant affections which are sometimes mistaken
for  polypi: for example, a scrofulous child may have difficulty of breathing
through the nostrils, and. on  examination the membrane is found  turgid
and vascular, with  an  excrescence upon it.  This, hoivever, Avill fre-
quently he nothing  more than  a  thickening  of the mucous  membrane
of the  nostril at  the anterior extremity of the inferior turbinated bone.
The mucous membrane may not be more thickened than  elsewhere, but
it is more apparent in that situation on  account of the  projection  of the
bone.
  In some cases in-which  the  mucous membrane has been  sufficiently
thickened to obstruct the respiration through the nostril, I have introduced
a pair of probe-pointed scissors, slightly curved, and snipped off a portion
of the  projecting mucous membrane.  There is no  harm whatever in its
excision.  You may suppose this to be a very simple operation ; and so it
is, for it is done in an instant, but yet it requires some care in order that it
may be done properly.  In the dead body you might snip off a bit,  and  if
you had not  completed it by one incision you could make another.  But
in the living subject the mucous membrane is full of vessels, and the part
must be snipped  off at once; for the moment  one  division is  made Avith
the scissors, the hemorrhage is  so great that you cannot see a bit of the
remaining part wdiich requires to be divided.
  Delicate children A\dio  are liable to  this  disease of the Schneiderian
membrane are always benefited by the exhibition of steel; it should, how-
ever, be given not in large doses, for a  short time, but  in small ones long
continued.  Where the  constitution is weak, you  may sometimes cure the
disease in three weeks, but the rectifying of the constitution is a work of
years.   Some good may be done by local treatment.  Dissolve tAvo grains
of  sulphate of zinc in an ounce of rose-Avater, and inject a portion into the
nostrils tAvo or three times a day;  or paint the inside of the nostril with
diluted ung. hydrarg. nitratis by means  of a camel-hair brush.
  I have seen some cases in which a small abscess had formed in the tumor
that I  have just described.   Suppuration has taken  place in the substance
of the Schneiderian membrane, just where it projects in front of the inferior
turbinated bone, and  the best plan to adopt is to  cut off, with a pair of
scissors, membrane and abscess  altogether.   When an abscess forms in a
pile, that is best relieved, not by laying open the abscess, but by snipping
off  the  pile.                                             Part ix., p. 93.

  Removal of Nasal Polypi.—Dr. D. McRuer has been in the habit, for
some years, of employing the following method for  the  removal  of the
gelatinous and soft polypi of the nasal passages.
  A piece of catgut is passed from the nostrils to the mouth,  to wdiich is
fastened a piece of soft and dry sponge, corresponding in size, wdien firmly
compressed, to the narrowest part  of the nasal passage; it is then gently
drawn forAvard by the posterior fauces through the nose, and in Dr. McRuer'a
experience of at  least ten cases it has never failed to bring with it  all 
POLYPI.
401
the morbid growths much more effectually and easily than could possibly be
     ipfished by the old methods of forceps, ligature, etc Part xxm., p. lo..
accomj
  Polypus of the Nose.—In a clinical lecture on this subject, Mr. byine
remarks as follows :  When you are going to remove a polypus  remember
that non-malignant diseases of this description are generally very limited
in the seat of their origin from within the nose.  They never proceed from
the floor, septum, or external wall, but always from the roof, or that part
which is formed by the turbinated  plates of the ethmoid bone,  so that the
growth  always  descends  and fills up  the lower  parts of the nose, even
extending  into the throat.   Never,  therefore, attempt to extract it  low
down, but high up.  Select  forceps of a very small size;  introduce  the
instrument  gently along  the upper  passage of the nose, with the blades
separated as much as possible, till you come to the neck of the polypus-
then compress the handles, and by combination of traction and torsion in
one uniform direction,  break through  the  connecting textures.  If the
growth does not follow the instrument, try again and again.  The mucous
polypus, always originating from the small extent of surface that has been
thus defined, ivhether it does so singly or, as more frequently happens, in
groups, descends so as to  occupy first the higher  and then _ the  lower
channel of the nose, but cannot attain any great size so long as  it is limited
to these situations; and  not possessing  sufficient  vigor  of expansion to
enlarge the osseous space, in oifler to  attain any considerable bulk, must
therefore proceed backward  toAvard the pharynx.  Keeping these things in
miud, you will  at once  perceive  that the plan of removing  polypus by
means of a thread or wire, whether simply put up the nose, or passed
through it into the throat, cannot possibly extirpate the growth, or do more
than remove a portion  of its substance.  You wdil  also require no argu-
ments to prove the inutility and inexpediency of trying to accomplish the
object in view by scissors, knives, or caustic; so that our  choice is thus
limited to evulsion by forceps.
  [Mr. Syme then proceeded in the way that has been described, and after
several introductions of the forceps,  succeeded in removing a large round
polypus quite entire, immediately after Avhich the  patient breathed with
perfect freedom through both nostrils.]
  It stiems not unworthy of  notice that in this case there are some points of
resemblance to that remarkable tumor named the fibrous polypus, of which
the characters are unity of groAvth, ligamentous toughness of consistence,
extreme firmness of attachment, and disposition to bleed.  Several cases
have occurred here in which the patients had nearly died of hemorrhage,
aiid  all  the strength that  I could  exert Avas hardly sufficient to effect
extraction, Avhile blood streamed in torrents from  the nose  and mouth.
But as this disease is  not malignant, the operation, however formidable,
proves satisfactory in its  result.  Now, you may have remarked, that the
tumor which  has just been removed  was solitary,  and confined  to  one
nostril, instead of occurring in both, as the mucous polypus almost  always
does; also that its connections Avere very firm, and that the bleedino- was
considerable.  It would seem as  if  there may be conditions intermediate
between the two sorts of growth, in A\diich the respective characters more.
or less closely approach  those of each other.   For instance, some years
ago, a nobleman returned  from public service in  one of the colonies, on
account of complete obstruction to breathing through  his nose, with a
    vol. n.—26 
402
POLYPI.
constant discharge of watery fluid  from it,  and occasionally alarming
hemorrhage, of which the amount was estimated not by ounces but by pints.
He remained in London for two months under the care of several practi-
tioners, wdio regarded  the disease as  incurable; and finding himself thus
given up as hopeless, he apphed to me, bringing Avith him a letter from the
late Mr. Bransby Cooper, which stated that the result of repeated consul-
tations with Sir B. Brodie, Mr. Travcrs, Mr. Caesar Hawkins, and himself,
was a decision against interfering with the disease, which they seemed to
regard as a tumor of the throat.   Seeing no  sign of malignant  disposition
in the aspect of the patient, wdio  Avas about thirty-four years of age, and
recognizing in the tumor the characters which Avere familiar to me as those
of a nasal growth stretching backAvard into the pharynx, I at once under-
took to remove the source of complaint.  The  patient and his friends at
a distance having given their consent, I introduced the forceps, and at the
very first pull extracted the Avhole growth, Avith immediate, complete, and
permanent  relief.  Four years have now elapsed, and there has not been the
slightest symptom of relapse to interfere wdth the enjoyment of perfect
health, or the vigorous  exertion of an  active fife.      Part xxxi, p. 223.
  Nasal Polypus—New Forceps.—Mr. Gant has recently  invented a pair
of forceps for the removal of nasal polypi Avhich cut and hold at the same
time.  " One edge of either blade is finished off someAvhat like that of an
ordinary pair of scissors ; the other edge is broad and rasped. This combina-
tion of scissors and rasped forceps is a modification of the grape or flower
scissors of  the conservatories."                     Part xxxviii., p. 148.

                              RECTUM.
  Polypus of.—[In his lectures on Surgery, Sir A. Cooper stated that he
had only met with ten cases of polypus  of the rectum.  Mr. Syme states
that he once saw  five in  the course  of a fortnight, and thinks it  not so
rare as is generally supposed.  Mr. Syme says:]
  It presents itself in three different forms, of which one usually occurs in
childhood,  and does  not appear much beyond puberty.  It is extremely
soft and vascular, of a florid red color, and assumes the  form either of a
worm from tAvo to four inches in length, or of a strawberry with a connect-
ing footstalk two or three inches long. The tumor seldom protrudes ex-
cept ivhen the boAvels are evacuated, and then admits of ready replacement,
though not without occasional hemorrhage, Avhich may be of considerable
amount.  The vascularity of this  growth, and  its attachment  above the
sphincter, made me averse from removing it by incision; and Sir A. Cooper
has mentioned the alarm that was on one occasion excited in his practice
by doing so.  I have always employed the ligature; and though the  soft
texture readily gives way wdien the thread is  drawn, bleeding has never
occurred in a single instance, or any other symptom in the least degree dis-
agreeable resulted from this mode of removal.  I am  therefore induced to
regard it as the best that can be employed.
  The disease appears in adults in tAvo very distinct forms.  In  one of
these, the groAvth  is soft, vascular, prone to bleed, lobulated or shreddy, and
malignant-looking, so as on the Avhole to resemble very much  the cauli-
flower excrescence of the os uteri, but possesses a peduncle or foot-stalk of
firm texture, capable of sound cicatrization after being divided.  The pro-
fuse, frequent, and protracted bleeding which proceeds from this  sort of 
POLYPI.                           403
growth, renders its removal an object of great consequence; and this may
be effected very easily, Avith perfect safety, by transfixing the radical cord of
connection with a double ligature, tying the threads so as to include a half
of it in each, and then cutting it across a little beloAV the constricted part.
In a patient  of Mr. Craig, of Ratho (avIio  detected  the  disease from the
great hemorrhage it occasioned), I could not accomplish protrusion of the
tumor, but guided a ligature on my finger, and tied it on the neck Avithin
the rectum.  It is more satisfactory to force or draw the swelling beyond
the sphincter, so that the sound and morbid parts may be distinguished Avith
certainty, and this can usually be done  with  great  facility, although the
growth has attained a large size.  In a hospital case  recommended by Mr.
Anderson, of Castle-Douglas, I brought into view and removed a tumor not
less than an  orange,  Avhich had a most malignant aspect, and had nearly
exhausted the patient by hemorrhage.
  In the other form wdiich polypus of the  rectum assumes in adults, the
tumor  is of a firmer consistence, smoother surface, and  more  regularly
spherical or  oval form, so as to resemble  the growth which in general con-
stitutes polypus uteri.   The symptoms resulting  from this simple swelling
are rather annoying than seriously alarming; and the patient, therefore, is
apt to delay requiring assistance for  a long while.   In the case of an old
lady, whom  I saw Avith Mr. Hillson, of Jedburgh, the tumor ivas  about the
size of a cherry, with a long stalk, and Ave were  assured had protruded
every time the bowels moved for tAventy years.  In another case, a gentle-
man Avhom I saw with Dr. Johnson, of Cumnock, the tumor was nearly as
large as an egg, had a cuticular covering, and appeared  to have existed
for a period equally long. I have ahvays removed these growths in the
Avay that has been already described, and never met wdth the slightest con-
sequence of a disagreeable kind.                        Part xii., p. 207.
  Polypus  of the Rectum.—[A little girl, five years old, had been subject
for two or three years to great distress in defecation, accompanied by the
protrusion of a  polypus.  She was  considerably reduced by sanguineous
discharge.   Dr. Burns says :]
  On examination of the anus, I found a polypus protruding as large as a
small seckel pear, being considerably diminished at the time from frequent
bleedings.   On dilating the anus as much as  possible, by traction in oppo-
site directions, I found the pedicle to be someAvhat elongated from the mu-
cous membrane of the rectum above the  sphincter; to this I immediately
applied a ligature of silk thread, allowing the ends to remain long, which
were secured externally by a strip of adhesive plaster; about twenty-four
hours after its application the polypus separated, and two days after, the
ligature came away.  She suffered some pain while the ligature  remained,
which did not demand special attention.  Since its  removal about  eight
months have passed away, and there has been no return of the disease; no
hemorrhage, the function of the part is normal, and the child's health and
appearance very much improved.                       Part xvi., p. 194,

  Polypus  of the Rectum.— Vide " Use  of the Ecraseur."


                              UTERUS.
  Polypus  of, expelled by the Action of Secale Cornutum.-—£M.r. Moyle
was  requested to attend Avithout delay a Mrs. W., who had suddenly lost 
404
POLYPI.
a large quantity of blood from the womb, and had just recovered from a
long state of syncope.  The blood was lost hi about two or three minutes.
She had frequently had small hemorrhages previously, and Avas becoming
weaker in consequence.   Her  legs  and thighs were  swollen almost to
bursting, her countenance pallid, respiration difficult, and general health de-
clining.  After she had recovered greatly from her fainting, and after Mr.
Moyle had satisfied himself that the flooding was owing to polypus of the
uterus, he proceeded as folloAvs :]
  A fresh appearance of hemorrhage induced me to give her at once two
drachms  of the tincture  of secale cornutum.  I also applied  -a bandage
firmly round the abdomen, and apphed cloths, wetted Avith cold vinegar and
water, to the pudendum.   The discharge proved to be little, and no faint-
ness folloAved.   In twenty minutes after the first dose, the tincture was re-
peated, and in  a few minutes she complained of being griped.   Suspecting
this griping to be a slight contraction of the  uterus, I ventured an exami-
nation by the vagina.  The vagina ivas full of coagula ; the  os uteri Avas
flabby and dilated to the  size of half-a-crown piece, immediately Avithin
which I found  a substance of someAvhat firmer  texture than the coagula,
and around which my finger passed freely.   During the examination there
was a pain of sufficient force of the os uteri to embrace the finger  firmly,
and I now felt confident of being able to subdue the hemorrhage for the
present, and was not wdthout hopes that I might, by a perseverance of the
remedy, enable the uterus to throAV off the extraneous substance wdthin it.
A third dose was noAV administered, which kept up the pains at short in-
tervals, but they were Aveak and feeble.  Finding this the case, the suppo-
sition was, that she ivas too much reduced from the disease and the recent
loss of blood for the medicine to have its full effect.  A cup of gruel, with
a small quantity of brandy in it, Avas given her, and in half an hour after,
another similar potion, wdiich had the effect of reviving her to a great de-
gree.  I now took my leave about  eight o'clock p.m., giving directions for
a repetition of the food, together Avith some beef-tea, at intervals of an
hour or every second hour, lea\dng wdth her four doses of the secale, to be
taken at intervals of half an hour; in case there  should be the slightest ap-
pearance of flooding, I was to be sent for immediately.
  Early on the followdng morning, I found her laboring under sharp con-
tractile pains of the uterus, from having taken, tAvo hours previously, two
doses of the secale. Examination discovered  the mass of polypus filling the
vagina.  The patient Avas very cheerful, and  expressing herself convinced
that the mass Avas coming aAvay.  The  pains wrere by this time not so se-
vere as they had been, and consequently I noAV gave her three drachms of
the tincture in  a little brandy. This had the effect, in about tAventy minutes,
of producing a severe pain, wdiich brought the mass  to the os externum.  It
wras now grasped with the hand, and, on the recurrence of the pain, the wdiole
was discharged. Slight hemorrhage only followed the expulsion of the po-
lypus, Avhich equalled in size two large placentas.   From  this moment she
recovered Avith great rapidity.  There was a  slight appearance of the men-
ses at the end of six Aveeks, succeeded by a more abundant appearance  at
the termination of another similar period. She daily improved in  health,
the oedema gradually subsided, and although she was for many months un-
able to put the whole weight of her body on her right leg, yet from ban-
daging, the use of tonics, etc., she is now, in all respects, a perfectly healthy,
robust woman. 
POLYPI.
405
  The successful result of this case induced Mr. Moyle to try the use of
the ergot in another patient who had previously been under his care.   He
gave her four  doses of the tincture of secale cornutum, 3ij. in each dose.
Two or three slight pains were noAV experienced, nausea and vomiting fol-
lowed.  Shortly afterward she had a  severe labor pain.   She then took
3iij. more of the tincture, and the pains increasing, the polypus mass was
felt at the os uteri.  By the further use of the medicine the substance ivas
completely expelled.  It was about the size of an average placenta.
                                                     Part iv.,p. 120.

  Polypus of Womb.—A  polypus descending from the womb is said to
be insensible, whilst an  inverted uterus is very sensible.   If, hoAvever, a
polypus descend with a covering from the inner surface of the womb, it is
evident that its sensibility will be more or less retained.
  In partial inversion of the uterus, M. Lisfranc thinks favorably of the
mode of examination proposed by M. Malgaigne, which we shall describe.
In this affection the bladder and a portion of the intestines are lodged in
the concavity formed by the depression of the fundus of the Uterus ;' if,
then, a curved catheter is passed into the bladder with its concavity doAvn-
ward, and the beak of the  instrument is directed to  the most depending
part of the Bladder, its extremity will be readily felt by the  finger in the
vagina, if the case is one of inversion, unless, indeed, the  intestines have
become adherent to the womb in such a way as to prevent the catheter
penetrating into the depression formed by the inverted organ, a circum-
stance of very  rare occurrence.   But  M. Lisfranc thinks that the best
Avay of discriminating betAveen rolypus and inversion of the uterus, is by
a mode of examination  similar to that above recommended, in the case of
an intra-uterine polypus or of a commencing inversion.   If  Ave seize  and
depress the tumor with two fingers passed into the vagina, and then intro-
duce the index-finger of the  other hand into the rectum, no tumor can be
felt through the gut above the one Avhich is grasjied in the vagina, if the
case is one of hwerted uterus.   But if, on the contrary, we  feel through
the rectum, a second tumor similar in shape to the uterus, above the Aagi-
nal tumor, then this  latter tumor is a polypus.   In one instance, indeed,
M. Lisfranc was misled by this mode of examination; he diagnosticated
inversion of the uterus, but the patient having died, a small fibrous tumor
Avas discovered implanted on the uterus, which was flattened  and reduced
to the tenth part of its natural size.
   M. Lisfranc has on several occasions removed by enucleation both polypi
and fibrous tumors which were not pedunculated, whether situated com-
pletely within the cavity of the uterus, or having partly (or in the case of
polypi entirely) made their way into the vagina.
   In one case having draAvn a fibrous polypus almost entirely through the
vulva, he perceived that its envelope,  which consisted of a thin layer of the
tissue of the uterus, Avas lacerated, and passing the index finger through
the rent, enucleated the tumor with the greatest facility.  In another case
enucleation Avas effected almost accidentally : M. Lisfranc, while examining
a polypus,  found  the  envelope  give Avay beneath the nail of the index-
finger, and  by an easy manipulation enucleated the tumor in a few seconds.
On examining the uterus immediately afterAvard, he found  that the part
of that organ to which  the polypus had been attached, had singularly con-
 tracted, that the depression  caused by the tumor had diminished greatly 
406
POLYPI.
in depth, and at least two-thirds in breadth, it seem:! to be diminishing
while the finger was in contact with it, and in ten hours the uterus had
regained its natural size, and the cervix Avould not admit the finger.  We
mention these latter facts, as we conceive they have an important bearing
on the question of hemorrhage after excision of polypi.  M. Lisfranc has
also frequently  enucleated, Avith the nail of the index-finger, small cellulo-
vascular polypi occupying the neck of the womb. In a case Avhere a fibrous
tumor as large  as the clenched hand projected into the vagina,  its envelope
was lacerated with the nails, and  the contained tumor turned  out.  But
enucleation must generally be preceded by an exploratory incision: and
by this combination of means, M.  Lisfranc has removed fibrous tumors
while still  completely included within  the cavity of the uterus.   A lady
was reduced almost to  extremity, by protracted  uterine  hemorrhage
caused by a fibrous tumor, Avhich could be felt  through the dilated cervix
uteri.  The neck of the uterus was seized Avith Museaux's hook, depressed
almost to the vulva, and a more perfect examination being then practica-
ble, the tumor was found  to extend from  the middle of the  body of the
uterus almost  to its loAver extremity, and  to be lodged in its posterioi
wall,  from which it was  commencing to disengage itself.  A straight,
blunt-pointed bistoury was passed along the fore-finger, a vertical incision
slowly and cautiously made over the tumor until the  finger was enabled
to be insinuated beneath the envelope and complete the enucleation, Avhich
was not accomplished Avithout  some difficulty.  Occasionally, enucleation
may be more easily  achieved by substituting a spatula for the finger.   If
it is necessary  to enlarge the incision in order to effect the removal of the
tumor, a grooved director will often  guide the knife  more conveniently
and safely than the finger.  In some cases where the cervix uteri ivas  in-
sufficiently dilated,  M.  Lisfranc divided it anteriorly.   Whenever the
peduncle of a  polypus  is very broad, Ave should incise the envelope, and
endeavor to enucleate  the  tumor ; in this,  however,  we  cannot ahvays
succeed.   If the  tumor is removed, the envelope  sometimes contracts and
cicatrizes, sometimes sloughs in whole or in part.
   Lisfranc, in common Avith many other French writers,  disapproves alto-
gether of removing polypi by the ligature; and the RevieAver agrees wdth
this opinion in general, although there may be cases in which it is neces-
sary to use the ligature: " Thus, if a polypus of moderate  size is com-
pletely included within the  uterus,  and is implanted  high up,  especially at
the summit of the organ, and if the  symptoms  imperatively demand an
operation, a ligature should be applied, if its application is  possible, as
it occasionally is  Avhen a sufficiently small peduncle can be detected; or if
a patient is so exsanguine that  the smallest loss of blood is to be dreaded,
we should employ'the Ugature, unless the peduncle is too thick, or unless
we are unable to  bring it, Avhen bulky, fairly Avithin  our reach, and pierce
it with several needles, each armed Avith a double ligature and thus tie it
in two or more separate portions."
   How should  wre proceed if Ave felt an artery pulsating in the peduncle ?
Dupuytren recommended excision, having previously placed a ligature of
reserve in case of hemorrhage: Lisfranc disapproves of  this, inasmuch as
it Avould certainly lose its place; and  instead he would at once place a
bVature  on the peduncle, and  then excise the tumor at  once, leaving  the
ligature on the peduncle for about eight or ten hours, and then removing
it.  If hemorrhage should come on, he is convinced that plugging would 
POLYPI.                          *407
be sufficient.  If the artery felt in the peduncle was only a small one, he
would not even apply a ligature, but excise the polypus at once, trusting
to plugging, if required.                            ^   Part x., p. 151.

   Uterine Polypi  and Ulceration.—Dr. Montgomery directs if small, to
remove them by twisting with a  forceps, consisting of a straight  stem,
eight inches long, having two short spring blades, with  serrated tips, upon
which slide a brace movable from the  handle, by ivhich they are  easily
pressed firmly together,  and made  to  grasp very  securely,  any object
caught between them. Apply nitrate  of silver to restrain bleeding. Where
it is necessary, in a larger pedunculated polypus, apply a ligature; Niessen's
double canula is recommended, and with it, silk salmon fishing-line soaked
in linseed oil, wdiich combines strength, perfect pliability,  and softness,
and  is unaffected by moisture.    N.B.  In  persons of a  high  habit,  and
Avho are subject to indulgences in  dietary, be careful not suddenly to sup-
press menorrhagic  discharges, because of the dangers of determination to
.cerebral congestion.                                 Part xiv., p. 301.

  Polypus Uteri.—"Very small polypi situated high up in the cervix, says Dr.
Locock, may be  rennwed by an instrument made for the  purpose, consist-
ing of a very small, sharp scoop, like a carpenter's  gouge,  inclosed in a
canula from which it  is made to protrude by turning a screw.  Larger
polypi should be excised; but should first he twisted round  several times
so as to produce torsion of the arteries; or, if they are very large, a liga-
ture  should be  applied for two   or three  days, and when the circulation
has  become well strangulated, the  neck  of the polypus should be cut
through above the  noose.                            Part xvii., p. 27-7.

  Polypus Uteri,  Intro-uterine—When the symptoms  afford reason to
suspect the existence of a polypus concealed within the uterus, says Prof.
Simpson,  the diagnosis may be rendered certain by the  dilatation of the os
and  cervix uteri, by means of sponge-tents.  The tents recommended are
of a  conical form,  and are introduced by the aid  of a director resembling
the uterine sound.   Usually a single tent, apphed for twenty  or  thirty
hours, opens  the  os and cavity of the cervix sufficiently to  allow an
examination of this part by the  finger.  In order to examine the cavity
of the body of the uterus, it is necessary  to employ a series of tents for
several days, taking care to  pass them within the os internum.  When
the  presence of a  polypus  is ascertained,  if it be gradually but certainly
making its  way doAvnward, and  the hemorrhage  and other symptoms
are not urgent, wait for its descent through the os, before attempting its
removal;  facilitating its passage by the dilatation of the  os and cervix with
sponge-tents, and by the internal use of ergot.   But if there is too much
hemorrhage to ivait, or if there is no likelihood of the tumor's descent,
prpceed forthAvith to remove it.  With this object, first dilate the os uteri
further; then if  the polypus is large, divide the pedicle with very curved
blunt-pointed scissors, or with a silver wire passed around it and tightened
by means  of a screw; or if these means  are inapplicable, contuse  and
crush  the  tumor by a  pair of lithotomy forceps, or similar instrument.
Or, if the  polypi are small and vesicular (in which case they are  generally
numerous, and situated in  the cavity of the cervix), remove those that
are fully formed and pedunculated, by the scissors, or by scratching them
off with the nail; and destroy those that are not completely developed, but 
408
POLYPI.
are imbedded like peas  in  the  mucous membrane of the cervix, by the
application of potassa fusa.                            Part xxi, p. 275.

  Polypus Uteri—Intra-Uterine.—When the womb remains large and
bulky after delivery, says Dr. Oldham, and when we are satisfied there is
not another  ovum, although we may suspect the presence of a polypus,
we are decidedly not justified,  so long as no alarming symptoms occur, in
endeavoring to make out exactly by manual interference, whether such is
the case or not, or in arousing the uterus to contraction by the exhibition
of the ergot of rye.  The system  of non-interference must be pursued ; the
Bafety of the patient consists in the quiescence of the uterus.  To insure
this, strict rest, mild  sedatives,  and  the avoidance of all local irritation
should be enforced.  But if, in spite of all endeavors, it be necessary  to
remove the polypus, the best plan is, if the pedicle is small, to twdst it off.
If, however, it occur at a time  Avhen physical injury to the uterus may be
hazardous, the ligature should be applied to the pedicle to prevent hemor-
rhage, and then the body of the polypus removed with the knife.
                                                   Part xxxi, p. 316'.
   Polypus Uteri— Varieties.—The term " polypus uteri," says Dr. Rams-
botham, has been given at different times to organic diseases of the uterine
structure, as well as to formations, within the uterine cavity, of very various
and dissimilar kinds;  and even  now, though it is restricted to tumors
attached  by vascular  connection to  the uterine substance, the phrase is
apphed to more  than one variety of morbid growths.  Some are dense,
firm, and compact, in  their structure ; some soft and cellular;  some of a
florid  scarlet; some of  a deep  peony color; and  some, when removed,
almost white.  They  take their origin also from  different parts of the
organ,—the  fundus, the body, the internal channel of the neck, or the
outer circle of the mouth itself.
   Dr. Lee has noted four distinct species of polypus  uteri, none  of them
malignant in their nature:—the  fibrous;—the follicular  or  glandular,
which he describes as a morbid enlargement of the Glandule Nabothi ;
and which, consequently, are  situated only at the mouth or neck;—the
cystic or cellular, made up of a congeries of small vesicles or  cysts, con-
taining a fluid more or less  transparent, and  yellowish in color.  This
variety is formed just beneath  the  lining membrane of the uterus, and
springs  from every part of the cavity.  The tumor is highly vascular;
and the cysts composing its chief bulk are bound together by fine fibrous
tissues ;—and, lastly, the mucus, which does not grow to  so large a size
as either of the others, and which  seems to  be produced by a morbid
change in the mucous membrane  itself, and to be analogous to the poly-
pous   tumors sometimes formed within  the  nose and  other mucous
cavities.                                           Part xxvii., p. 201.
   Ligature in Polypus  Uteri—In applying a ligature upon a polypus of
the uterus, says Dr. Ramsbotham,  we might grasp some of the structure
of the uterus itself.  To obviate  this, the neck of the polypus must be tied
some distance below its attachment; for that portion of the stem left  in
connection with the uterus will  wither and come away in shreds, or be
absorbed after the  main bulk has been" removed.  The sensation of pain
must, to a great extent, be our guide.  If the patient complains much, the
noose should be relaxed and again drawn tight over the lower portion of
the neck or body of the tumor.                      Part xxvii., p. 203. 
POLYPI.
409
  Polypus  Uteri.—Galvanism apphed  to  the  uterus  has  brought these
growths into view ivhere ergot had failed.            Part xxix., p. 266.

  Extraction  of  Polyi  from  the  Uterus.—Mr. Canney  recommends
excision rather than the ligature when the polypi are not  large.  Dr.
Tyler Smith prefers ligature ;  Mr. Hodgson says the torsion is sometimes
both better and safer than either excision or the ligature.   Dr. Copland
gives us an  interesting case  to  show  the effects of biborate  of soda.
He says:
  Polypi,  or fibrous tumors,  on the inner  surface of the uteNis, were
occasionally thrown off without  resorting to  the ligature, or any other
operation.  Some years ago he had been called in consultation to the case
of' a lady suffering from constantly recurring uterine hemorrhage.  A
tumor was  protruding from the  os uteri.   The question of removal was
discussed, and it was decided that biborate of soda should be given, with
a view of producing the contraction of the uterus, by Avhich the growTth
might be  throAvn off.  The medicine was given in large doses, and con-
tinued for two or three days.   The uterus  contracted powerfully, and  the
tumor was expelled.  All the symptoms abated for three  or four  days,
when a second tumor presented itself.  Dr. R.  Lee then joined  the con-
sultation, and it Avas determined that the use of  the soda should be per-
severed in.  The  result was that  this  second tumor, like  the first, was
thrown oft", and the patient  recovered.   He could speak  from his own
knoAvledge, that she was alive and well 13 or 14 years afterAvard.  This
might not  have been a case, strictly speaking, of  polypus of the uterns,
but it was certainly one of a tumor under the villous coat of that organ,
which was throAvn off by the  contractions  of the uterus.
                                                   Part xxix., p. 304.
  Polypus Uteri—Detection  of.—The   polypus  will  be  best  detected
during the relaxation and forcing doAvn, attendant on an attack of flooding.
The bi-valved speculum  assists  by expanding  and opening  the os.  Dr.
Locock particularly points  out that  the tumor is  always  best found out
during  hemorrhage, and  indeed it cannot be  detected at  all when very
small, and only in the cervix, in the intervals of the  attacks of hemorrhage.
  For bringing a polypus into view, the ergot of rye  may sometimes suc-
ceed, but galvanism is more safe and more efficacious.  The os and cervix
uteri may be dilated by means of sponge-tents—use two  or three gradu-
ated sponge-tents in succession so as to open the canal for inspection.  M.
Jobert de Lamballe has recently  contrived an intra-uterine speculum.
  In  those cases which indicate  the necessity of exploration beyond the
uterus, first bring the polypus  in view, if you can, by dilating the os uteri
by  sponge-tents, and giving repeated doses of ergot of rye, assisted by
the app ^cation of galvanism.   If you cannot get hold of the tumor so as
to enciicle the neck, pull it loAver down by the aid of a tenaculum,  if this
operation be not particularly resisted—and now try again to ligature the
neck ofjthe tumor.                                  Part xxx., p. 212.
  Exciiion  of Large Pedunculated  Uterine Polypi.—Prof.  Simpson
prefers ^o remove large uterine polypi by excision, rather than by ligature.
You can always  arrest hemorrhage by well plugging the vagina. For
excision] use a polypus-knife (called apolyptome).  First reach the pedun-
cle by tfie apex of the fore-finger of the right hand introduced along the
pubic surface of the vagina.   Then push the instrument along this finger, 
410                          PEEGNANCY.
and  by hooking down the peduncle it is divided by the knife, which is
placed in the concavity of the instrument, something like the lately im-
proved hernia-knife.                                 Part xxxi., p. 21o.
   Waterproof Ligatures.—In cases of polypus, etc., the ligature some-
times breaks abruptly from the corrosive effects of the discharges.  If the
ligature  be previously rendered waterproof by a solution of caoutchouc it
answers beautifully, and comes aAvay as sound as when applied.
                                                   Part xxxii. p. 318.
   Uterine Polypi.—These, when  pendent from  wdthin the os uteri by a
narrow  peduncle, may be readily removed  Avithout any hemorrhage by
the ecraseur.   Slip the loop  of the chain around it, and by tightening
slowly and steadily, the stem will easily be cut through.
                                                   Part xxxv., p. 253.
   Uterine Polypi.—For the removal of these tumors an instrument lately
invented by Dr. Aveling, of Sheffield, will be found  very useful.  It con-
sists  of a long curved stem, at one end of which is a hook, and fitting into
the concavity of this is a plate of metal, which by a screAv in the handle is
capable  of being Avithdrawn lower doAvn the  stem.  When used the plate
is  screAved half Avay down the stem, and the instrument is passed up so
that  the hook may be round the peduncle of the tumor : by means of the
screw the plate of metal is noAV forced up into the concavity of the hook.
Thus the tumor is removed, without the disadvantages of either the knife
or the ligature ;  viz.  of the former, hemorrhage,  which is  here avoided,-as
the peduncle is not divided by a cutting but -by a crushing action, and of
the latter, the fetid discharge caused by the putrefaction of the polypus.
                                                  Part xxxvi., p. 246.
  Removal of Large Uterine Polypus, by  the Curved Ecraseur.—Dr.
Savage of the Samaritan Hospital, lately removed a vascular uterine poly-
pus,  Avithout  pain or hemorrhage, by means of an ecraseur the curve of
which can be made to fall into the holloAv of the sacrum and  the point to
pass  up  into the  uterus.   When removed by this instrument,  the polypus
is first seized  by a pair of ring forceps, and the chain is passed over these,
and  drawn tight, precisely as the  cord in  the  ordinary  operation by
ligature.                                         Part xxxvii., p. 214.
  Polypus Uteri.—Mr. I. B. Brown is of the opinion that the best mode
of removing  these groAvths, is to  seize them  with a pair of long vulsellum
forceps, and having dragged them into sight to pass  a needle  armed wdth
a strong double ligature through the base, which can noAV be  tied in tWo
parts, then cut off the polypus just  anterior  to the ligature, and plug the
vagina with oiled lint. This plan is infinitely preferable to that of either.
simply cutting oft* the polypus, or the more tedious process with Gooch's
apparatus, where the sloughing of the polypus within  the \ragina generally
causes serious constitutional  disturbance, not  unfrequently pyasmia, and
sometimes death.                                  Part xxxvii.,/) 217.

                             ---•-*-»—.


                       PREGNANCY.
  Nux  Vomica, in  the Vomiting of Pregnant Women.—Dr. Croyher,
oi  Presburg, assures  us that minute  doses of the nux vomica, given in 
PEEGNANCY.                         411
some aromatic or in cherry-laurel water, are i specific remedy against the
troublesome vomiting to A\diich many Avomen are subject during the early
months of pregnancy.   In order to insure success, the boAvels must be
kept in a gently open condition,  but neither purged nor constipated.  The
author says, that the effects of this remedy  are  certain, provided  the
vomiting is the result of pregnancy alone, and is  not dependent on  any
morbid state, either of the stomach  or of any other organ.  The dose
recommended is  from tAvo to four drops of the tincture—the strength of
this  is not  stated—to be gradually increased to ten, tAvelve, or eighteen
drops every morning in bed, and again  hi the evening.   In many cases it
proves quite successful within a week  or even a shorter time ; in other
cases its use must be continued longer.                  Part hi., p. 125.
   Gravidine as  a sign of Pregnancy.—The  fluid portion of the urine
of pregnant women being  drawn  off,  there  appears  a " natural sedi-
ment," which,  whether held  in  solution,  or separated by  ether, has a
striking resemblance  to the serous globule, but, when in a sedimentary
state, bears an equally strong resemblance to  the  milk globule in recent
milk.  This substance differs from albumen and caseum, the two animal
substances most  analogous  to it: from the  former, in being  soluble in
water by means of heat; from the latter, in being soluble by sulphuric  and
nitric acids.  From gelatine it also differs : first, in being precipitated from
its solution in  water  on cooling ; secondly, though partially precipitated
by tannin, the  precipitate ivas soluble in water on  boiling.  The author
calls it " gravidine," both from gravidus, big with  young, occurring as it
does in pregnant Avomen ; and also from gravis, heavy, seeing that it falls
to the bottom of the vessel.  Kiestein is but the pellicle which results from
the  decomposition of gravidine.   As   the globules forming the latter
substance are  decomposed, urates  and  purpurates are developed in  the
urine ; and Avhen  these have  broken up and assumed neAV combinations,
the triple phosphates  appear, A\dth that beautiful  crystalline appearance
described by Dr. Bird as one of the characteristics of kiestein.
                                                       Part v.,p.lQ2.
   Severe  Gastric Irritation in Pregnancy.—Whenever in a pregnant
woman, in any  stage of her  gestation, severe vomiting, wrearing away the
strength of the patient, and  preventing proper nutrition, shall ha\re for
several days resisted all the usual remedies, AA'hilst the fever continues una-
bated, and the  vital forces are failing,  Ave ought not to  delay a moment,
says Dr. Edwards, in procuring the  expulsion of the fastus.
                                                     Part xiv.,p. 284
  Diagnostic Sign.—A good diagnostic is the enlargement of the anterior
wall  of the womb, its ordinary flatness becoming effaced by the fourth or
fifth  Aveek.  In congestion of the womb, it is the posterior Avail which is
chiefly enlarged.                                       Part xv.,p. 315.
  Appearance of the Os Uteri during Pregnancy.—Dr. Whitehead says :
In order to ascertain the existence of pregnancy  from  a few days after
conception to the middle or end of the fourth month, examine the os uteri
with the speculum.  Immediately after the conception, as during menstru-
ation, the labia  uteri are in a state of great vascular turgescence, and the
os closed and linear.   In from ten to twenty days the whole uterus is found
enlarged, and the circulation in it augmented ; the labia are thickened  and
apparently elongated, the commissures less distinct, and the os apparently 
412
PREGNANCY.
sunk in or dimpled.  In the fourth week the os tineas, which ivas before a
mere chink Avith parallel boundaries, now an elliptical or rounded aperture,
separating the labia to the extent of a line or two, and occupied by a plug
of mucus.  At  six or eight w'eeks it becomes decidedly oval or circular
Avith a puckered or indented boundary..                Part xvi, p. 239.
  Menstruation in  Relation to Pregnancy. — Conception,  says  Prof.
Dubois, may take place in a Avoman not yet arrived at the age at which she
ought  to menstruate. There are, in fact, many women Avho do not  mens-
truate  till the seArenteenth,  eighteenth, or nineteenth  year.   Such Avomen
may become pregnant at  that  time of life,  although they have  never
menstruated.   M.Dubois has knoAvn a lyoman become pregnant tAvo years
after the cessation of the  menses.   The Avoman finding her abdomen en-
larging, entered the medical department of an hospital.   The physician
under  Avhose charge she was, had so little idea of the woman's being preg-
nant, that he delivered a  clinical lecture on  the case, as  one of ovarian
dropsy.   On making an examination of the case, M. Dubois easily made
out the pulsation of the foetal heart.   In  fact, labor very soon supervened.
   The menses may be suppressed physiologically, and yet pregnancy take
place.   Thus, it is not rare  to  see nurses become pregnant before mens-
truation has reappeared.  We  find also, that women wdio  are extremely
irregular, wdio, for example, menstruate only once or twice a year, become
pregnant; although, in general, this state is one  very unfavorable for
conception.
   Various diseases and changes in  habits  may derange the menstruation,
 and give rise  to  the idea of pregnancy.   This  error occurs frequently,
. chiefly to persons anxious to become in the family Avay. Nothing is more
 common than to find the menses suppressed for some time after marriage.
 It  is also very frequently observed,  that  women leaving  the country to
 reside in the teAvn  suffer  from sujmression.  This may be said to occur
 habitually in young women coming from the country into domestic service
 in  Paris.
   In other cases, the menses, after  haAdng been suppressed for three or
 four months, re-appear  suddenly, Avith  some  profuseness.  This is some-
 times  taken for the occurrence  of abortion,  Avhen it is merely the recur-
 rence  of the menses after they have been suppressed, in  consequence of
 some change in the habits  of the female.              Part xxii, p. 272.

   Nausea and Vomiting  of Pregnancy.—You must first try to get the
 secretions into a healthy state.   One of the most serviceable remedies in
 these  cases, according to Dr. Tyler Smith, is  the infusion of calumba Avith
 soda and hydrocyanic acid, or  you may give this in an effervescing form
 Avith citric acid—in some patients opium answers better, and  perhaps the
 solution of the bimeconate of morphia is the best form in which an opiate
 can be given.  Salicine, in doses of three to five grains, three times a day,
 is a valuable medicine.   Creasote, in one or two drop doses made into phis
 Avith bread, is  an efficient remedy.  Professor Simpson particularly recom-
 mends the nitrate of cerium in doses of one to twro grains in Avater, and
 also the inhalation of the vapor  of laudanum.         Part xxxiii., p. 251.
   Molar Pregnancy.—If the life of the mother should be threatened, the
 ovum  should be  detached by the catheter or the  uterine sound wdthout
 hesitation.  Ergot of rye must  also be given to excite contractions, but in
 ordinary cases, as in simple abortions, Ave must wait until the ovum can be 
PREGNANCY.
413
reached wdth the  finger  before wre attempt to remove it.  In  hydatid
degeneration, the treatment may be more positive—give ergot, and if the
os uteri be dilatable, introduce the hand to detach and remove the hydatid
mass.                                              Part xxxiii., p. 270,
  Pregnancy—Diagnosis of,  from Abdominal  Tumors.—Dr.  Oldham
says:  By applying the hand, the tumor at first feels  soft and ill-defined,
but by pressure it  rapidly assumes a tense rounded form,  becoming firm
and resisting.  This may  be  taken as  a trustAvorthy characteristic  of a
pregnant uterus, since there is  no other tumor which possesses any power
of altering its form Avhen irritated by palpation.      Part xxxiii., p. 270.
  Pregnancy—Duration  of.—To ascertain  the most probable  day of a
woman's confinement, add 278 days to  the last menstruation.
                                                   Part xxxv., p. 209.
   Vomiting of Pregnancy.—In a  case wdiich  occurred  to Dr. Clay,  of
Manchester, where the induction of premature labor seemed absolutely
necessary, from the failure of  all other means,  for relieving the incessant
vomiting—on introducing the finger to guide an instrument for this pur-
pose,  the os and cervix uteri  were  found vepy tender and painful Avhen
touched, and violent efforts of vomiting caused.  Considering this state to
be  produced by pressure  on the os uteri, instead  of proceeding Avith the
operation, he caused the  patient to be laid  quite prostrate on  the back,
wdth the head very low and hips considerably raised.  In about 24 hours
the tendency to vomit was considerably less, and small  portions of food
could  be retained: she continued  to improve,  and ultimately safely  com-
pleted the period of utero-gestation, but at any time the slightest attempt
to resume the upright position Avas folloAved by violent retching and dis-
tressing vomiting.  Dr. Clay Avas convinced that there is pretty generally,
if not ahvays, considerable congestive  inflammation and  great tenderness
about the os and cervix uteri which are best treated by local bleeding at
the seat of mischief.  That the irritable  state of the stomach  is purely
symptomatic of that condition  of the os and cervix uteri (that is) in these
obstinate cases of the latter months.  That these cases differ ividely from,
and must not  be confounded  wdth, those of nausea  and  sickness of the
early  months, however severe; and where the stomach itself particularly,
and in some measure  the  entire digestive functions are much deranged ;
and attention to the  condition of the  stomach  will, in most, if not in all
cases, be remedied by medicine and diet.   That diet or medicine  have
little  or no effect in the severer  cases above described, in  the latter
months ; but that  a position of the body  calculated to relieve the os and
cervix from pressure  against the pelvic viscera, is best accomplished by
lying  on the back  with the  hips raised and head low, with food in  very
small  quantities given at long intervals.  Lastly, and mainly,* Dr.  Clay
places much reliance on the application of a  few leeches,  by means of the
speculum, directly to  the os  and  cervix uteri—the  seat of  congestive
inflammation, and consequently the cause of general irritation and sympa-
thetic action of the stomach and its consequences.  The leeches are to be
repeated if  any tenderness  remains,  and the  position strictly  observed
until the symptoms are entirely conquered.          Part xxxvii., p. 202.
  Pseudocyesis.—Diagnosis.—There  is a form  of  spurious pregnancy,
says Prof. Simpson, in which  there  is  a firm unyielding SAvelling of the
abdomen, often supposed to be due to the enlargement of a gravid uterus, 
414
PROLAPSIONS.
but which is in reality due to a tympanitic state of the bowels and a
peculiarly tonic condition of the  abdominal muscles ; and the abdominal
Avails are so firm and tense, and resist the pressure of the hand so effect-
ually as to render  an adequate examination utterly  impossible.   In such
cases  as this give chloroform; under its influence,  if deep  enough, the
abdominal muscles will become perfectly relaxed, and on pressing on the
abdomen the walls Avill give way before your hand, and sink backward
until you can feel the spinal column quite distinctly.  This curious affection
is probably owing  to some affection of the diaphragm,  which is thrown
into a state of contraction, and pushes the bowels doAvnward in the abdo-
minal cavity.                                          Part x\.,p. 180.




                      PROLAPSIONS.

                         PROLAPSUS ANI.
  Prolapsus Ani.—Bransby Cooper makes the followdng remarks on pro-
lapsus ani,"wdiich  so frequently accompanies piles:  Under ordinary cir-
cumstances, you will cure the prolapsus by palliative  means, and by curing
the piles which have caused it, but if the mucous membrane and the mus-
cles have been so much relaxed as to render a large prolapsus permanent,
you must take up twro  or three folds of the mucous membrane which covers
it, and surround each fold with a ligature, then  return the prolapsed gut
into the pelvis.  The patient will be  disappointed at first as he is not re-
lieved ; it is the case that there will be no great relief till the ligatures come
away, but after that  the cure is permanent, at least so it has proi^ed in three
or four cases in which  I have employed  this method.       Part iii., p. 88.

  Prolapsus Ani — Neiv Mode of Treating.— Dupuytren's method of
curing a prolapsus ani in the adult Avas at first by excising a portion of the
mucous membrane of the bowel, and afterAvard by cutting aAvay  only the
folds of the skin at the margin of the anus.  The anus in these cases being
immoderately dilatable, this process causes a degree of consolidation and
contraction.  It is seldom that this is required in the  child.  Sir Benjamin
Brodie's plan will generally succeed by injecting every morning 2 or 3
ounces of a lotion composed of 3j. of tinct. ferri muriatis and a pint of
water:  at the  sanie time giving occasional  gentle aperients,  and  not too
much vegetable food.  Dr. McCormac, reflecting on the method of Du-
puytren, applies the same principle to cases  of children in the following
simple way^: When the child goes to stool, the skin anterior to the anus is
to be  drawn to one side by means of the fingers extended around.  At first
the child may not be able to evacuate its bowel, but  Avhen  encouraged to
persevere it will do so, and will often, in this simple way, be entirely cured.
                                                    Part viii., p. 162.
  Prolapsus Ani.—Five different means of treating this affection  are men-
tioned by M. Dieffenbach  in his operative surgery.  1st.  By diminishing
the anal opening by excision of folds around it.  2d. By excision of Avedge-
shaped pieces from the anus.   3d. By excision of parts of the anal ring,
and of the callous prolapsus.  4th. By extirpation of the spongy prolapsus.
And 5thly. By cauterization.                          Part  xxii., p. 218. 
PROLAPSIONS.
415
  Pelvic Viscera,  Prolapsus of.—In these cases, Avith lacerated perineum,
the object must be  to remove the actions of the sphincter ani and the leva-
tores ani, byremoving their points of attachment to the coccyx.  Mr. Hilton
describes his plan of operating in these cases as follows : A narrow, sharp-
pointed knife was introduced through the skin on one side of the point or
free extremity of the coccyx, about half or three quarters of an inch from
its end ; it was then passed into the pelvis betAveen the concave surface of
the coccyx and the rectum, special care being taken not to puncture the
intestine.  The cutting edge of the knife Avas now made to sweep over the
sides and ends of the coccyx, so as to separate from it  the coccygeal at-
tachments of the sphincter and levatores  ani.   The knife was then wdth-
drawn through the same small opening by Avhich it had been introduced,
scarcely any blood escaped at the wound, but a compress of lint, supported
by adhesive plaster, was applied over it to keep the parts  quiet, and to in-
tercept the flow of blood.                            Part xxix., p. 277.

  Nitric Acid.—Apply nitric acid as  folloivs : Wipe the acid down the
protruded part in separate streaks  or tracts vertically from the sphincter
down  to the lowest portion of the gut; then replace the protrusion and
alloAv no motion for tAvo days.  Dr. M'Dowel says : You may re-apply the
acid at intervals of seven or ten days if necessary.      Part xxx., p. 154.

  Strychnine.—Dupuytren's method of treating prolapsus ani, was by ex-
cising radiating folds of the skin round the anus, while Guersant used the
actual cautery.  Duchaussay thinks these acted,  only by stimulating the
sphincter muscle, and therefore he applies strychnine.  Apply one-sixth to
one third of a grain of strychnine to a blistered surface in the neighborhood
of the anus.  Repeat this  occasionally according to its effects.
                                                    Part  xxx., p. 155.

   Treatment of Prolapsus Ani by Strychnia and by the Actual Cautery.
—Dr. A. Johnson says: If the child be about  tAvo years old,  apply a  blis-
ter to the cleft betAveen the nates, and dress the blistered surface with one-
tAventieth of a grain of strychnia—on  the fourth day one-sixteenth of a
grain may be applied on a second  blistered surface, the cuticle, of course,
being removed.  Five or six days  afterward this maybe repeated if neces-
sary.   In a child of four years -old, one-eighth of a grain may be used each
time.   If this fail, apply  the actual cautery in three or four places  at the
junction of the skin with the mucous membrane.   This may be repeated in
a few weeks, if necessary,  but less  extensively. Strychnia may do for very
mild cases, but the actual  cautery is the most certain remedy.
                                                    Part xxxi., p. 156.
  Prolapsus Ani  treated  with Nitrate of Silver.—Dr. Lloyd says: Smear
the wdiole surface of the protruded bowel wdth solid nitrate of silver, and
then  return it.  Repeat this once a Aveek or fortnight.   This  need not be
confined to simple prolapsion, but may be used in cases of hemorrhoidal
congestion and thickening of the mucous membrane about the verge of the
anus.                                               Part xxxi, p. 158.

  Prolapsus Ani and Hemorrhoids—The Ecraseur.—The ecraseur  is not
so frequently used in these cases as it deserves. Tavo cases are related by
Dr. I{. Davies, in wdiich a  speedy and  safe cure Avas effected, and that after
the nitric acid plan had failed.  "                         Part xl.,p. 111. 
416                         PROLAPSIONS.
                        PROLAPSUS UTERI.

   Use of Nitric  Acid.—Mr. Benj. Phillips, in one  case of prolapsus uteri,
treated by him at the St. Marylebone Infirmary, succeeded in effecting a
cure, or, at least, in affording complete relief by destroying a portion of the
mucous lining of the A^agina by means of nitric acid. The contraction con-
sequent on the separation of the sloughs reduced the size of the vagina so
much as effectually to retain the uterus in situ.             Part i.,p. 95.

   Use of the Actual Cautery in Procidentia Uteri.—Almost every remedy
Jias been in vain tried in many of these cases.  The actual cautery, though
a severe remedy, will often be successful when  all other applications have
failed.  Cases where this was successfully applied are brought forward by
Dr. LoAvrie, of the Glasgow infirmary.
   The following case shows the efficacy of this valuable remedy in proci-
dentia uteri.  C. M'L., aged 18, a servant, while carrying a heavy tub, felt
something give Avay in the pelvis, and as  if the \ragina immediately after-
ward was  unusually distended.  Some days after this, the uterus distended
the vagina, and rapidly descended so as completely to prolapse.  It could
 easily be returned by pressure, but again  descended almost immediately.
 She derived no benefit from the free application  of the nitrate  of silver,
 astringent injections,  pessaries, bandages, and the ordinary treatment.
 Strips of the mucous membrane of the vagina Avere dissected  off from the
 lateral and posterior parts  of  the vagina, Avithout any benefit.   Weiss's
 three-pronged speculum was introduced and dilated, and the actual cautery
 freely applied to both lateral surfaces of the vagina, nearly as high as the
 uterus.  Great pain  was of course experienced, followed by  other severe
 symptoms ; the patient was kept recnmbent for about six  weeks.
   Nine weeks after the operation the following report was entered in the
 journal: "Not the slightest tendency to reneAval  of the procidentia; she
 has no feeling of prolapsus. Uterus felt nearly in its natural position, Avith
 a circular  contraction of the vagina a little below os uteri.  The contrac-
 tion firm,  but quite elastic."  We need hardly mention that the contrac-
 tion of the vagina is  here made to support the Avomb ; and this must occa-
 sionally give way, especially when previously over-distended by the use of
 large pessaries; and therefore in all  cases of procidentia it w ill be Avell to
 make use  of some kind of support, such as that recommended by Mr. Clay,
 previously noticed, ( Vide Article '■'■Pessaries,'''') which will not produce this
 relaxation of the vaginal parietes.                       Part iv.,p. 129.

   Prolapsus Uteri.—[Mr. Whitehead says  that  prolapsus is  most  fre-
 quently a  consequence of inflammation and ulceration of the lower part of
 the uterus.  He thinks that pessaries only aggravate the disease, and re-
 marks, that in addition to attention of the general health,]
   The local treatment should consist in applications of nitrate of silver, or
 other suitable remedies to the diseased  surface, and in  the insertion of
 medicated tents by the aid of the prolapsus  tube.  This latter procedure
 may be practised immediately after the nitrate has been employed, although
 the remedy with which the tent is charged be  of a very different nature
 from that of the caustic. The manner of using  ihe prolapsus tube—which
 will be found of equal service in the management of prolapsed displacement
 of the uterus, as in most other forms  of uterine  disease, and enables the 
PROLAPSIONS.                         417
patient safely and efficiently to apply the remedies herself, without the in-
terference of the practitioner—is extremely simple.  The charged tent, to
which a length of thread has been  previously attached, must be placed in
the tube, the upper orifice of which is to be applied against the protruded
portion of the uterus, in such a manner as to receive the os uteri within it.
The instrument, previously smeared with some unctuous material, and
having its curved arm  placed anteriorly, in a direction toward  the  abdo-
men,, is noAV to be forced gently and steadily backAvard, until the Avhole, or
greater portion of it, has passed within the canal, or until a moderate de-
gree of resistance is felt to oppose its further ingress.
  The uterus being thus restored to its natural position, the tent or pledget
must be passed upward against the cervix, and held in  that situation by
means of a skevrer or other suitable instrument, the  tube at the same time
being gently Avithdrawn.  The recumbent posture should be strictly main-
tained for several days, and very little exercise taken for some weeks after-
ward.   The lotions, used for moistening the lint-tent, are strong solutions
of nitrate of silver,  sulphate of zinc, sulphate of copper, matico, opium, and
tannin.   The metallic preparations should not be employed oftener than
every third or fourth day, the vegetable  applications being used  interme-
diately.  An emollient injection should be made use of after the  removal
of each tent.                                       Part xvi., p. 277.

   Prolapsus  Uteri—Galvanic  Cautery.—In a case  of long continued pro-
lapsus, and in which the vagina was very lax and distensible, Mr.  Marshall
determined to apply the galvanic cautery to produce  a series of eschars upon
the walls of the vagina.   A peculiar speculum made for the purpose, con-
sisting of two large blades, and inclosing double roAvs of fenestrse  about an
inch in length and half an inch in breadth, having been introduced and
the blades separated, the mucous membrane was seen to bulge through the
apertures.  The coil  of heated wire was now applied, and eight eschars
rapidly made on each  side of the vagina.  For the first fortnight the  pa-
tient Avas confined  to bed, and detergent injections used twdce daily; as the
sloughs separated, mildly stimulating ones wrere applied.  The capacity of
the vagina was considerably diminished, and on moving about no prolap-
sion Avas found to take place.  It is important to observe that if the \*agina
is protruded, it must be first  returned, as,  although under  these circum-
stances, it may be easier to apply the cautery,  yet it is most difficult and
dangerous to return the mass afterward.        •     Part xxviii., p. 273.

   Prolapsus  Uteri.—Having made the usual horse-shoe denudation in the
operation for the cure of this disease, Mr. Fergusson applies the common
interrupted  suture  instead of the  quill  suture, which is generally used.
Mr. Fergusson beheves that the quill suture sometimes causes tendency to
sloughing from over pressure.                       Part xxxvi., p. 238,

   Prolapsus  Uteri—Plastic operation.—In this operation,  says  Dr. Hut-
chinson, the great element of success is to  denude a sufficient portion of
the back part of the vagina, to get  contraction of at least the lower  two
inches.  To this end do not denude tAvo narrow slips, but a portion ex-
 tending from an inch to two inches on  each side, commencing at the  anal
commissure, and extending an inch  and a half upward into the vagina.
                                                   Part xxxvii., p.  221.
   vol. n.—27 
418
PROLAPSIONS.
                      PROLAPSUS VESICAE.
   Cured by Operation.—[This patient first observed a small tumor to pro-
trude from the vagina, which gradually increased to the size of an orange,
and then to the size of the fist, hanging between the thighs:  the greater
part was formed by the bladder and anterior paries of the vagina.   After
remaining in bed  twenty-four hours, the tumor could be easily reduced,
but owing to the capacity  of the vagina it soon prolapsed again  in  the
erect posture, and was then accompanied, on making exertion, Avith an in-
voluntary dribbling of urine.  Mr. Lightfoot performed the operation for
episcorraphie, as recommended by Dr. Fricke, of Hamburg, in the follow-
ing way:]
  The bowels having been previously evacuated, and  the hair removed
from the parts, the patient was placed, on a table, in the same position as
for lithotomy, without, however, tying the hands and  feet.   The thighs
being well separated by two assistants, I took hold of the left labium  and
transfixed it  obliquely about the middle Avith a narroAV  bistoury three
quarters of an inch from the edge, and in such a manner as to include more
of the skin than  of the mucous membrane; the knife was  then  carried
rapidly downward in  the  same direction to the raphe, half an inch or so
in front of the anus: the superior attachment of this flap Avas next divided,
by carrying the incision upward as high as on a level wdth the meatus uri-
narius.  The same was repeated on  the opposite side, after which the fre-
nulum, and other parts included Avithin the angle formed by the union of
the two incisions in front of the anus, ivere carefully dissected off.   The
two surfaces thus formed extended from opposite the urethra to wdthin
half an inch of the anus, each being about two inches long, and varying in
breadth from an inch posteriorly to  half an inch  anteriorly.   The hemor-
rhage was so trifling, as merely to require the torsion of one small vessel:
the oozing having ceased,  six strong hempen sutures were passed through
the  entire thickness of the denuded surfaces, and tied moderately firm.
The first one was applied a few lines in front of the anus, and the  last one
immediately below the meatus urinarius,
   A gum elastic catheter was introduced into the bladder, and the knees
were bound together, after which the patient was placed in bed on her left
side.  The antiphlogistic  regimen was strictly adhered to for four or five
days, during wdiich cold water was constantly applied to the parts, and the
vagina occasionally washed out and cleared of coagulated blood, by means
of cold water injections.  An anodyne was given  at bed-time, and repeated
for three or four  nights, to allay irritation and confine the bowels.   Two
of the sutures were removed  on the fourth day, and the other  four on
the sixth;  at the  expiration of which, union  by the  first intention had
taken place throughout the whole  extent.  The bowels were moved on
the eighth day, and an occasional dose of aperient medicine was afterward
given.
   In the course of three weeks she was allowed to leave her bed, and walk
about a little.   The bond of  union is very firm, and appears like an elon-
gated perineum, extending from the anus to within a quarter of an inch of
the urethra.
   In performing this operation, I think it would  be better not to  attempt
 the union of the posterior part of the labia, but to leave an opening into
 the vagina between the bond of union and the  frenulum sufficiently large 
PROSTATIC AFFECTIONS.
419
 to allow of the discharge of the vaginal, mucous and menstrual secretion.
 By adopting this method the  operation  would be  much  facilitated; the
 most troublesome part of it, and, at the same time, the most painful to the
 patient, being the dissection required for  the removal of the frenulum and
 the parts in front of the anus.  During the treatment, likewise, coagulated
 blood, and the  secretions from the vagina and wounds, could be more
 easily removed;  and in case of considerable inflammation occurring after
 the operation, cold water could be more  readily and continuously applied
 by means of a syringe.  By this modification of the operation, the union
 of the labia ivould form a kind of bridge, Avith two communications into
 the vagina;  care, however, must he taken to make  the  bond of union of
 sufficient extent, so  as to allow for  the subsequent contraction  of the
 cicatrix, otherwise one or other of the openings might become so large as
 to alloAv the inverted mucous membrane gradually to be insinuated through
 it, and any unusual effort would expose the patient to a return of the com-
 plaint.                                                Part v., p. 125.

                               —•-•-•---

                  PROSTATIC  AFFECTIONS.
   Iodine as  applied to reduce Enlargement of the third Lobe of the Pros-
 tate  Gland.—After alluding to the difficulty he had in applying the iodine
 on the third lobe of the prostate, without touching any other part of the
 urethra, Mr. Stafford proceeds:
   " I at length thought of a very simple mode of applying it, which is by
 charging a bougie at its point wdth the iodine,  iodide  of potassium, or
 any other substance you may wish, and then dipping it into melted tallow
 so that a coating may be formed upon it.  By such method I  have been
 enabled to introduce any application I might desire up to the prostate
 gland, without touching the surface of any other part of the urethra.   The
 bougie having reached the desired spot, its point is alloAved to  rest upon
 the  diseased part, Avhen the tallow gradually melts and  brings the iodine
 or iodide  of potassium into contact with it, and by drawing the  bougie
 gently backAvard and forward the necessary friction is produced.  I have
 found it advisable to be very cautious as to the strength of the application.
 for the prostate  gland will not bear a strong preparation  either  of the
 iodine or iodide  of potassium at first.  It is usually in  an irritable or in-
 flamed state; consequently, even the mechanical pressure  of the  bougie
 will  give pain.   The preparations I have  used, therefore, have been very
 mild.  At first I have found it necessary to employ even anodynes, such
 as belladonna, opium, hyoscyamus, etc., to quiet irritation and pain.  When
 these have subsided, I have begun carefully by introducing  the  iodide of
 potassium in the  proportion of one  grain to the drachm of unguentum
 cetacei, and increasing it as the patient could bear it.  I  have then gone
 on with twq,  three, four, five, and even as  far as ten grains, or a scruple to
 the drachm, according as the case required it.  After this I have added
 iodine to it; half a grain, one, tAvo,  three,  four, or even more grains in the
 same manner.   The surgeon who applies it can alone judge  of  its  effects.
When the swelling is so great that the neck of the  bladder is completely
blocked up, and no catheter can  be passed onward  into  the interior, the
patient must be relieved at all hazards, else the bladder will  slough or uri-
nary coma will succeed.  Under these circumstances the surgeon  is reduced 
420                    PROSTATIC  AFFECTIONS.
to the alternative of either puncturing the distended organ, or carrying an
instrument through the seat of obstruction."
  By the  use of a small elastic  catheter wdthout a stilet te, Ave have suc-
ceeded hi  relieving retention of urine under the most urgent circumstances.
We should say, as a general rule, that the greater  the swelling, the less
chance there is of passing a stiff,  curved instrument.  If, after the trial of
all ordinary expedients, the bladder still remains unrelieved, then the best
and safest plan unquestionably is  to perforate the obstruction.  The perfo>
ration is easily accomplished, and is never followed by disagreeable effects.
                                                      Part il,p. 128.
  Hemorrhage from  Diseased Prostate  Gland—Ruspini's  Styptic.—Sir
B. Brodie, speaking of hematuria dependent upon disease of the prostate
gland, says:
  " Those medicines which operate  as styptics when taken internally, and
which are useful in cases of hemorrhage from the lungs, are also useful vn
hemorrhage from the prostate.   I had a patient with very diseased pros-
tate.  A frightful hemorrhage took place.  The usual methods of treat-
ment were adopted,  but  were of no  avail.  The skin became pale, tne
pulse became weak, and the patient was exhausted; yet the bleeding con-
tinued.  Large  quantities of blood were drawn off with the catheter:
nevertheless, the bladder continued to become more and more distended
with blood, and was  felt prominent in the belly as high as the navel. All
other remedies  having failed, I gave the patient a dose4 of the nostrum
known by the name  of Ruspini's styptic, and repeated the dose  two or
three times in the course of-the next twelve hours.  In about half an hour
after the  first dose was  taken  the hemorrhage ceased, and it never re-
turned.   The patient lived a year  and half afterward, and there was no
reason to  believe that any ultimate harm arose from the bleeding."
                                                       Part .vl, p. 51.
   Treatment of Diseased Prostate—There is a description of enlarged
prostate,  says Mr. Colles, in which  surgery can render essential benefit to
the sufferer, and that  by a very simple operation.  When we find a  patient
in advanced  life, complaining of unusual frequency of micturition, with
more than ordinary straining, his urine depositing a good  deal  of muco-
purulent  sediment, and possibly a  muco-purulent discharge from the
urethra, we should make a very careful examination of the state of the
prostate.  If, under these circumstances, we introduce the finger into the
rectum, and find the gland enlarged in either lobe, and upon pressing on
one particular spot, we feel the point of the finger sink, as into a  cavity;
and  particularly if we find this pressure  to cause  the discharge, per
urethram, of a quantity of thin purulent fluid, to the amount, varying from
a few drops  to  a teaspoonful;  here we may hope to render an essential
service.   The operation  to  which  I  allude, is simply that  of  striking  a
lancet into this hollow, soft spot, which will generally be found,to  contain
some matter.  Now, as  such an  operation cannot  be conveniently  or
securely performed by the common  lancet, I have employed the pharyngc-
tome, having previously adjusted the instrument, so as to allow the lancet
to project only to a length, varying from one-eighth to one-half an inch,
according to  the apparent thickness of this soft part, our object being  to
open into this  cavity.  The operation will be found to cause very slight
pain indeed, and that confined  to the  region of  the wound ;  not even 
PROSTATIC AFFECTIONS.                    421
extending (as we might have anticipated) to the glans penis.  So  trifling
and so momentary is the pain, that I have at different times performed
the operation, and the  patient merely imagined I had  pressed  a little
more  rudely on  the gland.   We are guided to the spot where  the punc-
ture is to be made, by holding the point of the forefinger  of the left hand
gently pressed on the soft  part, and introducing the instrument on this
as on  a director.
  In  some of these operations I have had incontestable proof that some
pus had been contained in the cavity, for I have found it on the blade, and
hi the sheath of the instrument, yet in no instance have I been able to
discover, afterward,  any trace of matter discharged by stool, so  small
has been the collection of this fluid ; in some of the patients a few drops
of blood have  passed afterward through the urethra.  In one or two,
some  urine has passed for a time by the rectum ; the quantity, however,
was, in  general, very inconsiderable, but  often  sufficient, by its presence
in, and irritation of, the rectum, to cause the patient to go to stool, though
no fasces were in the rectum.   This occasional watery stool was at once the
only proof and inconvenience attending  on such  cases.   This  escape of
urine, however, gradually ceases in the course of a week or two, never to
return.
   In  one instance only have I seen hemorrhage follow this operation, and
in that it was easily commanded by laying on the orifice a small compress
of lintj and retaining it  for some minutes, firmly pressed against it by the
forefinger introduced into the rectum.                  Part xii., p. 214.

   Senile Enlargement of the Prostate.—The symptoms in enlargement of
the prostate gland depend with respect to their urgency upon the size
it has acquired ; they are, sense of weight in the perineum, intolerance of
pressureJroin the hardness  of a seat; difficulty in passing the urine, and
also in voiding the fasces, which will be found flattened by the encroach-
ment of the hypertrophied gland on the rectum.  Mr. Cooper says :
   At this stage  of the complaint, the retention of urine  occasionally super
venes, rendering the introduction of a catheter necessary.  This operation
should be performed with  the utmost gentleness, as  the slightest flow
of blood would cause decomposition of the urine, and consequent aggrava-
tion of all the symptoms.  An elastic gum catheter should always be used
for drawing off the wrater, and, if possible, it should be introduced without
a stilette ;  leeches should be applied to the perineum ; the rectum emptied
by means of enemata; and suppositories, recumbent position, and soothing
remedies employed.  I have  also found, colchicum  of great use in such
cases, and I  believe that its beneficial influence  arises from the circum-
stance that this  disease  frequently attacks subjects of a  gouty diathesis.   I
usually prescribe the colchicum in the following form.
   R Ext. colchici acet., gr. j.; pil. hydrarg., gr. j.; pulv.  Doveri, gr. v.;
ext. colocynth. co., gr. iij. M. Ft. pil. bis quotidie sumenda.
   It  does not always happen that the whole of the prostate gland becomes
hypertrophied  in old age; but very frequently the third  lobe  only is
affected, or perhaps it may more properly be said that a new development
arises;  for in  a state  of health, at the adult  period, the  third lobe is
scarcely perceptible.   When this  third lobe  enlarges, it presses the
inferior region of the bladder or " trigone "  upwrard above the commence-
ment of the urethra in the bladder, preventing the evacuation of the urine, 
422
PROSTATIC AFFECTIONS.
 and consequently producing retention.  Nor is this the only inconvenience;
 for by the raising of the bladder immediately behind the prostate, a kind
 of reservoir is established below the entrance  to the urethra ;  and, in the
 effort  to empty the bladder, a portion of its contents is always left;  this
 becomes specifically heavier than the newly-secreted urine, which does not
 intermix with it; and, after a time, the retained urine undergoes  decom-
 position, which  gives  rise to very urgent symptoms—such  as frequent
'desire to make  Avater, tenesmus, deep-seated  pain  in the perineum, and
 liability to positive retention.  It is quite clear that these symptoms  can-
 not be removed while  the  exciting cause remains; the fetid  urine must
 therefore be immediately draivn off by means  of the catheter.
   The mode of  introducing the catheter in such cases is similar to that in
 ordinary practice, until it  arrives at the  point of obstruction, wdien the
 penis  and instrument are  both to be drawn forward for the purpose of
 straightening the urethra ; the handle of the  catheter is then to be  con-
 siderably depressed, so as to  tilt up the  point, and it is then  pressed
 onward into the bladder.
   The cleansing of the bladder may be effected by  injecting it with tepid
 water by means  of a syringe;  and an improved instrument has been
 invented for this purpose, by which a continuous  current  is kept, the
 same  stroke of the piston removing one  quantity and supplying a fresh
 one.  Constitutional  remedies  must  not  be neglected; and when an
 alkaline state of the urine exists, medicines of  an  acid character are
 generally indicated.  Among the most efficacious of these  is the following:
   R Ntiro-hydrochlor. acid.  gtt. iij.; sir.  papav.,  3hj.;  inf.  colom.,  §iss.
 M.  Ft. haustus ter quotidie  sumendus.  '
   In addition to this an opiate suppository at bed-time will often be found
 of great advantage;  but  if  an acid  condition of the urine  be not thus
 restored, liq. potassae  will  frequently  be found capable of reestablishing
 the normal acid state; this anomaly has been accounted  for by Dr. G. O.
 Rees, on the supposition  that  the alkali  renders  the  secreted urine less
 irritating to the mucous  membrane of the bladder, and prevents  the
 secretion of alkaline mucus, from which the urine had acquired its abundant
 preponderance  of alkali.
   I must again direct  your attention to the propriety of employing the
 prostatic  catheter in  cases of enlarged prostate; for I have frequently
 known great mischief arise from a perseverance in the attempt to relieve
 a patient by the ordinary instrument.                  Part  xix., p. 183.

   Prostate, Enlarged.—M. Vanoye recommends the administration of sal
 ammoniac in large doses, commencing with 15  grains  e\Tery two  hours ;
 we  may double or treble this quantity,  so that gss. is  taken  per diem.
 Mucilaginous vehicles, bitter extracts or aromatics, and a  good animal
 diet, should be  employed at the same time.  This plan should not be fol-
 lowed in  hemorrhagic dispositions, or in affections due to poverty of the
 blood.                                             Part xxvi.,p. 111.
   Fibrous Tumors connected with  the Prostate.—Prof. Fergusson states
 that an important  circumstance connected wdth  lithotomy  is, that not
 unfrequently, in extracting the  stone, and Avithout any undue violence
 having been used, a portion of prostate  gland would  protrude before it.
 Formerly he had been in the  habit of attempting to avoid the removal of
 such portions, but finding that no inconvenience resulted from the prao- 
PUERPERAL AFFECTIONS.
423
 tice, he had latterly adopted the plan of always removing them.   He
 thought they  were probably tumors  connected with the prostate, and
 not parts of the gland itself.                        Part xxxiii. p. 283.

   Enlarged Prostate.—Amongst other means of treatment the following,
 by Dr. H. Thompson, are particularly worthy of note.  Let the patient sit
 every morning for about  twenty minutes in a tepid hip bath (90° or 94°,
 or Avarmer),  to which the  bittern or  mother  lye of  the Kreuznach
 springs has been added in varied proportions, beginning with half a pint,
 or pound,  according to the form in Avhich it is obtained, to four gallons of
 plain water.
   Local application may be made  either by enema or suppository; if by
 the former method the following formula  may be  depended upon as not
 too irritating to the rectum.   It should be  retained  there  as long as the
 patient can conveniently do so.  The best instrument for injecting it is an
 india-rubber bottle with ivory tube, as the constituents of the Kreuznach
 water will rapidly injure metallic apparatus.
   R Potass, iodidi, gr. v.  Kreuznacher bittern, 3ij.; dec. hordei vel  lini,
 giij.  Misce pro enema, quotidie utendum.
   To this a little opium may be added if necessary, in order to enable the
 boAvel to retain it.
   The suppository, Avhich, on  the whole, is perhaps  more  easily adminis-
 tered  and borne than  the enema,  may be used after the following
 form:
   R Potass, iodidi, gr. ii.-v., vel, potass, iodidi, potass, bromidi, aa. gr. ii-
 iij.; cerati, gr. viij.  Misce, fiat suppositorium.
   This should be employed  at the time of going to  bed, and may be
 repeated every night for a considerable period.
   The iodide and bromide of potassium may also be given internally, three
 to ten grains of the former, to one of the latter, twice a  day.
   The bromide of potassium  given internally in  these cases, has a very
 beneficial effect on the enlarged  organ, it  may be given week by week
 alternately wdth the muriated tincture of iron,  for  a  period of several
 months.                                          Part xxxvii., p. 163.

                              —*-•-•---

                 PUERPERAL  AFFECTIONS.
   Treatment of Puerperal Convulsions.—According to the views  of Dr. •
 W. Tyler Smith, the spinal system is chiefly concerned in the production
 of this form of convulsion, and therefore  all our  remedies must be such
 as aftect the nervous system.   " Remedies  affecting  the  spinal  system,"
 says Dr. S., "very naturally divide themselves into those  which  act  on
 the central organ, the spinal marrow, and those which affect the extremi-
 ties of incident spinal nerves."
  The action of bloodletting on the spinal marrow, is greatly modified by
the condition  of the circulation.  In fullness of the vascular system, it
is the most powerful  sedative  of spinal action we possess.   Hence, vene-
section is the grand remedy in the simpler form of puerperal convulsion,
where the disease chiefly depends on stimulation  of the spinal marrow by
excess of blood, on the  mechanical pressure exerted by the blood on that
organ,  together Avith the counter-pressure of the  distended brain on the 
424                    PUERPERAL AFFECTIONS.
-medulla oblongata.   In such cases, bleeding should be performed Avith a
view to its sedative action on the spinal marrow, and to avert the mechani-
cal effects of vascular pressure upon this organ.   Alone, it will be sufficient
to subdue  the disease, particularly when the fits come on before the be-
ginning of the labor, or after delivery.  But another most important inten-
tion of bloodletting should never be lost sight of—namely, that of preserv-
ing  the brain from injury during the convulsion.   Besides  the  primary
cerebral congestion, which has been the cause of the  attack by its counter-
pressure on the medulla, the  convulsive action itself,  Avith the glottis
closed, exerting great muscular pressure on the Avhole vascular system,
and causing, as it does, the great turgidity of the vessels of the head, is a
 dangerous source of fatal cerebral congestion, or of serous or sanguineous
effusion.   As in the  case of epileptics, women in  puerperal convulsions
frequently die of apoplexy, produced by the immense pressure exerted on
the cerebral column of blood during the fits.   It is in a great measure the
 effect of bloodletting in warding off the accident from the brain that bleed-
ing is so universal in this disease.   The due recognition of distinct opera-
tion of bloodletting on the  cerebral  and spinal systems'is of the utmost
 consequence.   In plethoric states of the circulation, it is in this disease,
 curative in its action on the spinal marroAV, preventive in its  action on the
 brain.
   In the absence of  definite ideas regarding the effects  of bloodletting in
 this malady, it has been often  pushed to excess,  or practised  where it
 should have been altogether avoided.   In the numerous cases where, be-
 sides vascular excitement of the spinal marrow, some irritation of spinal ex-
 citer nerves  exists as a conjoined cause of convulsion, repeated bleedings
 will often fail to subdue the disease, unless the eccentric irritation be at the
 same time removed.   When irritation of the  uterus, the rectum, or the
 stomach, is in part exciter of the convulsion, bleeding alone  cannot be re-
 lied on.  It may at first diminish  the impressibility of the central organ,
 rendering it less susceptible of the incident irritation, but if persisted in
 to  a large extent Avithout  the removal of the eccentric irritation, it be-
 comes in the end positively injurious, by increasing instead, of diminishing
 the excitability of the spinal marrow.
   [The propriety and extent of venesection are to be estimated, not by the
 violence of the disease, but  by the state of the  circulation in the intervals
 of the fits.   After  noticing that patients not rightly bled at first are fre-
 quently subjected to successive depletion till the loss of  blood  itself be-
 comes the cause of the final seizure, he says :]
   Similar remarks would apply Avith almost equal force to the other parts
 of the common antiphlogistic regimen.  Nearly allied to the modus  ope-
 randi of bleeding are the  effects of nauseating doses of emetic tartar,
 which have been found so  serviceable in the treatment of puerperal  con-
 vulsions by Dr. Collins.   It is  extremely probable  that this remedy acta
 on  the spinal system through the medium of its  effects on  the circula-
 tion.
   [During the attack of convulsion the glottis is in  great part, or wholly,
 closed, and Dr. M. Hall questions  if a true convulsion ever occurs without
 this symptom, and the cerebral  and spinal congestion it occasions.   Cold
 wrater must be dashed over the face  or chest, to excite sudden inspiration
 and dilatation of the glottis. Excitation cf the incident nerves in this way
 has been known to prevent  a convulsion. 
PUERPERAL  AFFECTIONS.
425
  Harvey mentions the  case of a woman wdio  became  comatose during
labor, and was  recovered by stimulation of  the trifacial nerve in the nos-
trils.   Denman also  relates a case, where a woman had a convidsion at
every labor pain, but he kept off the attacks, till delivery was completed,
by sprinkling cold water over the face on every accession of pain.  Cold
applied to the  head by napkins, iced  water,  ice  itself, and  cold water
poured from  a height, are  approved remedies in puerperal convulsions.
Does the cold act as a sedative on the cerebral portion of the spinal mar-
row, or does it lessen the distended state of the cerebral circulation ?   It
probably acts  in both these ways.   When used in the form of continuous
douche it would tend to excite  acts of inspiration, and thus dilate  the
glottis.]
  The application of cold to the spine  as well  as  to the head may here-
after be found beneficial in puerperal convulsions.   Whenever cold in any
form is resorted to, its use,  except for the purpose of exciting the respira-
tion, must be continuous, as the intermittent application of cold, locally or
generally, Avould excite instead of allay the spinal system.  The benefit
derivable from cold  must  arise  from  its  local action  on the  nervous
centres, because in tetanus, the  purest form of increased morbid spinal
action, cold applied to the spine is serviceable, whereas when applied to the
whole surface of the body, it is extremely dangerous, and even fatal.
   [It is important that Ave should learn precisely the true action of opium
on the spinal system.  Thus, some  give opium to allay after-pains ; others
say, you increase their  energy ; some say it excites contraction in uterine
hemorrhage ;  others maintain that it produces inertia, etc.   There  is a
great  discrepancy of opinion with  regard to the propriety of its adminis-
tration in puerperal  convulsions.  When a frog is narcotized by opium,
a slight touch  produces  universal convulsions.   Reasoning from  this
fact, we should judge opium to be an excitor of the spinal system ; its ab-
solute failure of arresting  spasms  in tetanus confirms  this.   Belladonna,
on the contrary, acts as a sedative to the spinal marrow.  Mr. Bonny sug-
gests  that it  stimulates indirectly the reflex actions.    Besides  this,  Mr.
Smith thinks there are good reasons for believing it to be a direct excitant
of the spinal system.]
   Some striking  distinctions may be made respecting the administration
of opium under different circumstances, particularly in puerperal convul-
sions.  If a dose of opium be given in this disease in a full state of the
circulation, before bleeding, there is an aggravation of the disorder ; while
if it be given  in puerperal convulsions in an anasmic subject, or after ex-
cessive depletion, it is of great service.   If in a case of convulsions opium
be giA^en at the  commencement, it is dangerous  in its effects; but the
same medicine is frequently valuable in  the advanced stage of the same,
when the vascular system has been powerfully depleted.  Thus it would
appear evident, that in convulsions with  a full state of the  circulation,
opium is a stimulant to the spinal marrow, Avhile in  convulsions, with
anaemia, it is  distinctly sedative.  It is certainly  an  important point in
practice, that the effects of opium  in puerperal convulsions  depend on the
state of the circulation ; that in plethoric or inflammatory conditions it is
always dangerous, while in anasmia and debility it may ahvays be used
beneficially.
   [A  case is related by Mr. Charles Vines, of Reading, which illustrates
some  important points in  the pathology  of  puerperal convulsions, and 
426
PUERPERAL AFFECTIONS.
seems to confirm the  above views on their nature.   The patient, tAventy
years of age, AA'hen eight months advanced in her first pregnancy, was
suddenly seized with  convulsions.  When Mr. Vines  first saAV her, the
symptoms  were : Face and whole body livid, features  distorted, frothy
mucus  about the mouth, oedema of the  upper extremities, frequent and
violent convulsions, and perfect unconsciousness ; there was also inordinate
and tumultuous action of the heart, and a quick, feeble fluttering pulse.  On
examining  the abdomen, the loAver part was found  greatly distended,
and retention of urine Avas  suspected.  The catheter Avas passed, and five
and a half  pints  of urine Avithdrawn.   Great improvement of the symp-
toms followed.   There Avas no return of the convulsions after this evacu-
ation of the bladder.  The patient had had for some Aveeksj oedema of the
hands  and feet, Avhich, when recurring in these cases, has lately been
shoAvn  to indicate albuminuria.   The cause of the fits seems to have been
the continual irritation of the vesical nerves ; at all events they were kept
up by it.]
  It appears clear that the  irritation of the vesical nerves was conveyed to
the spinal centre, and reflected  upon  the motor  nerves and the muscular
system  in  the form of convulsions ; hoAV, otherwise, can we account for
the cessation of  the fits, and the speedy return of consciousness, Avhen the
local irritation was removed.                           Part xii., p. 293.
  Puerperal Convulsions— Use  of Galvanism.—In those  cases where
there is  a  cold  skin,  congested  countenance, and slow pulse, galvanism,
Dr. Wardell says, will be useful.   One wire should he placed behind the
neck, and the other over the last lumbar vertebra.     Part xviii., p. 286.

  Puerperal Convulsions.—Puerperal convulsions  may seize the patient
either before, in the progress of labor, or after it has concluded.  Those
that occur before or in the commencement of labor generally  depend upon
the irritation of some other  organ than the uterus, and hence are much
more fatal than those which are  the result of labor; you have in fact tAvo
sources of irritation acting upon the spinal system in place of one.  Dr.
R. Lee relates the case of a lady who " returned home after midnight from
a large dinner party, at which she had partaken of a variety of dishes and
wines,  and had  been seated before a large fire."   Labor came  on soon
after, and with it violent  convulsions.   Another patient " being in  the
eighth month of her pregnancy, dined on  curry and  rice, and ate bacon
and eggs at tea;" the folioAving day she had convulsions and premature
labor.   Both these were fatal cases, and in both the  stomach Avas a pri-
mary, the uteruS a secondary source of nervous irritation.  Violent men-
tal emotions act precisely in the same manner.   More commonly, however,
these are not the cases that induce  the paroxysm;  on  the contrary, labor
proceeds to a certain point Avithout interruption ;  the action of the uterus
is  perhaps poiverful,  the head large, and the resistance to its  advance
great.   A  severe struggle arises, congestion takes place in the uterus, the
pains are interrupted, a morbid irritability is excited in the uterus, which
is communicated to the  spinal centre, and thence reflected  over  all  the
muscles in  violent convulsions.    The uterus alone is the source of irrita-
tion here, and therefore the cause of the attack is more easily removed.
  Dr. Murphy sums  up his remarks  upon the nature and causes of puer-
peral convulsions, as follows :
  1st.  Puerperal convulsions should not be confounded with  epilepsy, nor 
PUERFERAL AFFECTIONS.                    427
with apoplexy.  They agree with the epileptic attack in their physiologi-
cal, but not in their pathological characters.  Apoplexy is an effect of the
paroxysms, which may or may not follow from them.
  2d. The predisposing  causes  of puerperal  convulsions, are either an
excess of blood (hyperemia), a deficiency of blood (anaemia), or impure
blood.
  3d. The proximate causes of  convulsions are  chiefly eccentric causes,
being the morbid irritation of the afferent nerves supplying the  different
vital organs.
  4th. Morbid irritation of the  uterus  is the  most common proximate
cause of puerperal convulsions, the result either of hyperasmia or anaemia.
Hence the division into sthenic, or hyperaemic convulsions, and asthenic or
anaemic convulsions.   Under the latter head we include not merely loss of
blood, but poverty of blood, and impure  blood, because the effect  seems
to be similar, only differing in degree.
  5th. Morbid irritation of other organs also causes puerperal convulsions,
because, during pregnancy, and  at  the time of labor, the nervous system
is more excitable than at any other time ; and hence any organ may easily
be rendered morbidly irritable.  Puerperal convulsions so caused are much
more fatal than  the former, because the nervous centre is  exposed to a
tAvo-fold source of irritation—the organ primarily affected, and  the uterus
that is secondarily excited.
  6th. In the whole of these phenomena we must perceive a beautiful il-
lustration of the reflex nervous function ; the peripheral nerves that supply
the  affected  organ rapidly  communicating their irritation to the spinal
system, which, as an  excito-motor centre, radiates the irritation over the
whole of the voluntary muscles, and the muscles of respiration, in violent
convulsive paroxysms.   Even the  involuntary muscles, as the uterus and
heart, do not escape, but give every evidence of greatly increased muscular
contractions.
  In cases of hyperemic convulsions, bleed largely and promptly, at the
very commencement of  the paroxysm, or indeed as soon as  the premoni-
tory symptoms are sufficiently Avell marked.  Give  also  a terebinthinate
enema, and if the stomach is loaded, an emetic; or ten  grains of calomel,
folloAved by a saline senna draught  containing a little tartarized antimony.
And keep up the good effect of the depletion  by repeated doses of tarta-
rized antimony. Keep cloths Avrung out of iced water applied to the head,
and especially to the back of the neck ; being careful, at the same time, to
keep the lower extremities warm.   When the paroxysm comes on, dash a
basin of cold Avater rapidly in the face ; and if this does  not arrest it, take
care that the patient does not injure herself during the fit, but do not hold
her down, as  if with the expectation of stopping the convulsion.  Some
recommend immediate  dehvery of the child, but it is not right to  adopt
this practice indiscriminately.  Lf the head has descended within reach of
the  forceps, appfy them ; but do not use the forceps if the paroxysms have
subsided, for  fear of again inducing them.  If the head is impacted, and
the  child is dead, remove it by the crotchet.  In other cases trust to the
uterine action for effecting the dehvery.  Never turn, except the turning
be otherwise necessary, as for a preternatural presentation.
  Asthenic, or Anaemic convulsions require a different mode of treatment.
Get the bowels freely evacuated by the use of Avarm stimulating cathartics,
such as aloes  with assafostida, turpentine, etc.; and then give opium, stim- 
£28                    PUERPERAL AFFECTIONS.
nlants, as camphor, ammonia,  wdne, and  brandy, and  nutritious  food.
During the paroxysm, dash cold Avater in the face.  If venous congestion
of the head results from the convulsions, cup from  the back of the neck,
and then  apply a  sinapism ; taking  care at the same time to support the
patient's strength,  and to keep the surface Avarm.
  The treatment of hysterical  convulsions consists in the use of stimu-
lating  purgative enemata, followed by diffusible  stimulants wdth opium,
and in dashing cold water in the ^ace during the paroxysm.
                                                     Part xix., p. 264.
  Puerperal Convulsions, Anemic.—While stimulants are given, and the
contraction of the  uterus is secured, give opium, which Dr. Lever says,
will act like a charm.
  Hysterical.—In  this form of convulsions, Avhich occurs chiefly during
pregnancy, great  benefit  will  result from the administration of a mild
opiate as soon as the paroxysm is over.                 Part xxi., p. 305.

  Puerperal Convulsions.—In fullness of the vascular  system, says  Dr.
Steele, blood-letting is the most powerful sedative of spinal action.  Hence,
when  the convulsions depend on the stimulation  of the spinal marrow, by
excess of blood, or on mechanical pressure exerted by the blood on that
organ, or on  the medulla-oblongata, we  must  bleed.  Remove, also, if
possible, the eccentric  cause of irritation, whether it exists in the womb,
the rectum, or the stomach.  The blood-letting must be regulated, not by
the violence of the disease, but by the state of the  circulation in the inter-
val of the fits.  Evacuate the liquor amnii, which, by relieving the disten-
tion, diminishes the size of the Avomb, and the quantity of blood circulating
in  it, and also makes the organ  less irritating to the general system.
 Evacuating the liquor amnii, is to the womb  what an emetic or an enema
may be to the stomach or boAvels.   Do not trust to chloroform, as, " when
the function of the true cerebral  or  sentient portion of the nervous system
 are diminished or abolished, as is the case in anaesthesia, the irritability of
 the  excito-motory, or true spinal system of nerves, is increased."
                                                     Part xxx., p. 196.
   Puerperal  Convulsions.—After the more common remedies have failed,
 the  administration of turpentine conjoined wdth castor oil by the mouth
 has been found by Dr. Woodhouse, of the Royal Berkshire Hospital, to
 be very efficacious.                                 Part xxxiv., p. 236.
   Puerperal  Coma.—A middle aged, stout multipara was seized suddenly
 after  her last confinement AAdth loss  of consciousness ; the labor was natural
 and had  not  been preceded  nor followed by convulsions.   The friends,
 imagining the case to be one of apoplexy,  were much alarmed.  Dr. Winn
 being called-to the case, says: "I found  her  in a condition closely resem-
 bling that  induced  by pressure on the  brain.   She was hi a  perfectly
 unconscious state, from which no impression made on the  senses could
 rouse her.  As the breathing, however, was  not stertorous, the  heart not
 much depressed, and the countenance tranquil, I was induced to refer the
 affection  to a class of phenomena Avhich I  have termed puerperal coma, to
 prevent  its  being confounded AAdth puerperal apoplexy, a disease of infi-
 nitely graver  importance, and for Avhich  a totally different  treatment is
 required. In the above instance, I ivas glad to have it  in my power to
 assure the relatives of my patient that the complaint would in all probabi- 
PUERPERAL AFFECTIONS.
429
lity terminate safely.  The  only remedies employed were a  mercurial
aperient, an ammonia draught every four hours, and the  frequent adminis-
tration of small quantities of fluid nourishment.  The result justified my
diagnosis:  on the following day the comatose state had  passed away, and
the patient was free from any alarming symptoms.
  This affection, in most cases, appears to owe its origin to one or more of
the following  causes:  nervous  shock,  a  loaded portal system, uterine
hemorrhage, and the too frequent administration of cordials and narcotics.
A varietyof this disorder frequently ensues after convulsions, and requires
equally mild treatment.                            Part xxxvii., p. 205.


                      PUERPERAL  FEVER.

   Contagiousness of.—Mr. Storrs  thinks that  medical men do not go far
enough in considering this disease to be propagated by medical men and
nurses from one. puerperal patient to another.   He thinks that it is quite as
frequently carried by the medical attendant to each fresh labor-case from
some original infectious case, whether of gangrenous erysipelas, or typhus
fever, or of wdiatever animal poison besides may hereafter be found to pro-
duce it.  In some  cases which occurred in his own practice, he has no doubt
that he took it to each patient from a case of gangrenous  erysipelas Avith
subsequent abscess, which he was attending at the time of these unfortunate
occurrences.  And such may be the case of other practitioners. They think
that they convey the contagion from  one puerperal patient to  another,
instead of from one common source.  They probably lose a puerperal case
and immediately take every precaution to  prevent a similar occurrence, by
careful ablution, and a complete change of dress. Nevertheless, the next case
of labor is attended with the same fatal result; simply because the practition-
er is still in attendance on the case Avhich originally gave rise to the mischief.
  Mr. Storrs enumerates  cases  recorded  by different practitioners, all of
which prove that  each disease had a common origin from some case of erysi-
pelas or sloughing ulcer.  He concludes his paper with the following advice.
  As  it is well to be always guarded against such a misfortune, I think it
desirable for midivifery practitioners to avoid attending  labors in the same
dress in which they attend their ordinary patients, especially the coat, as this
garment must be the one most likely to be the means of conveying fomities;
and at any suspicious period, when typhus or erysipelas are prevailing, to
carry  out the same carefulness even in the after-attendance on labor cases.
I should also, after a post-mortem of any kind, or after any operation upon
any case of erysipelas,  or of typhus, recommend the most careful ablutions
of the hands, and for the surgeon to  avoid attending  on a labor in any
part of the dress  in which such  operations have been performed, not for-
getting the gloves, as the hand and arm are the chief instruments of con-
tact.   Where, hoivever, the disease has been unfortunately once set up hi a
practice, an absence from home for a fortnight or three weeks, a total
change of raiment, the most careful ablutions, and a perfect avoidance of
every case likely to have been the  source of animal poison, should alike be
adopted by the practitioner.                            Part ix.,p. 195.

  Malignant Puerperal Fever.—[Dr. G. B. Clark had  two fatal cases of
puerperal fever  in quick succession ;  a post-mortem was refused in both
cases, and therefore he ivas unable to ascertain the exact pathology of the 
430
PUERPERAL AFFECTIONS.
disease; but on the occurrence of the second case, he ascertained wdiat
was supposed to be its cause.  He says:]
   On revolving these cases in my mind, and remembering the connection
of erysipelas with this  direful  disease, it immediately flashed across me
that I had been treating, and had then under my care, a most severe case
of phlegmonous erysipelas in  a sailor, ivho Avas brought into the hospital.
   The disease  extended from the hand to the axilla, and Avas treated by
free incisions, aided by nitrate of silver.  The man recovered from one of
the  most severe  cases  I  ever Avitnessed.   The  day that I made the
incisions, on that afternoon I attended Mrs. F., and I think, however pain-
ful for me to feel and relate, there can be little doubt that  if no noxious
matter Avas carried, at  all events the effluvia remained, and thereby arose
this malignant fever.
   [Dr. Clark very prudently desisted from midwifery, and  as  soon  as
possible from all practice Avhatever, and took a sea voyage.]
                                                     Part xvi., p. 284.
   Puerperal Fever.—Any fluid matter in a state of putrefaction,  commu-
nicated by linen, a sponge, small particles of placenta, or by the  ambient
atmosphere, may induce  puerperal fever.  To  remove such matter from
the hands, wash them in a solution of chloride of lime.  Part xxiv., p. 292

   Puerperal Fever.—Dr. Tyler Smith  places  great confidence  in the
chlorate of potash as a prophylactic  against this fatal disease.  It appears
to act by liberating  in the economy the oxygen and  chlorine  it contains.
It should be  given in doses from five to ten grains three times a day.  The
hands should be washed, and if necessary, in  a solution of chloride of
lime after touching any wound, purulent surface or pathological specimen;
for, as Dr. Simpson  remarks, the fingers may sometimes be compared to
the armed points used in vaccination.  Under suspicious circumstances the
hands should even be washed before and after every \raginal examination.
The nails  of  the  practitioner should be kept  closely cut, and some have
even  recommended  that gloves should not  be worn at all, as they have
been known to become infected, and so keep up the mischief in spite of all
precautions.  The mucous surfaces are in the most favorable state  conceiv-
able for inoculation, and the surface of the os uteri is almost universally
partly denuded of epithelium during labor.  Students should not be alloAved
to attend labor except at certain seasons set apart for the purpose, during
which time they must neither dissect, nor attend the wards of the hospital
or the deadhouse.                                   Part xxxv., p. 216.
  Puerperal  Fever.—In  this disease Dr. Copeland  says: " There is no
remedy so efficacious as a decided and judicious use of spirits of turpentine."
The same author also recommends camphor in doses from eight to sixteen
grains; but by far the most important question is the prophylaxis of this
disease.  All bad or imperfect drainage must be avoided, and no medical
man should  attend a case of midwifery after making a P-M-examination
without first washing his hands, and especially his nails, in a solution of
chlorine.  We  must  recollect that inflammation is owing to a  poison, and
our treatment must be directed rather to destroy or remove  this poison,
than to combat the inflammation.                   Part xxxvi., p. 232.
  Secondary Affections  of the  Joints in Puerperal  Women.—Mr. Coul-
son, surgeon  to St. Mary's Hosnital, gives the following : 
PUERPERAL  AFFECTIONS.
431
  Puerperal Avomen are occasionally attacked by a se\*ere form of disease
attended by low fever,  ivith  effusion  of pus  into the joints, and almost
always terminating in death.
  The local affection occurs under twro circumstances; viz., after delivery,
at the full period of gestation:  or after  abortion in the earlier months.
It is important to  include  the  latter  kind of cases,  which have not been
sufficiently noticed, as they throw great  light on the true  nature of the
disease, and dispose of  the theory which Avould attribute the secondary
affections to child-bed fever.
  The articular disease  is merely one of the  effects  of pyasmia, but it re-
ceives certain  modifications from the puerperal condition Avith which it is
associated.  Even in puerperal Avomen these secondary joint affections may
occur under several states  Avhich may be distinguished  from  each other.
They are most commonly developed during the  course of puerperal fever,
from the third to the sixth day of the complaint.  In  other cases, they
Occur after convalescence from an attack of  puerperal fever.  Lastly, in
some other cases they set in after  parturition, without the patient having
presented any symptoms of puerperal fever.
  When the articular affection occurs during the course of puerperal fever,
the following train of events is generally observed. For the  first three or
four days, the  ordinary  signs of puerperal fever are alone recognized; then
some symptoms of phlebitis may present  themselves; or these symptoms
may be  so slight as to be overlooked.  They are  soon folioAved by a change
hi the condition of the patient.   Severe  rigors often usher in this change ;
the fever increases ; the  countenance is anxious and sallow ; the respiration
becomes more hurried; there is irregular  delirium;   and  the  patient
sinks.
  In these cases, there are  two dangerous maladies;  viz., puerperal fever,
and purulent infection, running  their course at the same time; and it is not
to be wondered at, if the general condition of the patient presents an ano-
malous appearance,  or if it  be rendered obscure by the predominance of one
set of symptoms over the other.
  In another set of cases, this obscurity does not exist.   The  patient has
completely recovered from  an attack of puerperal fever, or has not had any
attack of that  complaint; all the dangers of the puerperal state having ap-
parently passed over.  She  goes on well for the first week or two; there is
no fever; no abdominal pain ; no apparent danger of any kind.   Suddenly,
a severe rigor  sets in; this  is followed by febrile symptoms, small, quick
pulse, etc.; or the attack may commence with local symptoms,  the general
disturbance  being  scarcely perceptible.   These  latter cases are very re-
markable, and  not long ago Avere mistaken for rheumatism.
  The disease  with its local effects and constitutional  symptoms, may occur
after abortion  in the early months.  Here there are no symptoms of puer-
peral fever, properly so  called ;  but there may be some slight symptoms of
uterine phlebitis.  These are often chronic  and  obscure cases;  yet they
proceed and terminate like the former series.
  The secondary joint affections are the same under  all these different cir-
cumstances. They may be either  purulent or non-purulent;  articular or
periarticular;  acute or  chronic.  These different conditions are found to
exist in various cases; but the most common  form of attack is acute, of a
purulent nature, and occupies the interior of the joint.   At other times,
though extremely acute, the attack is non-purulent, and confined to the ex- 
432
PUERPERAL AFFECTIONS.
terior of the joint; while in several cases, there is' pus in the cavity of the
joint^ wdthout any lesion of the articular tissues.
  It is also worthy of remark, that in several cases  some of the joints are
attacked by purulent inflammation, while  other joints in the same subject
suffer from simple inflammation with effusion of scrum.
  The period at Avhich the  articular affection  sets in is various.   In a few
cases, it has happened on the second day after  delivery: in many other
cases it does not appear until a few days before  death, viz., from the 23d
to the 25th day.  Generally, however, the joints are attacked between the
third and fourteenth days.  The knee joint is most frequently the seat of
the disease.  I have found  that it is attacked in one-third of the eases in
whieh the joints have suffered; next comes the wrist joint; then  the ankle,
the  shoulder, elbow,  hip; and lastly,  the smaller joints. In a  few cases,
the purulent effusion has been  confined  to the symphysis pubis ; but I am
inclined to think, from the  history of these rare cases, that the suppuration
of the pubic joint wras primary, not  secondary—the  inflammatory action
having extended from the  cellular tissue of the pelvis.
  The duration of the joint-disease necessarily depends on the duration of
the  primary affection Avith ivhich it  is  connected  as an  effect.  It is not
often prolonged beyond a  week, but it may last  from one to three weeks.
In chronic cases the duration may extend to  three months.
   I am  quite unable  to determine the circumstances which give rise to
these differences, to explain why the effusion is purulent in some cases,
serous in others ; why it takes place now in  the joint, at another time out-
side it.   Moreover,  the kind and seat of the effusion bear no relation to the
gravity of the case, or to the intensity  of the local  symptoms.
   The joint-affections are  frequently accompanied by abscesses in the mus-
 cles of  the legs and arms,  preceded  by pain  and  attended by doughy
 swellings.  When these occur in puerperal women they should  ahvrays ex-
 cite attention, for they are too often  the forerunner  of purulent infection
 of the blood.   The changes  discovered after death  are purulent effusion
 into the articular cavity without any alteration of tissue; frequently, signs
 of synovial inflammation Avith erosion and ulceration of the cartilages; more
 frequently still, purulent or serous infiltrations outside the joints, Avith ab-
 scesses in the neighboring muscles. In no cases have  the bones been found
 diseased  ; in no case, likewise, are the lesions confined to the joints ; yet in
 a few cases the joints and  intermuscular tissue have only been affected.
   The other lesions are those of purulent infection ; viz., secondary deposits
 in the lungs, liver, etc.  The brain has not been found affected, as far as I
 am aAvare.  Pus is always found either in the veins or lymphatics of the
 uterus;  or there is primary abscess in the walls of the uterus, in the cellu-
 lar  tissue of the pelvis, in  the symphysis pubis, or elsewhere.
   Practitioners are noAV agreed that the puerperal disease of the joints  de-
 pends on blood-poisoning.  The only question on Avhich differences of opinion
 exists is, as to the nature  of the poison.  Is it pus ? Is  it some morbid
 secretion or putrid element  introduced into  the blood ?  My own opinion
 is that these secondary joint-affections, as ivell as  many others, are caused
 by purulent poisoning of the blood.                 Part xxxvii., p. 221.

   Puerperal Fever.—When the fluids passing from the vagina  are putrid
 and offensive, says Dr. T. P. Ileslop, of Queen's College (which of itself,
 if it cause not the disease, will at any rate greatly aggravate the symptoms 
PUERPERAL AFFECTIONS.
433
 from absorption of the poisonous matter), inject weak solutions of hydro-
 chloric acid at frequent intervals.  A competent person must be found to
 do this or it will not be done effectually.            Part xxxviii., p. 74.
   Use of Turpentine and Opium.—The use of turpentine and  opium  in
 puerperal affections, though a treatment by no means new, does not seem
 to be sufficiently known or valued by the profession.  The opium may be
 given in the form of pills,  and the turpentine in that of enemata. Trousseau
 prescribed the opium at first in doses of 5 centigrammes during the day,
 gradually increasing to double  the dose (centigramme =0'15432  grain) ;
 the turpentine may be administered, if given by the mouth, in the form of
 capsules.                                        Part xxxviii, p. 215.
   Puerperal Convulsions— Chloroform.—Two interesting cases of puer-
 peral convulsions are related by Dr. R. T. Tracy, in Avhich subsidence of
 the paroxysms and tranquil*sleep followed the use  of  chloroform.  In the
 first case the chloroform was given at each return of the fit, and about two
 minutes at each inhalation.   The  patient being of  a very plethoric habit,
 ten ounces of blood were  taken away prior to the administration of the
 chloroform.                                      Part xxxviii, p. 2 21.

                      PUERPERAL MANIA.
   3Iusk in Delirium of.—Pills composed of musk  or assafoetida  and  cam-
 phor, to  Avhich may be added a feAv grains of calomel, and also some exr-
 tract of henbane, if considered  judicious, are  recommended  by Recamier
 in puerperal mania.                                   Part ix., p. 11.
   Puerperal Insanity.—The treatment generally  proper for  anasmia, says
 Dr.  Mackenzie, of Paddington Dispensary for Women and Children, will
 be found, upon the whole, to be most  appropriate for puerperal insanity.
 Special indications will require to be fulfilled by special means ; and slight
 forms of the disease Avill often yield to the unassisted efforts of nature.  But
 Avhen the attack is severe, and resists the natural efforts, as well as specific
 treatment, it  will generally be found that this  obstinacy is connected Avith
 an aggravated form of anasmia, and that in proportion as the condition of the
 blood is improved, will the cerebral disorder disappear. Part  xxiv., p. 286.
   Treatment of Puerperal Mania.—Speaking of the  treatment of a case
 of puerperal convulsions, Dr. MaAver appends the following observations :
  In the  first place, it serves to confirm the imperative  necessity of  large
 and  adequate depletion in the congestive variety of this formidable dis-
 ease, affording at the same time ample proof of its undoubted safety and
 success.   It also furnishes a remarkable example of the tolerance of tartar
 emetic—a fact long well established in  reference to its use in pneumonia
and some other pulmonary affections, but not  that I  am aAvare  of to the
 same extent in cerebral disorders, as this case so strongly illustrates, a grain
and a half having been  taken every hour for eight  consecutive hours with-
out the least nausea resulting from it.  While speaking  of this valuable
medicine in connection with  this class of affections, it may not be out of
place to add,  that I have  employed it wdth marked benefit in combination
 Avith camphor and morphia  (aided by cold applications to the  head, and
 preceded by  active purgation and leeches to the temples), in tAvo very
 severe cases of puerperal  mania.   General blood-letting being for the most
 part inadmissible, it is  very  desirable to possess a remedy so available as
   vol. n.—28 
434
PULSE.
this proved in both the instances referred to, in controlling the excited state
of the circulation, and in tranquillizing the extreme irritability of the nerv-
ous system, both Avhich conditions are so constantly present in the more
active forms of the distressing malady.               Part xxvii., p.  213.

                              ---hi

                            PULSE.
  The Pulse.—[In a clinical lecture on this subject, Dr. Todd says :]
  The frequency of  the pulse is affected by various morbid influences, of
which the folloAving are the most potent:
  The Condition of the Blood.—A poor blood is almost always associated
with a rapid pulse; in animals bled to death the pulse attains an increasing
frequency as  the blood flows ; this occurs in 'men Avho have been very
largely bled,  and in cases  of  excessive hemorrhage, Avhether hemoptysis,
epistaxis, or hematemesis, or after surgical operations, the  pulse attains
great rapidity.
  The Existence  of jt Poison in the Blood.—This tends generally to" in-
crease the frequency of the  pulse, and so you find the pulse quick in the
early periods of the  exanthemata of typhus.   The administration of alco-
hol to a healthy man affords a good illustration of this; as  soon as he has
taken a certain quantity of it, acceleration of the pulse takes place.  But
some poisons will  produce a  contrary effect, by depressing and Aveakening
the heart's action, as you Avell know in the administration  of digitalis, or
of hydrocyanic acid.  So  also, some of the animal poisons, if taken in large
doses, will cause  depression  of  the heart's action and a slow pulse.  We
have noAV a case of scarlet fever,  in  a  man  named  Boon, in Rose Ward,
with ivhom the pulse was as slow as 6Q before the eruption had come out
fully ; a state which seemed  to me to indicate  the use of stimulants, and
under their  administration the heart's action increased in force and fre-
quency, and the patient did well.
   The state  of the Nervous  System exercises a very remarkable influence
upon the rate of frequency of the Pulse.—It is one of the features of the
hysterical diathesis, that the pulse always quick, becomes accelerated under
the slightest  disturbance, physical or mental.   Cerebral lesion sometimes
causes a very depressed state  of  pulse ; as,  for example, inflammation of
the brain, vomiting, pain in  the head,  and  sluggishness of pulse, are
symptoms Avhich should always awaken the anxiety  of the practitioner,
as regards the state of the brain.   In many instances of injury to the
head, concussion,  fracture witfc depression,  the pulse becomes  notably
retarded until the  compression of the brain has been  removed.   So  also,
in many cases of apoplexy, the  pulse is sluggish, and the heart seems op-
pressed.
   Of intermitting Pulse. — Among the most interesting  modifications
of pulse, which we meet with in practice, is that which arises from im-
pairment  of  the rhythm  of  the pulse,  or what is called the intermitting
pulse.
  The most common form of intermitting  pulse, is that in which the phe-
nomenon  of intermission results  from the  prolongation  of the natural
period of rest in the  series of changes which constitute the heart's  rhythm.
The heart's rhythm  consists of a regular succession of first sound, second 
PULSE.
435
sound, rest—first  sound,  second sound,  rest—and so on.  IN ow in an
intermittent pulse this rest is unnaturally long—the first sound of one beat
succeeds tjie second of the previous beat, but after  too long a  pause.
Sometimes the intermissions are very regular, occurring after every fourth
or every  third beat;  sometimes perfectly irregular,  at  one time after
'every one or two beats, at another every thirty or forty.
  Now Avhat are the indications of this form of intermittent  pulse? Is it
indicative of organic disease ?  I think I may state positively that an in-
termittent pulse of itself affords  no  indications  of organic disease  of the
heart.                                                     .    ,
  Nor are we justified in  pronouncing unfavorably of a  patient because
he has an intermittent pulse.  You wdll meet with many persons who  will
tell you that they have had intermitting pulse nearly all their lives.
  But undoubtedly this form of  intermitting pulse denotes aderangement
of the heart's action of a sympathetic nature,  and almost invariably in
sympathy Avith the state of  digestion.  This kind of pulse is  of very com-
mon occurrence in men Avho work hard, neglect exercise,  are irregular as
to meals, and sit up late at night.  It is also very common, and  doubtless
from  the  same cause, in  gouty  men.  Intermittent pulse is not  uncom-
monly a precursor of a paroxysm of gout.  Certain ingesta  are very  apt
in some  people to  cause  intermission of  the  pulse.   Tea,  for example,
especially green tea, is one  of these; ices, more particularly cream ices,
Avill do the  same.  So, also, certain medicines—as digitalis and colchicum.
  I have stated that the intermittent pulse is not  a necessary  indication
of organic disease of the heart.  It  is a  curious fact, which is in some
measure confirmatory of this remark, that of the various  forms  of disease
to which the heart is subject, intermitting pulse is not of very frequent
occurrence  Avith any, nor is it constant to any particular form. s
  The intermittent pulse  depends upon  some interference with the healthy
nutrition of the muscular system of the heart;  and hence you get it so
frequently in bad states of "the blood—as  in dyspepsia, gout, rheumatism.
  You may gather, from  what I have stated more than  once in the pre-
ceding part of this lecture, that  there is another form of intermitting
pulseliesides that to which  I have alluded.  The characteristic feature of
this form is, that the intermission  of the  pulse does not result from the
intermission of the heart's rhythm, but from irregularity in the strength
of  the heart's systolic contractions.   The heart may  never intermit, and
yet the pulse may; or,  in other Avords, the intervals between the beats
of  the pulse may  vary considerable in duration.  This form of inter-
mitting  pulse  sometimes occurs  alone,  sometimes simultaneously  with
that in wdiich  the  heart's rhythm  is deranged.   When  it occurs in the
progress of an acute disease, as of fever, erysipelas, etc., it must be looked
upon as a sign  foreboding the worst results.  I apprehend that it is  this
form of intermitting pulse which most commonly accompanies fatty disease
of the heart; and, on the Avhole, in all states  of disease, both  acute  and
chronic,  it is that form from wdiich we may augur  least favorably  for the
patient.
  Posture influences these  tAvo forms  of intermittent pulse  differently.
The first form, or  that  Avhich depends  on -a prolongation of the natural
period of rest in the heart's rhythm,  is diminished by the erect  posture,
and the heart becomes more regular in its rhythm.   On the other hand,
the erect posture increases the number  of intermissions in  the second 
436
PURGATIVES.
form by embarrassing the heart's action in the way which I have  already
described.                                                        \
  [ In considering the means best adapted to keep doAvn the frequency of
the pulse, we may employ either  direct means acting  at once upon the
heart, or indirect or general means.]
  Of the direct means the administration of digitalis, or of opium, is the
most important.   You may give digitalis as a diuretic, or with a vieiv  to
obtain its specific action in reducing the frequency of the heart's  action.
Given with this latter vieAV it must be administered Avith due regard to a
correct diagosis, for Avhile it is a very valuable remedy in one case it is a
dangerous one in another.  I would lay it doAvn as a rule, that in all cases
where there is regurgitative valvular disease, but especially aortic, dig-
italis given in doses ivhich will depress  the  heart's action is a dangerous
medicine ; it Aveakens the heart, and thereby increases the  embarrassment
under Avhich it already labors.
  Now, opium operates upon the heart through its tranquillizing influence
upon the nervous system, and so quiets the heart without weakening  it,
and therefore it is more generally applicable to heart affections than digi-
talis.  The diuretic properties of digitalis may be often  called into play  in
cases of cardiac disease ; and for that purpose  you may often  combine it
with a stimulant, as ammonia, or Avith some preparation  of  iron, so as  to
counteract the depressing effects.   But the  best combination, for a diuretic
purpose, is with  blue pill  and squill, after a formula attributed to the
late Dr.   Baillie.  I have seen, under the use of this combination,  consid-
erable dropsy disappear, and the heart become disembarrassed in its action
in the most remarkable manner.
   But then there are certain other indirect means of acting on the heart,
as purgatives, Avhich  diminish  the quantity of the blood  Avithout impo-
verishing it; or steel, which improves the condition of  the  blood already
poor; rest, the recumbent position, a nutritious and moderate diet, mental
quiet.   It is generally from the efficacy of some of these  remedies, espe-
cially the three or four last,  that heart cases often experience a marked
alleviation of all their symptoms on their first entering the hospital.
                                                     Part xxiii.,/). 100.
                      PURGATIVES.
  Remarks on Drastic Purgatives.—Veratria, the alkaline principle which
is supposed to give activity to colchicum, and white and black hellebore, is
a powerful, and it may even be said intractable and  dangerous, hydra-
gogue-purgative.  In  arthritic  cases, says  Dr. R. Dick,  attended  with
plethora and  distinct constitutional fever, wdth morbid and loaded bowels,
scanty and high-colored urine, and tumultuous action of the heart, veratria
is indicated.  Veratria, one grain  ; poAvder of acacia, tAvo scruples and a
half;  sirup, a sufficient quantity.
  The dose may be carried to three pills daily.  This  is the formula re-
commended  by Majendie.  We  haA~e  seen no good effect from  it in
paralysis, for which  some  recommend it.  Veratria may also be used in
tincture and ointment.
  Elaterium is somewhat analogous in  its  properties to veratrum.  Its
action, which is that of a hydragogue-purgative, is extremely violent.   It 
PURGATIVES.
437
is useful in the inflammatory anasarca of robust or young subjects ; but its
use is to be deprecated in chronic dropsies, and in the cases of persons feeble
or aged.  I have seen it poAverfully check rheumatic fever, and wonderfully
re'ieve  rheumatic metastasis to the heart.  I  have also seen it  rapidly
reduce the effusion into the cavity of the large joints, consequent on acute
articular rheumatism.  Some degree of its febrifuge power no doubt de-
pends on the extreme nausea which it usually induces.  From ten grains of
the extract of elaterium, one grain of an alkaline principle called elateria, or
elaterin, may be obtained.  A tincture of this is more manageable than the
extract.   Elaterine, one grain ;  spirits of Avine, eight drachms ; nitric acid,
tAvo minims.   Dose, thirty or forty drops.   This dose, I may remark, will,
with many persons, act drastically. Where it does not operate sufficiently,
it may be repeated, in a full or half dose, after three or four hours.   In
suspected scirrhus of the pylorus, neither A^eratrum nor elaterium should be
ordered, unless in very particular exigencies, and then Avith very particular
precaution.                           •
  Croton oil is another of our drastic purgatives.  In torpid states of the
boAvels, and Avhen the vena portae is in a state of congestion  and distention,
constituting Avhat is called abdominal plethora, wdiich some German writers
consider a very important pathological condition, croton oil often brings
sudden and marked relief.  It also decidedly eases cerebral congestion and
plethora,  promptly dissipating the most  intense and alarming headaches.
Unless cautiously administered, however, it is a debilitating cathartic, and
its use is not to be thought of in irritable states of the gastric or intestinal
mucous membrane.
  The half of the following combination will be found to be nearly corres-
ponding in strength to a similar dose of castor oil: Croton oil, one minim;
oil of almonds, two ounces.
  We may here observe that oil of turpentine has almost all the advantages,
without any of the disadvantages,  of croton oil, while the former possesses
some good  properties Avhich the latter Avants.   In sluggish and  flatulent
states of the bowels, in tumid states of  the intestinal mucous membrane,
with a congested and distended condition of the rectum, oil of turpentine
often gives surprising relief.  Its nauseating taste and smell, and its  ten-
dency  for some  time after  it is  taken, to rise  in eructations from the
stomach, are its draAvbacks.   But this is compensated by the siugularly
warm  and invigorating  influence it  has on the abdominal organs.  In
gouty, rheumatic, and paralytic cases,  it is a most valuable means.  It may
be used Avith great benefit, in injection as Avell as in draught.
                                                      Part xv., p. 114.

  Oil of Anda, a  new Purgative.—[The  Anda Gomesii is a Brazilian
plant,  belonging to the class and order Monussia Monadelphia,  N. O.
Euphorbiaceas.  Its seeds are used as a cathartic by the inhabitants of the
Brazils;   and  the oil  expressed  from  them  has been  used  in  North
America.  Mr. Ure haAdng administered this oil in several  cases, gives the
following account of its effect.  He says:]
  It may he observed, that the average dose of oil of anda  administered
Avas 20 drops, and to secure its entrance into the stomach it Avas SAvallowed
on sugar.  It offered nothing unpleasant to the  taste, produced none  of
that heat  in the throat which croton oil creates, seldom occasioned nausea
or griping; it rarely operated Avithin  a period  of two hours, although in 
483
PYROSIS.
 one or two instances I have  knoAvn it act within  half an hour  after its
 ingestion.                             -               Part xx., p. 290.

   Best Means of Obtaining the Purgative  Operation of Calomel.—[For
 the purpose of obtaining the best purgative effect of calomel, Dr.  Hall
 recommends it to be mixed wdth a little table, salt, and placed dry upon
 the tongue ; no other purgative being combined with it, and the patient
 abstaining for some time from taking water or other fluids.  Dr.  Hall
 observes:]
   This is a point of practical importance, and well Avorthy the attention of
 the practising surgeon and physician.  It is a Avell knoAvn fact that the in-
 habitants of maritime localities, and sailors, after a long voyage, in wdiich
 they have been deprived of the use of fresh provisions, and kept upon salt
 meat,  are more liable than others not so circumstanced to the influence of
 mercurial preparations ; Avhich arises in the opinion of Mialhe, from the
 bodies of such men containing large quantities of the alkaline chlorides—
 so that there  is more complete conversion of calomel into corrosive subli-
 mate than under the usual state jof the body.
   Children, and patients confined to  a milk  diet, support large  doses
 of calomel, because the fluids in their alimentary  canals are destitute,
 or contain  only  very  small quantities of the alkaline chlorides.  Pa-
 tients, also, Avho  have lived for a long time on broth, or low diet, the fluids
 of whose bodies are also exhausted oT chlorides, consequently bear larger
 doses of calomel without the  system becoming affected.
                                                     Part xxi, p. 151.

                              —"i

                           PYROSIS.
   loduret of Silver.—In  about one-quarter of a grain dose, three times a
 day, recommended, by Dr.  Patterson, in pyrosis and gastric  affections.
   R loduret  of  silver,  nitrate of  potassa, each ten  grains.  Pulverize
 thoroughly  and  add pulv.  liquorice ext.,   half a drachm;  white  sugar,
 twenty grains; mucilage of gum arabic,  sufficient to  mix.   Divide into
forty pills.  Dose,  one three times a day.                 Part vl, p. 13.
-   Oxide of Silver in certain  Diseases of Debility.—Sir James Eyre says,
 he has found half a grain of the  oxide of silver, three times a  day, uni-
 formly succeed in curing pyrosis; he administers at the same time two of
 Dr. Hamilton's pills (composed of ext. colcynth, c. 9ij.; ext. hyosciam, 9j.;
 in  pil. xij.) every night.  He gives numerous cases illustrative of his
 success.  He next advances instances of similar  successful  results  in
 hematemesis and hemoptysis, but he does not exclusively confine himself
 to  the oxide  of silver  alone, but assists  its administration by bleeding,
 blistering, and other means.
   From having found this remedy much superior to all other means em-
 ployed during an active  professional life of upward of thirty yeaJrs, Sir
 James feels fully justified in inviting a trial of the medicine.   That it is a
 tonic and sedative there can be no doubt, and there is also good evidence to
 prove  that it is a safe and efficient astringent.   In the cases enumerated,
 the dose never exceeded three grains a day, instead of six, as recommended
 wdien first introduced; and its employment where febrile action  exists is
 not recommended. 
PYROSIS.
439
  In addition to its value in gastrodynia,  in  pyrosis, in hemoptysis,  m
hematemesis, and in the first and second classes of menorrhagia in Dr. ±.
Churchill, it will be found to be  productive of infinite benefit in restrain-
ing when absolutely necessary, hemorrhage proceeding from the intestinal
canal, obstinate  chronic diarrhoea, colliquative perspirations,  leucorrhoea,
and other maladies.                                    Part xx., p. 107.
  Treatment of Pyrosis.—The mineral  acids, being astringent tonics, are
especially suited to relieve obstinate pyrosis  in feeble  individuals.   Some-
times the sulphuric,  sometimes  the nitro-muriatic acid  succeeds  best;
nor can the one best adapted for each  particular case be always deter-
mined beforehand.  If there be much debility, however, the former should
be first tried, and the latter if bilious disorder be conjoined with indiges-
tion.  It is perfectly consistent  practice, according to Dr. Child,  to pre-
scribe regular doses of acids and occasional doses of alkalies for the  same
patient, each medicine fulfilling a separate purpose.   Alkalies are merely
palliative, and relieve only when the irritating fluid that has been poured
out is of an acid nature ;  on the other hand, the mineral acids strike at the
root of  the pyrosis, and produce  a radical cure by checking the secretion
of the fluid itself, in consequence of their tonic and astringent effects upon
the  vessels of the mucous  membrane.  The mineral acids, therefore,
should be given,  like  other tonics, Avhen the stomach is empty;  while
alkalies are of little use unless administered toward the end of digestion, at
the  moment when the  acid fluids are irritating the gastric  nerves.  If
taken Avith care in this manner, the one  does not  interfere with the action
of the other.  When pyrosis is obstinate,  counter-irritation to the epigas-
trium, as by means of a blister, is often highly useful: it operates by re
lieving congestion of the mucous membrane, and imparting  tone to the
secreting vessels.
  Medicines can palliate, even in the worst cases; but in order to effect a
lasting  cure, careful rules of diet must be enforced.  In particular, fat,
fried, or cured meat, pastry, nuts, cucumbers, pickles, and malt liquors, are
to be eschewed.  Moreover, all articles of food Avhich, although generally
wholesome and digestible, are yet found by patients  to " turn to acid or
water, or to ferment," as they express it, are to be avoided.  Among the
things in  common use most apt to excite  pyrosis, may be mentioned oat-
meal, potatoes, fish and tea.  As a general rule,  a vegetable diet  is more
acid-producing than one chiefly composed of the easily digested kinds of
animal foods ; hence many patients remark that they are more troubled
with acidity when they live on slops—farinaceous articles—than Avhen they
make use of a full meat diet.  When bilious pyrosis  occurs the first thing
in the morning, it is often prevented by taking a little food before getting
out of bed.   Many patients find that  exercise  or constrained  postures are
sure to bring on an attack:  hence clerks are extremely apt to suffer there-
from when closely confined to the desk.                Part xvi, p. 318.

  Treatment of Pyrosis.—If the disorder should seem to be caused mainly
by a diet  not sufficiently nutritious or consisting too much of farinaceous
substances, the most effectual remedy Avill be a wholesome nourishing diet,
containing a proper quantity of animal food in  its  most digestible form.
Little permanent benefit can, indeed, be expected from medicine unless the
diet is impixwed.
  If the  disorder should seem to haire been  induced, or to be  kept up, 
440
QUrNDTE.
wholly or in part, by fatigue, it is very essential that the patient  should1
rest ;  if by constipation, that this condition should be removed  by purga-
tives, such as aloes or colocynth, that do not offend the stomach.
  After these points have been attended to, much further good may be
done by medicines.   Give a combination of astringent and sedative reme-
dies, as five grains of bismuth wdth 1-12th of a grain of the muriate of
morphia, or five grains  of the compound kino powder, or an efficient dose
of catechu, krameria, or logwood, Avith opium, two or three times  a day.
Astringents are useful sometimes, as half a grain of argent, nit. three times
a day ; or three to five grains of nux vomica three times a day; or quinine,
or the mineral acids.  If there be  anasmia present, steel should be given.
  The medicines of which Dr.  Budd has had most experience in disorders
of this class, and which are probably as efficacious as any, are bismuth, with
morphia; krameria, and logwood, wdth opium ; and steel.
                                                   Part xxix., p. 107.
  Gallic Acid in Pyrosis.—Dr.  Bayes says that in pyrosis, where this
disease  is unaccompanied by  extensive ulceration, or organic  malignant
diseases of the stomach, or by  disease of the liver, the most marked benefit
will follow the use of the remedy.   Gallic acid, here, not only checks  the
secretion Avith a certainty and rapidity he has never seen follow the admin-
istration of any other remedy, but it gives general tone to the stomach, in-
creases the appetite, and (what I very little expected wdien I  first used it)
in many cases removes constipation.  This I can only account for on the
supposition that the relaxed atonic  state of the stomach wdiich favors pyro-
sis is continued throughout the alimentary canal, the constipation in these
cases arising from want of power in the muscular coats of the intestines to
expel the fasces.  This want of tonicity is remedied by gallic acid.
                                                     Part xxxv., p. 94.
                          QUININE.
  To disguise the Taste of Quinine.—Administer it in coffee.
                                                      Part xvi.,p..67.
  New Preparation of Quinine.—Dr. Kingdon introduced a new prepa-
ration of quinine which he had lately succeeded  in preparing.  It is the
di-arsenite—that is, it consists of one part  of arsenious acid, and two of
quinine; it is a poAverful  medicine, and one which he  has found of great
benefit, especially in chronic cutaneous  affections, and has no doubt it
would be equally beneficial in ague, tic douloureux, and neuralgia. It pos-
sesses both the qualities of a mineral and vegetable tonic, and when the
system has become habituated  to either  the one or the  other (Avhich we
frequently find the case from  long-continued use), by the administration
of this  medicine  you will keep up  the  former action, Avhile at the  same
time a new one is introduced into the system.   He related a case Avhich
demonstrates this very satisfactorily.  A young ivoman who had been af-
fected Avith lepra six years, was admitted a patient  at the Exeter Dispen-
sary, under his care, and ivas ordered  the  liq.  potassae arsenitis, with de-
coct, dulcamara, three times a day.  For a time the  disease appeared to
be improving, but it gradually got back  to its  former  state, although the
quantity of arsenical solution was increased to the full extent; he then or- 
RECTUM.
441
dered one-third of a grain of di-arsenite of quinine to be taken tAvice a day,
and the following Aveek the eruption Avas much  improved.  It has  been
gradually increased to four times a day, and now she is nearly well.
                                                    Part xvi, p. 297.
  Quinine, without its Bitterness.—To deprive quinine of its bitterness, com-
bine ten grains of it with two grains of tannic acid.    Part xxiii., p. 336.
  Disguising the Taste of Quinine.—A piece of chocolate  should be half
masticated, and reta'ined betAveen the  cheeks and the teeth.  The  quinine
draught is to be rapidly SAvallowed; and then the mastication  of the cho-
colate is to be completed, so that it may be swallowed also.  The taste of
the quinine is thus hardly perceived.                  Part xxvi., p. 326.
  Action of Quinine.—The folloAving are the general rules, established by
M. Briquet,  for giving quinine in fever:  1st. Give  each  hour or  second
hour the sixth or twelfth part of the quantity to be  taken daily, and leave
ten hours' interval Avithout any quinine.   2d.  Gradually increase the dose,
until head symptoms, vertigo, and pain are produced.  In ague, give the
quinine so as to produce the maximum effect  at the commencement of the
febrile action.   In typhoid fever, give quinine during the night, for the ac-
cess comes on in the afternoon, and it requires some hours after  adminis-
tration before.it produces its full effect.   Ahvays give it in solution : when
given in  the form of pills it is only one-sixth as active  in three hours.
                                                   Part xxxii., p. 277.
  Quinine.—As a prophylactic, quinine is especially valuable Avhile in  un-
healthy localities.   It should be  given in three or four grain doses tAvice a
day in a glass of sherry, and its use should be continued for fourteen days
after leaving an unhealthy district. Its effects in tropical climates are very
manifest,, producing a refreshing and exhilarating  effect  on the  system,
which nothing can equal.                   _         Part xxxv., p. 17.
                          RECTUM.
  Relaxed Rectum.—Dr. Hunt describes this as a malady of not unfre-
quent occurrence, and productive of  much  inconvenience and  distress.
The  most  prominent  symptoms  are  obstinate  constipation, a frequent
desire to evacuate the boAvels, a constant sensation  of load in the rectum
—which is not relieved by an  evacuation—and the  discharge, after much
forcing, of mucous streaked with blood.  The bladder, urethra, and other
adjacent organs, often participate in the irritation.  On examination, the
rectum will be found  preternaturally enlarged, and more or less filled Avith
large folds of mucous membrane pressing down on the anus, which impede
the evacuation of the  faeces, introduction of instruments, and injection of
enemata.   This morbid condition  of mucous membrane, the author attri-
butes to a neglected state of the boAvels, and repeated great distention of
the rectum by faeces, which causes the mucous membrane, Avhen the bowel
is empty, to hang in loose folds. This  disease, if neglected or mismanaged,
gives rise to prolapsus ani,  an irritable and painful state of the sphincter,
and an intro-susception of the upper and mutilated  portion  of the intes-
tine,  into  the lower and dilated  part.  The treatment recommended for
the simple relaxed rectum is, the avoidance of all aperient medicines, and 
442
RECTUM.
the injection of a pint of cold water into the bowel e*-ery night previous
to going to bed, the removal of the prolapsus, and the application of bella-
donna ointment to the irritable sphincter.  In the case of intro-susception
of the rectum, in addition to the use of the cold water injection, the exhi-
bition of some mild aperient, taking care that Avhilst a costive and hardened
state  of the faeces is prevented, purging is avoided, and a course  of the
hyd. cum creta, with hyoscyamus or conium, or the iodide of potash and
sarsaparilla.
   [Dr. James Johnson disagrees with Dr. Hunt Avith respect  to  the use of
mild aperients.  He considers them to be essential to the successful treat-
ment of the affection.   He says:]
   In cases of  constipation, it is essential, to effect a cure, that the colon as
well as the rectum should be acted upon.  Faeces  often collect  above  the
rectum, and cannot be  reached by small injections of cold water.  These
injections are, moreover, not so harmless as people seem to imagine; at all
events, he has seen them productive  of violent  tormina and great pain;
in some instances, producing faintness. He Avould, in this class of cases,
administer some mild aperient, which would act  on the colon,  and soften
the faeces in that tube—such, for instance, as the tartrate of  potash or the
confection of senna.  These medicines produce no irritation or  unavailing
efforts to evacuate the rectum ;  on the contrary, they soften  the faeces
above, and soothe rather than irritate.  In the second class 01 cases men-
tioned, in Avhich  there  was intro-susception of the rectum,  he  has found
Ward's paste corrugate the folds and give tone td the part.   In this class
of cases, when the bowels  have protruded, and have  not been carefully
returned, it Avas  liable  to become inflamed, and be productive of greal*
suffering.
   Mr. Barnsby Cooper agreed with Dr. Johnson in reference to the expe-
diency of applying remedies that would act on the colon in the first class
of cases described by Dr. Hunt.
   He recommended evacuating the bowels at night, just before  retiring to
bed.   In diseases of the rectum, this rule Avas one of the greatest impor-
tance.   When evacuated just before bed-time, the patient remained in the
recumbent  position for many hours, and the  affected boAvel Avas, during
the whole of that  time, in the  pelvis.  By this simple plan a cure was
effected wdthout the use of instruments or of medicine, both of which
combined Avould only alleviate and not cure.
   [For  the support  of the rectum in  these cases mechanical means may
be resorted to similar to those applicable in prolapsus uteri.]
   In cases  of constipation  from relaxation, aloes in  combination  with
sulphate of quinine Avas  a favorite  prescription  of Dr. Abercrombie, and
often succeeds remarbably well, especially in persons advanced  in life.  In
cases of great dilatation, might not injections of nitrate of silver be of
service, administered as  recommended  by Trousseau in the diarrhoea of
children ?
   It  has a great  effect  in  producing contraction of the calibre of the
vagina.   In  the  habitual constipation which so  often produces this affec-
tion, Dr. Graves, after objecting strongly to the use of mercurial  purgatives,
 recommends the followdng combination:
   R  Electuarii sennas,  §ij.; pulv. supertart. potass., §ss.; carb. ferri, 5ij.;
 eirupi zingib. q. s.—Ft. electuarium.
   The dose must be regulated by its  effecte, but in general a small tea- 
RECTUM.
443
 spoonful in the middle of the day and at bed-time will be sufficient.  Dr.
 Graves says, that the value of carbonate of iron as a tonic aperient has not
 been appreciated.                                      Part xi.,p. 160.

   Irritable Ulcer of the Rectum.—Mr. B. Cooper describes  this painful
 form of disease—painful to the patient, and sometimes not less so by its
 obstinacy to the practitioner.  Speaking  of irritable ulcer, he says:  Such
 a condition of ulcer  not unfrequently attacks the  rectum, under the form
 of a narrow elongated fissure, running along one of the folds of the mucous
 membrane, near to the orifice of the anus. The edges of the fissure are free
 from any callosity, and  it bears a strong resemblance to the cracks Avhich
 frequently affect the  lips.  The most usual situation for the ulcer, as far as
 my  experience goes, is  at  the posterior  aspect  of the rectum  in the
 mesial line, although  I have  sometimes found it on the  side of the bowel.
   The symptoms of  the  disease are  highly characteristic; a burning pain
 is experienced during the act of defecation, which continues for a consid-
 erable  time after each evacuation.  During the intervals the patient enjoys
 comparative  ease,  but still occasionally suffers from  heat and lacinating
 pain about the anus,  but nothhig to  be compared to the agony produced
 by the passage of the fasces  over the ulcerated surface and  through the
 Bphincter, and which  is commonly more  or less in a state of spasmodic
 contraction.  The  bowels are hi these cases generally constipated.
   The ulcer may involve merely the edge of the verge of  the anus, or
 extend a considerable Avay up the intestine, but may ahvays  be detected
 by passing the finger into  the rectum, when  the nature of the  sore is
 readily appreciated by  the  extreme pain Avhich the patient  experiences
 directly the finger comes in contact Avith the fissure.
   The finger on being withdraivn, will be marked with a streak of blood,
 and  lead to the discovery of the size and position of the ulcer.
   Pass the forefinger of the left hand up the rectum, and direct a straight
 probe-pointed bistoury  along it, beyond the very extremity of the fissure ;
 then divide the ulcerated surface, and  the fibres  of the sphincter ivhich
 are connected wdth it.  In the after-treatment, advise the patient to get
 the habit of evacuating  the bowels at bed-time, instead of in the morning.
                                                    Part xvii.,  p.  172.
  Stricture of the Rectum.—The rectum is sometimes, Mr. Cooper ob-
 serves, the seat of spasmodic  stricture, resembling  the stricture of the
 oesophagus which occurs in hysterical females.  But  permanent stricture
 is a frequent occurrence, and one of the prominent symptoms of this state
 is constipation, partly due to  the obstruction, and partly occasioned by the
 avoidance of defecation  by the  patient, who dreads the acute pains Avhich
 it occasions.
  The egesta, Mr. Cooper observes, in  stricture of the rectum are passed
in  small rounded portions, or if " figured," of  very small diameter,  from
being forced through the contracted part;  the patient  usually complains
of distention of the abdomen, interference Avith the function of respiration,
and  loss of appetite.  With  these symptoms an examination should be
made per anuin, at first Avith  the finger alone, and  this will probably lead
to  the  detection of the  obstruction, Avhich is often very firm, and resists
the entrance of the finger into the bowel.   This excessive hardness  may be
produced  either by  scirrhus, or by  a mere attack of  inflammation, and
therefore, the hardness  alone is not to  determine the judgment of the 
444
RECTUM.
surgeon as to the disease being malignant, as that question will be best
decided by the age of the patient, the length of time the disease has ex-
isted, and by the nature of the pain.  If, for instance, the  patient be old,
the pain constant, severe, and of a lancinating character, and he has  great
dread of exciting the muscular action necessary to the  evacuation of the
boAArels, and if at the same time there is an appearance of what is termed
malignant diathesis, the prognosis Avould be unfavorable.   But, if the ob-
struction results from simple inflammation in a youthful patient, it will  be
indicated by the suddenness of its appearance, by the  febrile symptoms
attendant upon it, and by the peculiar sensation conveyed  to  the finger;
for although there is considerable hardness, it is not of the stony character
that marks scirrhus, but gives the idea of its being a dense projection of
the natural structures into the bowel, rather than an adventitious deposit.
When the disease  is malignant, bleeding is frequent, particularly  upon
examination either  by the finger or instrument, and the pain lasts  for a
considerable time after, which is not the case with common stricture. The
treatment in  the non-malignant disease consists  in the occasional applica-
tion of leeches around the anus, the patient being kept in the recumbent
posture, and I believe that enemata will be  generally found better than
bougies, as a mechanical means of overcoming the obstruction, unless they
act, indeed, too  much upon  the  bowels, in which case bcugies must of
course be employed.
   The introduction of the bougie is a matter requiring considerable skill
and anatomical  knoAvledge.   From  want  of this knowledge, indeed,
unskillful practitioners often do  great mischief,  sometimes lvounding the
rectum, from Avhich accident extravasation of faeces,  peritonitis, and death,
may be  produced.   The  bougie should, therefore, only be employed  by
scientific  surgeons.  Leeches, the recumbent posture,  injections, and  in
some cases the use of the bougies, and cupping in the loins when the pain
is severe, are  the means to be had recourse to in non-malignant obstruc-
tion.  And often, by such  measures, a disease which at first  appeared to
be of an alarming character, is quickly removed.  In  malignant  disease but
little can be done : the adventitious matter  indefinitely increases, so as at
length completely to obliterate  the  bowel,  and the  patient dies from  the
insuperable barrier opposed to the escape of the excretions, unless an arti-
ficial anus be made in the colon, or as some surgeons have recommended,
a  cutting gorget, or some instrument of the kind be forced through  the
obstruction; but this, if it afford any relief, can only.do  so temporarily.
Scirrhus stricture generally destroys the  patient, however, by the propa-
gation of the malignant disease through the medium of the absorbents to
some  distant  part: thus,  perhaps,  transplanting it to important vital
organs, in  wdiich case the reaction  on the constitutional  powers is very
rapid,  and the patient soon  sinks beneath its influence.
                                                    Part xxm.,p. 195.

•   Stricture'of the Rectum.—An operation for this disease  was performed
at St. Thomas's Hospital, as follows :  The patient being placed upon her
face, the stricture soon reached, the mere point of the finger getting into
it, a grooved director ivas  passed up to it, together with a  bistoury.  The
director was next let  fall  out, and the knife carried through all the parts
up to the coccyx.  The intestine aboA-e the point of the stricture seemed
quite free.  The rectum was laid open, and two vessels, probably branches 
RECTUM.
445
of the superior hemorrhoidal, spouted out pretty freely, and were tied ; the
fibres of the upper  and lower  sphincter wrere also  visible.  The thick
mucous membrane with the  stricture, and the various veins and nerves
Avere all divided.  After the hemorrhage had ceased, a large plug of tint
was put into the wound, and secured by a T bandage.  The operation was
quite successful.                                      Part xxii., p. 216.
  Fungous  Tumor  of the  Rectum in  Children attended with Bloody
Discharges.—M. Martin has already directed attention  to the affection as
it occurs in  the adult, producing discharges which are mistaken for those
from hemorrhoids.  The first case occurred in a child, aged 5, about whom
the author  was consulted in consequence of hemorrhages Avhich occurred
during a prolapsus ani, and winch arose frpm an excrescence that he at first
mistook  for hemorrhoids.  Examining it more closely,  he found  it wras a
spongy vegetation, not unlike a portion  of the placenta, which  protruded
from beyond the sphincter Avhen the child Avent to stool, and was quite in-
sensible to the touch.  As the hemorrhage  had been considerable, the fun-
gus Avas  touched Avith  the nitrate of silver, Avhencver it protruded ; and,
owing to its softness, four or five applications, at intervals of several hours,
sufficed for  its destruction.   In a second case, a girl,  aged 8, had become
much reduced by the quantity of blood she had lost during several weeks;
and a fungous tumor, about  the  size of an almond, was  easily removed in
the same way.  A  third case  occurred in  an infant  six months old, in
whom efforts  at  stool protruded a tumor the size of  a pea, Avhich bled.
The author belie\dr\g it to be the germ of the  fungous tumor, also treated
it with caustic.
  M. Leclayse  believes that  this affection is  often mistaken for hemorr-
hoids ; and especially when  the  bleedings  are said to  be due  to internal
piles.  The caustic could not be applied very high up, but as the bleeding
has only occurred on the protrusion of the tumor, this has been easily
reached, the application being successful  even when the  base of the tumor
could not be attained.                                 Part xxii., p. 218.
  Irritable Ulcer of the Rectum.—Give chloroform, and divide the fissure
by a longitudinal incision through  the centre of the ulcer, including the
sphincter muscle.  The great source of mischief is now set at rest, and the
ulcer heals ; but the healing process is promoted by applying a plug of lint,
coated with the  following application :  Liq. plumb, diacet., 3j.; confect.
rosas, fj.  This plug, dipped  in SAveet oil, is to be applied to the part.  In
sensitive ulcers of the rectum,  and in painful affections generally, Mr.
Curling uses the following ointment: Chloroformyfi, 3j- to 3ij ; zinci oxydi,
3ss.;  ohvas, 3j ; ceiat. cetacei, 3iv. M. ft. ung.         Part xxiv., p. 215.
  Inflammation  and  Ulceration of the Rectum.—At a meeting of the
Medical Society of London, Mr.  Coulson said, that he saw a patient, aged
thirty-four, ivho passed a semi-solid feculent motion  once  in twenty-four
hours,  tinged with mucus and blood, and in addition to this, wdthin the
same time, four or five evacuations consisting solely of small quantities of
mucus and blood.  On examining the bowel with the speculum, it wras found
that the  mucous membrane was destroyed to the extent  of two inches from
the anus, and pus and blood Avere seen exuding from the ulcerated surface.
Various local and constitutional remedies Avere employed ivith little relief
except a slight diminution of the discharge.  It Avas then suggested that
the decoction of tormentilla should be tried; three ounces of this  root in a 
446
RECTCM.
pint and a half of boiling water  were boiled down to a pint, and four
ounces of the decoction  were thrown up  the  rectum  tAvice  a day, and
retained  each time a quarter of an hour.   Under the use of this  remedy
the pus and mucus gradually diminished, and Avithin  five weeks the ulcera-
tion had completely healed ;  the only medicine taken during this time ivas
a little castor oil, to keep the boAvels loose.  Mr. Coulson believed the
rectum to be occasionally the seat of inflammation, attended wdth muco-
purulent discharge, which, if unchecked, proceeds  to  the destruction of
the mucous membrane of the bowel, and to the formation of abscesses in
the neighborhood of the anus.  A frequent desire to go to stool exists in
these cases; and unless this be yielded to at once, the motions  come aAvay
of their oivn accord, loose, and mixed with blood and mucus ;  at  last  the
patient's health  gives wray, and he  is Avorn  out by continued suffering.
Mr. Coulson showed a preparation  taken from a patient who had died of
this complaint:  the  cellular tissue  round the anus was hardened,  the
mucous membrane of the rectum completely destroyed, and the  internal
surface of this bowel presented elevated hypertrophied muscular fibres,
betAveen which there were several openings eommunicating  wdth  external
abscesses, so that these in fact were the result of the disease of the interior
of the gut-—the diseased action wdthout being continuous Avith that Avithin.
The ulceration of which he had been speaking, was not to be  confounded
with the fissured rectum which often occurs from mechanical causes,  or the
ulcerated rectum  which is  sometimes found in persons laboring  under  a
syphilitic taint.  These conditions of the boAvel were very painful, and the
source of great distress to the sufferer, but they easily yielded to remedies
—as the black oxide of mercury ointment (one drachm  of the  black oxide
to  an  ounce of  lard) or if this failed, to  a division of  the surface  of the
ulcers—and  when left to  themselves did not destroy the  patient.  Mr.
Coulson said it wras most desirable, in  all diseases of the rectum,  to make
an examination of the bowel with the speculum.         Part xxv., p. 213.
   Rectum— Ulceration and Excoriation  of.—Keep the boAvels free by
the management of diet after the  confection of  senna  has  been used.
Touch the small surface of ulceration with the point of a piece of  sulphate
of  copper morning and evening, and after the bowels have been opened,
apply  hot water wdth a sponge for a few minutes,  and then an  ointment
consisting of hyd. c. creta and ceratum cetacei, 3ss to §j.
        ********
   Place the  forefinger of the left hand upon the sore, and with a  probe-
pointed bistoury fairly divide the ulcer longitudinally by passing through
it into  the subjacent tissue.  If the ulcer is extensive, or complicated with
other  diseases,  some addition is  necessary  to  the treatment by  simple
incision according to the complication.   Sir B. Brodie and Mr. Copeland
agree in the above method of treatment.               Part xxvi., p. 187.
   Irritable Rectum.—In a  case  of this  disease, under the  care  of Dr.
Barlow, attended with constipation, in which repeated clysters and large
doses of castor oil had failed in giving any relief, perfect success  followed
the administration of five grains of pil. saponis c.  opio, given three times a
day; with 3ij- cf castor oil on alternate mornings.  The opium did not in
any way interfere with the powers of digestion.        Part xxvi., p. 196.
  Affections of the Rectum caused by certain conditions of the Womb.—
Mr. I.  B. Brown  says: Displacement forward or backward, and  enlarge- 
RESPIRATION.                         447
ment of the uterus, from wdiatever cause, whether pregnancy, hypertrophy,
inflammatory engorgement, distention by fluid or by hydatids, polypi, or
scirrhus, or any other disease, alike tend to injuriously affect the rectum.
  As displacement may occur  without enlargement of the uterus, it may
operate singly in  inducing  rectal disease;  but more often the tAvro con-
ditions concur,  and  it is then  chiefly that the mischief is so considerable.
The evils, too, will be greater Avhen, with retroversion, engorgement  of
the body of the uterus,  and A\dth anteversion, that of its* neck, go together.
On the other hand, enlargement,  without deviation of the  womb forward
or backAvard, may, and  oftener does, act singly in provoking disease of the
rectum, than either of these displacements does without it.
  The conditions  of  the uterus  under consideration act  on the rectum
injuriously in tAvo ivays; first, by mechanical pressure; and,  second, by
inducing vascular disturbance like that present in themselves. An enlarged
uterus drags on its lateral ligaments, elongates them, subsides lower down
in the pelvis, and so  comes to press on the loAver boAvel, to interfere with
its muscular action, and the circulation  through  its blood-vessels, and to
irritate  its mucous lining.   At the same time any hyperaemic state of the
uterine  vessels  causes an increased fullness of the hemorrhoidal,  and a
determination of  blood to  them. Thus, by reflecting on the anatomy of
the parts, it will easily be understood why and hoAv diseases of the rectum,
such  as hemorrhoids, prolapsus,  fissure, stricture,  fistula,  as Avell  as  dis-
ordered functions  of  the bowel, as constipation, dysenteric irritation, etc.,
do  sometimes result  directly, either  from the mechanical pressure of an
enlarged uterus, or simply from the derangement  of the  hemorrhoidal cir-
culation, resulting from uterine disease.               Part xxx., p. 217.

   Ulcerated Cancer  of the Rectum.—For the relief of the  dreadful pain
caused by defecation  in this disease,  and Avhich alone is a  principal cause
of the great exhaustion, Prof. Erichsen recommends Amussat's operation.
You relieve the pain, and remove the cause which would stimulate  the
disease to make more rapid and extensive ravages than it otherwise  would.
                                                   Part xxxv., p. 106.
  Rectum, Hemorrhage from.—After  operations on the rectum, instead
of using lint to restrain the  hemorrhage, Mr. Salmon would introduce into
the return a.large  plug  of the finest jeAveller's wool, and  press it  gently
into  the  whole length of the wound.  The w^ool must on no account be
oiled, as it is by its loose absorbing texture, that it is so valuable.  Styptics
are never necessary, continued pressure is almost invariably found efficient.
                                                   Part xxxv., p. .114.
                      RESPIRATION.
  Respiration.—The ingestion of fats and pure starch decrease respiration;
sugar largely increases respiration;  albumen, gelatin, milk, and all ordi-
nary nitrogenous diet,  increase it  to  a moderate  degree only.  Whilst
brandy, Avine, and kirchemvasser greatly decrease respiration, rum largely
increases it.  Ether, tea, and.  sugar are the most powerful respiratory
excitants: ammonia, opium, morphia, tartarized antimony, kirchenwasser,
and sleep, are the most powerful depressants.         Part xxxv., p. 309. 
44:8                         RHEUMATISM.
  Artificial Respiration—May be carried on by alternately squeezing the
chest with the hands, so as to induce a forced condition of expiration, and
removing the hands, when the elasticity of the  parietes will restore them
to a medium state and cause the entrance of air.  Mr. Humphry has more
than once saved life by resorting to this simple  process.
                                                    Part xxxix., p. 95.
  Artificial Respiration.  Vide Art " Drowning."

                              ----Mi

                      RHEUMATISM.
  Abstracts from the best writings on  Rheumatism— Colchicum.—Mr.
L. Wigan, of Brighton, confidently asserts the following mode of using this
remedy to be heroic, in proportion as the case is violent and recent.  Eight
grains of the  poAvdered colchicum root (preserved by being kept ground
to an impalpable powder Avith twice or thrice its  weight of Avhite sugar),
are given every hour, in  wTater,  or ginger, or apple  tea, until  vomiting,
purging, or profuse perspiration take place, or at least till the stomach can
bear no more.   If nausea is felt after three or four doses, he stops a quarter
of an  hour, and gives brandy on sugar or soda wrater, when the medicine
is again continued.   The  usual quantity supported is eight or ten  doses;
the maximum fourteen;  the minimum  five.  After six or seven doses a
slight nausea comes on ; but  by keeping  quiet, with something  in the
mouth, three  or four doses might  be  received, when perhaps the disgust
becomes  unconquerable.  After  this there  is generally sound sleep, wdth
occasional nausea on waking.   The pain  ceases, but the more active effects
of colchicum do not take place for some hours after the last dose, and after
a few hours more is succeeded by " Elysium."  The  inflammation  of the
 joints subsides, and they resume their size wdth miraculous rapidity.  The
acidity of the perspiration ceases as well as the peculiar odor.  As soon as
a cup of souchong tea can  be obtained, a sound sleep  comes on, from
which the  patient  awakes perfectly well.  When enabled to do so, Mr.
W. prefers giving a breakfast of bread and butter and tea only, very early
in the morning, and two hours afterward to commence the colchicum.
Nothing more but  tea,  and bread sopped in it during that day.  It is Avell
to indulge the returning appetite very sparingly on the day folloAving, on
which we may allow a small snap of devilled  meat and rice, w ith  a little
curry, if  desired.   Afterward  the  patient may resume his ordinary diet
as soon  as  his  appetite indicates it.   Mr. W. has never known a relapse,
and strongly urges the  practice.  We confess to have some doubts of the
safety of this plan, unless in robust subjects and in a very acute form of
the disease.
   Emetics, Purgatives, Peruvian  Bark, etc.—Dr. Davis says that the
duration of the disease, under the  folloAvtiig plan does not exceed a Aveek
in the majority of cases : Bleeding  from the arm to faintness,  succeeded
by an  emetic of ipecacuanha and tartar emetic, and in five or six hours by
a  purge  of calomel  and  jalap;  after this he  gives  a scruple  to  half  a
drachm of  poAvdered yellow  bark, every  three  or  four hours.  This is
similar to Haygarth's plan, and has the sanction of very varied experience.
   Bleeding, Calomel, Opium, etc.—The late,  and  much-to-be-lamented
Dr. Hope, after six years' experience upon 200  cases, gives decided pre- 
RHEUMATISM.
449
 ference to the following plan :  After one, or even tAVo full bleedings in the
 robust, he gave seven to ten grains of calomel, with one or two of opium,
 at night, a draught with fifteen to  twenty minims of colchicum wine, and
 five grains of Dover's powder in saline mixture, three times a day. It was
 seldom necessary to  repeat the calomel more than from tAvo to four times,
 after which he continued the opium at  night, with the colchicum draught
 and a  senna  laxative every morning.   The  patient was  almost ahvays
 well in a week, and able to commence his work in seven to ten days after
 pains had ceased.   Ptyalism was avoided unless  the heart was involved.
 In chronic cases he  gave  five grains  of calomel, and one of  opium, at
 night,  for five or six  times, with the senna and colchicum draught as be-
 fore.   Local  depletion  with some form of counter-irritation were usually
 employed.
   Tart. Emetic,  Nitre, Colchicum, etc.—In  the acute  stage Dr. Graves
 principally relies on bleeding, wdth large doses of tartar emetic and nitre,
 and in less urgent cases, particularly if complicated with bronchitis, he has
 derived much benefit from the following mixture:
  R Almond  emulsion, eight ounces ; vinegar of colchicum, half an ounce;
 acetate of morphia, one grain; nitrate  of potash, half a drachm.   Mix.
 Half an ounce every  hour or every two hours.
  If colchicum does  not relieve in  two  or three days we must have re-
 course to mercury.
  Peroxide of Mercury, Opium.—Dr. Pitschaft has for twenty years em-
 ployed mercury, preferring the red  precipitate, in doses of one-eighth to
 one quarter of a grain twice a day,  combined Avith opium if the system be
 irritable.
  Bleeding and Dover's Powder.—Dr. Christison, after premising bleed-
 ing, thinks that keeping up perspiration by frequent doses  of Dover's
 powder for  36  to 48 hours is an admirable  plan.   Purging must be
 avoided till the sweating is over, nor is the plan  so successful if  com-
 menced later  than the fourth day.
  Bleeding, Purging, Guaiacum, etc.—Dr. Macleod advises bleeding from
twelve to thirty  ounces during  the first week, giving  three to five grains
of calomel at night,  and a senna purge in the morning.   Opium to the
extent  of tAvo grains  in the  twentydbur hours is  often  useful, andldie
guaiacum  is recommended as the best  after-treatment.  In lumbago, Dr.
M. thinks well of a brisk calomel purge once or twice a  week as above,
and considers  half a drachm to tAvo drachms of the compound tincture
of guaiacum three times a day, with a  grain of opium  at  night, the best
plan.
  Tinct. Guaiacum,  etc., in Lumbago.—Dr. Marryatt's principal remedy
against lumbago was  half an ounce of the compound tincture given at bed-
time, with other means adapted to promote diaphoresis.
  Diet—Hydriod. Potass—Liq. Potas.—Mr. Henry Rees says, " In all
cases of acute rheumatism, the diet should be strictly regulated ; avoid
rigidly, beer, Avine, spirits, and animal food.   Milk, beef-tea, butter, eggs,
fish, etc., are all pernicious.   His theory is that the disease depends on an
excess  of nitrogen.
  In very urgent cases bleeding and mercury may be necessary, but he
regards the hydriodate of potass as certain an antidote to the rheumatic
diathesis as mercury  is to that of syphilis.   Its combination with liquor
potassas acts,  he says, like a charm in rheumatic iritis.
    vou n.—29 
450
RHEUMATISM.
   Colchicum Mag. Sulph. Decoct. Bark, Soda.—Dr. Hughes never found
it necessary to  bleed.   He gave a pill of opium and antimony at night,
repeating it two or three times daily, if the pain was urgent.  Calomel
Avas only used Avhen  the inflammatory symptoms Avere severe.  Half a
drachm of the  colchicum wine, wdth a drachm  of the  sulphate of mag
nesia, ivas  given  three or four times a day, producing, after two or three
days, copious liquid, yellow evacuations, with evident relief, when he im-
mediately ordered decoction of bark with soda.  In a feAv days the patient
was Avell.
  Emetics of Tart. Antimony.—In the report of the Worcester Infirmary
it is stated " that emetics of tartarized antimony, administered at the com-
mencement, haire cut  short the disease in acute cases."
  Mixture of Nitre—Lotion Iod. Potassium.—Mr.  Home speaks veiy
favorably of the following mixture :
  R Nitrate of potash, half an ounce; potassio-tartrate of antimony, two
grains; spirits of" nitric ether, one ounce;  water  twelve ounces.  Mix.  A
wimsglassful three times a day.
  He also  strongly recommends the external use of  a strong solution of
the hydriodate of potass when the joints are implicated—a hint Avorthy
of trial.  The same lotion he has found serviceable in neuralgic pains.
  Nitrate of Potash.—Dr. Brocklesby, in 1764, first directed attention to
the value of nitre in  large doses, giving  as much as ten drachms in the
day and  night.   Mr. W. White, in 1774, confirmed its value, carrying the
maximum dose to twelve drachms.   In 1833, the same practice has been
revived by Messrs. Gendrin and  Solon.   Sixteen cases are recorded, of
which the average period of treatment was eight days.   The mean quan-
tity of the salt given in one day was one ounce in three quarts of Avater;
the total average quantity, eleven  ounces.  They advise commencing
Avith two drachms and a half in a quart of fluid.
  TAvelve  successful  cases are  recorded  by M. Arran, where  the mean
dose Avas thirty-six grains in three pints of  fluid,  and the average total
quantity 374 grains.  The mean duration was eight days.
  We suspect the above doses to  be excessive, and believe M. Arran's
practice  the most reasonable and prudent.  Such evidence is illustrative
of the differences prevalent  among  practical  men  as  to the necessary
doses of medicine. There are  enthusiastic  givers as well as takers of
physic.
  Opium,  Quinine,  Warm  Embrocations.—Dr.  Corrigan,  hi a  very
interesting paper in the " Dublin Journal," asserts that the treatment of
rheumatism by large doses of opium shortens the  duration, diminishes
suffering, husbands strength and lessens  the tendency  to complications.
It is important that full and sufficient doses are employed, increasing them
in amount  and frequency, until  the patient feels decided  relief, and then
continuing the  same dose until the disease  has steadily declined.   The
mean quantity given in twenty-four  hours was from ten to twTelve grains,
but it often amounted to more  than double.  It does not affect the cere-
bral function, and, as  we have  more  than once observed, in some  cases
excites diarrhoea.   The average duration of treatment was nine days.  The
plan is not adapted to gouty subjects.  Warm embrocations, Avith turpen-
tine, or  camphorated spirits, were employed.   Against the  consequent
stiffness  he advises frictions, Avith half an ounce of  camphorated oil and
turpentine, and a  drachm of sulphur.  In cases Avith  sweating, erratic 
RHEUMATISM.
451
pains, and  quick  small  pulse, the combination of quinine and opium is
admirable.   Other practitioners have confirmed Dr. C.'s experience ; and
his suggestions, though not absolutely novel,  possess  great  practical in-
terest.
  Aconite. —Dr. Basse,  of Berlin, in a monograph upon the subject, advo-
cates the value of Richter's  treatment both of acute and chronic rheuma-
tism.  He gives from fifteen to sixty drops every two hours, of the follow-
ing solution:
  R Extract of aconite, four scruples; antimonial wine, three ounces two
drachms.  Mix.
  It excites diaphoresis without distress, and relieves pain.  The evidence
in its favor is very strong.
   Dr. J. B. Watkins  of Philadelphia also speaks in favor of extract of
aconite.  It may be given in doses of one-fourth of a grain three times a
day, to six grains, or even more, daily.
   Mr. Curtis recommends an aconite plaster, made by evaporating four
ounces of the tincture to the consistence of oil; this  quantity to be spread
with a brush on half a yard  of adhesive plaster.
   Belladonna.—Dr. Osborne ("Dublin Journal," June 1, 1840), remarks
that belladonna  causes  an immediate  cessation of  the migratory  pains,
without benefiting those wdiich are fixed.  The dose  is one-third of a grain
three  times a day, increased to  one-half  every three hours.   Its effects
seem limited to muscular pains.
   Pills of Guaiacum, Camphor etc.—Dr. Hassack " Practice of Physic,"
(p. (572)  considers  the following pill a good diaphoretic stimulant in chro-
nic cases:
   Guaiacum, six drachms; camphor, one  drachm;  opium, two drachms;
potassio-tartrate of antimony, one drachm. Mix. To be divided into  120
pills, two three times a day.
   Alkalies, Laxatives.—Cases occur, says Dr. Watson, Avhich are not ab-
solutely acute or chronic.  There is some fever, the joints are  affected, the
skin dry, thirst, the urine loaded w ith lithic deposits,  and strongly acid.
In this state alkalies are of great use.  A drachm  of the liquor  potassae
daily for several days  together, keeping the bowels free, has done more
than any other treatment.
  Rheumatic Headache—Treatment.—Against  rheumatic headache  Dr.
Johnson  has  found no  treatment so  successful as the  following:   Eight
grains  of Dover's powder and  twro of calomel at bed-time  on alternate
nights for two or three times, followed by a third part of the following
mixture the next morning, to be repeated in two hours, if necessary:
  Infusion  of rhubarb,  three  ounces ; tartrate of soda, three  drachms;
powder of rhubarb, half a drachm; tincture of senna, half an ounce; wine
of colchicum, a drachm and a half. Mix.
  The same observer remarks that many of the most stubborn cases will
yield to a course of blue or Plummer's pill,  taken at bed-time, and followed
by a Avarm saline colchicum  draught in the morning.   Flannel  clothing,
and an occasional warm bath, are valuable  adjuvants. *
  Muscular Atony—Ammonia.—Dr. Paris asserts that against the mus-
cular atony succeeding to acute disease, ammonia in large doses is the best
reiivdy.
   Treatment of an Obstinate Case.—In a very obstinate case, characterized
by severe pains, relieved by heat, and unaccompanied by much SAvelling, oo» 
452
RHEUMATISM.
curring in the practice of Mr. John Brady, of London, the following means
proved very successful:
  Compound extract of sarsaparilla, six drachms ; iodine, half a grain; hy-
driodate  of potash, half a  drachm ;  boiling water, six ounces.  Mix.   A
fourth part three times a day, wdth one of the subjoined pills.
  Hydrochlorate  of morphia, one  grain; ..disulphate  of  quinine, nine
grains; blue pill, ten grains; rhubarb pill, tAvelve grains.  Divide into
twelve pills.
  Quinine.—M. Briquet has recently addressed a letter  to  the Academy
of Medicine of Paris, stating that large doses of quinine ivere as successful
in rheumatism as in ague.   All will not coincide Avith M. B., and some late
experience has proved that an excessive use of this agent is not Avithout
inconvenience and danger.
  Sulphur.—We shall now adduce  some  evidence in  favor  of  sulphur,
which entitles it to the practitioner's serious attention.  It is  an  old but
very  partially employed remedy, and has now almost descended from the
profession to the people.
  Dr. Munk states that he employed it successfully in 300 cases.  It seemed
more effective ivhen combined with the carbonate of soda, in the proportion
of two drachms to an ounce of sulphur.  Half  an ounce of the latter war
the maximum quantity in twenty-four hours.
  The celebrated nostrum, well known as the " Chelsea pensioner," owes
its efficacy to sulphur.
  Dr. Law states that in subacute rheumatism  there is  no one means  he
he has found so generally useful.
   R  Sulphur, one ounce ; bitartrate of potash, half an  ounce;  powder
of rhubarb, two drachms;  powrder of guaiacum, one drachm; poAvder of
musk, one drachm; honey, four ounces.   Mix. A dessertspoonful three
times a day.
   If it  purge too much, a drachm of Dover's powder to be added.  Dr.
 Graves also praises it, and substitutes the followdng electuary :
   R  Powdered bark, one drachm;  poivdered guaiacum, one  drachm;
 cream of tartar,  one  ounce; flour of sulphur, half an ounce; poAvdered
 ginger,  one drachm.  To  be made  into an electuary with sirup. A tea-
 spoonful three times a day.
   If it purge too much, we diminish the  dose; if constipation exists, we
 increase it.  A teaspoonful of sulphur, with half the quantity of ginger,
 taken eA ery morning in a glass of milk, has proved very useful.  We knoiv
 a lady liable to severe rheumatic pains in the scalp, who considers she  can
 at any time cure them by a dose of sulphur at bed-time.
   Professor Otto, of Copenhagen, treated four cases, three of wdiich were
 chronic, with four drops every two hours of tincture made of tAvo drachms
 of the carburet of sulphur in half an ounce of  rectified spirits.  The same
 quantity, rubbed up AAdth half an ounce of olive  oil, wras employed as an
 external embrocation.
   External Applications*—In chronic, obstinate affections of the joints,
 rubbing  them witfh castor oil  every night, and  wrapping  the  limbs in
 warm flannels, is extensively employed in  the East, and is said to be very
 successful.
   The external application  of colchicum has been strongly recommended,
 and Ave have ourselves found it useful in cases where the sensibility ivas great,
 the pains diffused and recurrent, and the temperature of the part raised. 
RHEUMATISM.                         453
  Painting the surface Avith tincture of iodine has been found useful. Equal
parts of the compound camphor and soap liniments, with  laudanum, is  a
good form of embrocation ; and in case of severe focal suffering, the fol-
loAving ointment has succeeded in allaying pain.
  R Veratria, half a drachm;  opium, one drachm; lard, one ounce and a
half.   Mix.
  The endermic application of morphine is also worth remembering.
                                                     Part viii., p. 24.

  Rheumatic FeVer,  General Treatment of.—Dr. R.  B. Todd,  in his
article  on the " Dietetic and  Medicinal Treatment of Gout and  Rheuma-
tism,"  proceeds to say :
  Those  channels Avhich are obviously the most  favorable for the elimina-
tion  of the  rheumatic matter, are the skin, the bowels, and the kidneys;
hence the use of sudorifics, purgatives, and diuretics is indicated.  Of su-
dorifics, Dover's poAvder is among the best, and is sanctioned  by  the expe-
rience  of many years; pure opium answers the double end of promoting
diaphoresis Avhile it procures rest and relieves pain ; or the nitrate of potash
may be given either in combination Avith opium and ipecacuanha (a nearer
approach to the original formula for Dover's poAvder), or in solution along
Avith minute doses of tartarized antimony.  I am not in the habit of exceed-
ing five or six grains of the nitrate of potass Avith one-eighth  of a grain of
the tartar emetic (to which, if there be nausea, a few drops of tincture of
opium may be added)j every four or six  hours.  The  practice  of giving
very large doses of nitre, tried formerly in this country, and lately revived
in France, does not appear to have any decided influence  upon  the mean
duration  of the disease.   The administration  of opium,  however, is of
great importance: it must be given in large doses, and is borne well by the
patient.   A good opiate should ahvays be administered at night,  and Avhen
ihere is much suffering, two or three doses should be given throughout the
day.   The irritative character of rheumatic fever is strongly in favor of
this medicine.
   The purgatives which seem most applicable are those Avhich produce co-
pious watery evacuations.  The  combination of  sulphate and  carbonate of
magnesia ansAvers very well, the addition  of the alkaline  earth serving  to
neutralize some of the free acid which is so abundantly secreted.  Colchi-
cum is useful as a purgative, and if employed in large doses, exerts a pow-
erful action  on  the intestinal canal, but the employment of it  is not de\Toid
of serious objection. The tartate of potass is also a useful purgative.  The
best mode  of  promoting diuresis in this disease is to allow the  patient  to
use simple diluents freely; to these no other  limits need be put than those
Avhich his own  sensations will dictate.  Any more direct stimulants to the
kidneys Avould probably excite those organs too much.  The saline effer-
vescing draughts are agreeable and cooling, and have the additional recom-
mendation of serving for the neutralization of the free acid, in its passage
through the kidneys.
   The objection Avhich has been  urged  against local applications to the
affected joint during a paroxysm of gout, does not apply to rheumatic fever.
In the latter disease the morbid  element is escaping at many  places, in the
former at a  single joint;  if we disturb its attraction to this one joint  in
 gout, it may fly to a new one, or to some internal viscus.   These risks, are
obviously Avanting in rheumatic fever, as the disease is more generalized in 
454
RHEUMATISM.
its  effects.  And experience teaches us that the greatest relief may be
obtained by local bleeding in this malady.
  As, however, local bleeding does not prevent a joint from being revisited
by the rheumatic irritation, the employment of it in ordinary cases, and as a
general practice, is  not to be recommended.   You may apply leeches to-
day to  a joint,  to-morrow it will be free from pain, and  the next day it
may be swollen and  painful again.  If the pain and SAvelling, both or either,
be great, and such as  to excite apprehension  for  the  ultimate integrity of
the textures, then  the application of leeches will be really useful, and
should not be deferred.
  When the  articular affection  is disposed to be chronic, and the rheu-
matic matter appears to  finger about a joint, local  bleeding  may be of
essential service.  Its timely use, in such instances, may save the patient
from  a  tedious  convalescence, if not from a chronic rheumatism.   Local
bleeding, in the earlier stages  of the rheumatic paroxysm, has the addi-
tional advantage of  contributing to relieve the general fever in a manner
not likely to injure the constitution.   Warm fomentations or poultices often
give considerable relief, and if agreeable to the patients, they may be used
with safety.  It has  been proposed to  foment the  joints with a solution
of  an  alkaline salt, as of  soda  or potass.  I have seen this practice tried,
but did not perceive any superiority of the  alkaline fomentation  over that
of plain water.
  I am strongly inclined to believe that counter-irritation by blisters to the
affected joints will be found a very useful practice in the severer cases of
rheumatic fever, even in the acute stages.   It wdll generally, however, be
advisable to precede  the application of blisters by that of leeches.
                                                        Part ix., p. 46.

  Rheumatic Diathesis.—In his article on the " Dietetic and Medicinal
Treatment of Gout and  Rheumatism," Dr. R.  B.  Todd  remarks as fol-
lows :
  In  the  Rheumatic Diathesis, if  the joints  suffer much, they may be
best treated by local  stimulation, or counter-irritation.   A strongly stimu-
lating terebinthinate  liniment  is often beneficial; but, on the Avhole, no-
thing is so  useful in chronic rheumatic states of the joints as blisters applied
in rapid succession.  In some  instances where there have been much pain
and swelling, the application of a few leeches will almost alwrays do good.
I learn from Mr. Busk, wdio  has had great experience in the treatment of
those painful articular affections  connected Avith gonorrhoea (gonorrhoeal
rheumatism), that blisters are an invaluable remedy in them, even from the
first, and this accords with my own more limited experience.  Doubtless in
the case of rheumatic joints, blisters  act in a similar Avay, by attracting the
morbid element from  the  articular textures.  I have lately employed
pretty extensively,  and with  unquestionable  benefit,  the local  application
of  iodine  to the affected joints, for which purpose we may employ either
the tincture of iodine, or a stronger  compound, wdiich  is used at  the
King's  College  Hospital,  and is called iodine paint, the  formula  of which
is as follows:
  R Iodinii, gr.  lxiv;  potassii iodidi, gr.  xxx ; alcohol, 3j.   M
  The mode of application is by painting the part freely Avith a camel-hair
pencil.  More  or less  smarting is produced, and frequently vesication, or
a herpetic eruption  may come  on.   The  painting may be repeated as 
RHEUMATISM.                         455
often as circumstances may demand.  It is extremely useful where any effu
fdon has taken place into synovial membranes or sheaths.  Part ix., p. 45.
   Chronic—Anodyne  Pomade.—Take  of  Galen's  cerate,  31 parts;
extract of belladonna,  8; acetate  of  morphia  (previously  dissolved), 3.
Mix well together.
  This  pomade  is exceedingly useful in  cases of muscular pains, chronic
rheumatism, etc., Avhen  rubbed on the affected parts.     Part ix., p. 192.
   Quinine in Articular  Rheumatism.—In France, M Briquet, M. Guerard,
and Professor Fouquier,  have employed sulphate of quinine for the treatment
of acute articular rheumatism, with the most  satisfactory results, the dose
varying from 9j. to 3j- daily.  Sulphate of quinine can be deprived  of its
bitterness by being taken in coffee.                     Part xvi, p.  67.
   Oil of Turpentine Externally in Rheumatism.—When the  essence of
turpentine is poured over a surface, its volatilization is not attended with
any pain, or with the production of heat; but,-when a compress imbued
with the oil is applied to the skin and covered with waterproof cloth, the
result is far different; violent  pain folloAvs in a  quarter of an  hour, and
doubtless, if the application was prolonged, vesication might ensue.   It is
this revulsive action  of the essence of  turpentine, that M. Hervieux has
endeavored to  produce, and wdiich he has found extremely useful for the
purpose of dispelling rheumatic pain.   In cases of paralysis due to disease
of the spinal cord, muscular Aveakness and pain Avere also relieved.
                                                      Part  xvi., p. 68.
   Phosphate of Ammonia.—After subduing the more inflammatory symp-
toms by antiphlogistic treatment, Dr. EdAvards  gives ten grains of  phos^
phate  of ammonia every eight  hours.  This medicine acts beneficially by
decomposing the uric acid  or  urate of soda, which is formed in excess in
gout and rheumatism.   Instead of urate of soda, a very insoluble, Ave have
thus formed phosphate of soda, a most soluble salt.       Part xvii., p. 26.
  Rheumatism—Acute.—The treatment of rheumatic fever is a subject
upon Avhich much  difference of opinion exists among practitioners.  Dr.
Todd insists very strongly upon the importance of curing the disease with
as little impairment of the power of the constitution as possible; and  re-
marks that Avhile we should, aim at securing for the  patient a short conva-
lescence, Ave must  guard equally against the danger of relapse, which the
so-called speedy cures by the heroic treatment are too apt to leave behind.
  The indications are  to relieve pain, to promote the action  of the  skin,
kidneys and bowels, to use antacids, and to give large quantities of diluent
fluids.   For these purposes give a grain of opium, a grain of ipecacuanha,
and five grains of nitre, every two, three, or  four  hours; and  a mixture
with sulphate and carbonate of magnesia.  Envelop the joints  in a large
quantity of cotton wool,  and cover with oiled silk ;  changing it  every
tAvelve or tAventy-four hours.  Give plenty of simple diluents, and from the
first, let the patient have a little good beef tea frequently through the day.
And Avhen the patient begins to pass pale urine, Avith or without pale lith-
ates, he will he the better for generous  diet, Avith Avine, ammonia, or qui-
nine, even though the articular affection persists.   Too much sweating,
too much purging, or too much opium,  are  equally unadvisable. If the
patient cannot bear opium, extract of hyoscyamus, hop or lettuce may be
substituted.  If the state of the joints does not yield to the application of 
456
RHEUMATISM.
cotton wool, apply a small sinapism for half an  hour to redden the skin,
then ivash and dry the skin, and apply a blister the size of a croAvn-piece ;
the blistered surface maybe allowed to heal, or may be dressed with stimu-
lating ointment; or a succession of small blisters may be used. Watch the
state of the heart from the first;  and on the first indication of pericardial
or endocardial  affection, apply a large sinapism over  the  region  of the
heart, and Avhen it comes off, a large blister ; but do not  bleed either locally
or generally.  Give calomel and opium to affect the gums ; and, if needed,
rub in mercurial ointment, or use it to dress the blistered surface.   When
delirium, resembling delirium-tremens, occurs as a  complication of rheu-
matic cardiac affections,  it is " a signal of distress," and must be responded
to by an immediate alteration in the treatment.   All too free evacuations,
whether from the skin or boAvels, must be checked ; nourishment must be
given frequently in small quantities; and even wine,  brandy, or porter,
may be administered.   If the patient is wakeful, give  opinm.  And  take
care that all exertion is avoided, lest fatal syncope be  induced.  If, howr-
ever, there is coma, do not give opium, but apply sinapisms or blisters.
                                                     Part xviii., p. 36.

  Anemia as a consequence of Rheumatism.—Dr. O'Ferrall, of  St. Vin-
cent's Hospital, believes an anaemic condition may supervehe in the course
of acute rheumatism, resulting, apparently, rather from the natural course
of the disease than from the remedies employed.  Chalybeates  should be
given in this condition.                                 Part xx.,p. 34.

   Acute Rheumatism.—Dr. Watson says that " the younger the patient
is who suffers from acute rheumatism, the more likely will he be to suffer
from rheumatic carditis."
   This patient'had the various symptoms of rheumatic fever.  The heart's
action, being examined, wras found natural, with the exception of a slight
systolic murmur heard over the interval between the fourth and fifth ribs,
about an inch below the nipple.
   The patient ivas ordered six drachms of lemon-juice, to be taken in sugar-
water, three  times daily.   He Avas, however, in a couple of days much
worse ;  the pains were very acute, and the joints along the arms and hands
became involved; the pulse  rose to  120, full; the systolic murmur was
more distinct;  the perspiration profuse, very acid, and the urine  high-col-
ored.  Dr. Barlow, after giving a purgative draught, with  Avine of col-
chicum, prescribed a pill, composed of a quarter of a grain of tartar-emetic,
half a grain of opium, and one grain  of calomel, to be  taken  every fourth
hour.  These measures  contributed to lessen the pains,  and the patient wTas
desired  to take the pills only three times a day, with the following draught:
—half a drachm of acetate of potash, and ten grains of nitre, in camphor mix-
ture. The improvement was very great on the next day; the pills were
discontinued, but the mixture persevered in.  The favorable impression
produced by the salts of potash  increased during  the next few days; all
the symptoms gradually gave way, and  ten days  after the draughts had
been first taken, and regularly continued, the  patient was convalescent.
He took, before being finally discharged, small doses of iodide of potassium
and carbonate  of potash, and left the hospital quite well about three weeks
after admission.                                       Part xxii., p. 38.

    Treatment of Acute  Rheumatism by Local  Anesthetics.—The applica- 
                            RHEUMATISM.                         457

tion, locally, of the Dutch liquid to the joints in this disease is highly re-
commended.   A moist compress sprinkled Avith the agent, is applied and
renewed once in tAventy-four hours, being inclosed in impervious bandages
so as to prevent its  evaporation.  It is to be applied to  each joint in  suc-
cession as it becomes inflamed.   The complications of rheumatism may be
treated on general principles at  the same time.          Part xxiii., p. 54.
  Rheumatism—-Lemon-juice.—Dr.  Babington  had  generally  ordered
three ounces of lemon juice to be taken three times a day, but  he has re-
cently ordered as much as six ounces.  He states that there is no remedy
with which he is acquainted to be compared in value to  lemon-juice in the
treatment of rheumatism.  In gout and chronic rheumatism its effects are
far less obvious and uniform.  He believes it will be found a valuable agent
in inflammatory diseases generally.                     Part xxv., p. 32.
  Acute Rheumatism—Colchicum.—In all cases where  albumen and urea
are vicarious, and where coma supervenes, evidently from the accumulation
of the latter principle in the blood., colchicum will prove of great value.
                                                      Part xxv., p. 38.
  Articular Rheumatism.—In  proportion as this disease approaches in its
characters to gout we may expect to be successful wdth colchicum.   Give
twenty minims of the tincture of Avine every six hour3 until some relief is
obtained, or a grain of the inspissated  juice or of the acetic extract of col-
chium every four hours.                               Part xxv., p. 41.
   Collodion.—In  gout and  articular  rheumatism  cover the part wdth a
layer of collodion, so as to preserve it from the atmosphere.
                                                     Part xxv., p. 325.
   Pathology  of Rheumatism and Gout.—The present theory Avith regard
to  these affections is, that they are  both connected wdth an increase of
lithic acid in the blood.  In rheumatism, this is dependent on excess of the
secondary, and in gout on excess  of the primary, digestion.   In rheuma-
tism, hoAvever, there  is  considerable excretion of lactic acid  by the
skin (Todd), wdiilst in gout there is an excess of soda, Avhich, uniting Avith
the lithic acid, produces a compound of lithate of soda, that  may be de-
tected as such in the blood (Garrod),  Avhile sometimes  it exudes into the
cellular  tissue of the skin,  constituting  tophaceous deposits.  In  both
diseases  there is an undue balance between the excess of lithic acid and
the poAver of  excretion—in rheumatism by the skin, and in gout by the
kidney.  This pathology serves to  explain the similitudes and differences
existing betAveen the tAvo affections.   In both there is  a certain constitu-
tional  state,  dependent on  deranged digestion,  during which  exciting
causes occasion local effects.  These exciting causes in rheumatism are bad
diet, hard work, exposure to cold  and wet, and its subjects generally are
the poor and laboring population.  In gout the  causes are good diet,
indolence, repletion, or indigestion, and its subjects are for the most  part
the rich  and sedentary.  The local manifestations in  both are acute wan-
dering pains, Avith pain and swelling—in rheumatism  of the large, and  in
gout of the small joints, constituting the acute attack in the one, and the
so-called regular attack in the other.   These are combined Avith a tendency
to various complications of the internal viscera, wdiich  are more or less
dangerous to life.
   The general indications of  treatment are, in both  diseases—1st. So  to 
458
RHEUMATISM.
regulate the nutritive functions as to  insure  a due balance between tb»
amount of matters entering the blood as the result of digestion, primary or
secondary, and the amount of matters discharged from the economy by the
excretory organs.   2d. To conduct the acute  attack to a favorable ter-
mination, carefully watching the internal viscera and being prepared to act
Avith vigor should  these become affected.   Hence  the  treatment of these
diseases resolves itself into Avhat  may be  called curative  and preventive
■—the first having  reference to the acute attack, the second to the means
most likely to hinder its return ; the one must be carried out by remedies
which act upon the blood and execretory organs, the other by the man-
agement of diet and exercise.                         Part xxvii., p. 45,
   Treatment by Ash-leaves and  Guac ->.—Give an infusion of ash-leaves
(Fraxinus excelsior).  It possesses the advantages without the inconve-
niences of colchicum.  Generally, under its use, at the end of four or five
days, or sometimes sooner, the pain, redness, and savciting visibly diminish
in intensity, or even disappear.  Each dose of the powdered leaves ought
to be infused for three hours in boiling water, and before taken should be
strained through  a linen cloth, and sweetened to  taste.   Dr. Otterbourg
says that 32  grammes, infused in a  sufficient quantity of water, may be
taken several times during the day.  There is no need to change the mode
of living.
   As a tonic, guaco (Mikania guaco) is  a  most valuable drug  after the
fever has passed off; its effects  were magical, ivhere quinine produced
restlessness, thirst and headache.                     Part xxvii., p. 249.
   Rheumatism.—One of the exceptional cases in wdiich lemon-juice is of
no avail, is that  of a gonorrhoeal character. A  Avoman, 'aged 30, was
admitted into Guy's hospital with rheumatism and a copious yelloiv dis-
charge from the vagina.   All ordinary remedies  failed  to relieve,  until
the purulent discharge had been removed  by 3j. doses of cubebs.
                                                    Part xxviii.,jp. 34.
   Treatment of Acute Rheumatism by Acetate of Potash.—Dr. Golding
Bird seems to depend on this remedy more than any other in the treat-
ment of acute rheumatism.  But, after all, it appears that the efficacy of
lemon-juice itself depends not so much on the acid as upon the supercitrate
of soda which dt contains.  It seems that all these kinds of satis are useful
when they act poAverfully on the  kidney, and eliminate poisonous matter
from the system.   Thus citrate of potash, citrate of ammonia, acetate of
ammonia, nitrate of potash, as well as the acetate of potash, all act  very
beneficially in  rheumatism.
  Dr. Bird gives  half an ounce, largely diluted, in divided doses every
twenty four hours.                                   Part xxix., p. 43.
   Chronic Periosteal.—Dr. Basham has observed that in cases of chronic
periosteal rheumatism, wdiere the patient  has been benefited by iodide of
potassium, at some antecedent period he  has been salivated by mercury;
whereas if no  salivation has  previously occurred, he has found the iodide
of potassium  of little or no effect.  This disease may depend upon the
impregnation of the system by mercury, or from the syphilitic virus. If
the former, iodide  of potassium is  the remedy; if the  latter, alterative
doses of  some mild preparation of mercury.             Part xxix., p. 45.
  Occurrence of Delirium  Acute Rheumatism.—When  delirium occurs 
RHEUMA1 ISM.
459
in acute rheumatism, says Dr. Durrant, it is of grave import.  Examine
the heart carefully—there is very likely to be pericarditis upon which the
delirium depends.  Bleed generally or locahy according to circumstances,
give calomel and opium, with salines and colchicum.  Blister the cardiac
region well, both in front and back.  At the same time support the patient
with broth, and even wine  if necessary;  ahvays remembering that many
of these apparently inflammatory diseases are asthenic and not sthenic.
                                                     Part xxx., p. 222.

  Alkaline Treatment.—During the attendance of Dr. SwTett, at the New
York Hospital, all the  patients admitted with acute articular rheumatism,
were put under the " alkaline treatment."
  The salt  chosen was the  tartrate of soda and potassa, a  neutral salt,
possessing  the property of rendering the urine alkaline.
   " The plan of treatment  usually pursued Avas, if the patient presented
himself with  unusual  excitement of  the  skin and pulse, to administer a
mixture of sulphate of magnesia  and tartarized antimony, until  the skin
was relaxed, and the  pulse  reduced  to a  more natural  standard.  The
Rochelle salt was then  directed, in drachm doses, every two or three hours
during the day-time,  till the  urine  wras rendered  alkaline, Avhen it was
gradually suspended.   A lotion of carb. potassa §j. Avith opium 3h\, to the
pint of water, Avas  directed as an external  application.  The administra-
tion of the salt was not attended  Avith disagreeable consequences,  Avith the
exception occasionally of some ulceration about the fauces; in no  case Avas
its action so severe upon the bowels as to require  its entire suspension.
The persons attacked were in full vigor of health, and the  character of the
disease acute in its form.  The frequency of administration of the remedy
wras governed very much by the reaction of the urine.
   On  the  admission of the patient, the  urine was tested, and in  all cases
was found  to be of acid reaction, and the secretion  of the skin presented
the  usual  acid odor.   The  treatment was generally commenced  the
second or  third  day  after  admission, and the urine wras  rendered  of
decided alkaline reaction in an average of five days after its commence-
ment; the  longest period  it resisted the alkaline reaction  having been
tAventy days, and the shortest tAvo.
  In one case, attended with profuse  perspiration, which  yielded readily
to treatment, the colored shirt the patient Avore entirely lost its color ; and
it was suggested Avhether the same change did not take place in the per-
spiration, as in the urine.  The average  amount of the salt administered
was from five to seven  ounces.
  The average date of commencing  improvement was seven days after
commencement of treatment, coinciding, in the large majority of the cases,
with the commencing  alkalinity  of  the  urine.  The improvement ivas
invariably permanent, and, after the urine wras rendered alkaline, no neAV
articulations Avere affected, as a general rule.
  The  average period of convalescence Avas  tAvelve  days after admission;
and the whole duration of the disease, including the  period previous to
admission,  Avas twenty-two  days.  One  of the most gratifying results
of the  alkaline treatment Avas the  liminished frequency of cardiac com-
plications.
  Not one  patient Avas attacked with any heart complication during the
treatment of the disease.                              Part xxxi., p. 43. 
460                         RHEUMATISM.
  Treatment of Acute  Rheumatism.—Lemon-juice is still  relied upon
extensively, but since it became knoAvn that it contained some of the salts
of potash, these have been largely prescribed in the acetate, tartrate, or
nitrate of potash.  Give half a drachm of acetate of potash, ten grains of
the nitrate of potash, and  ten  minims of vinum opii diluted with barley-
water, two or three times a day.                       Part xxxi, p. 46.
  Treatment of Acute.—You must be guided entirely by the specialties
of the case; there are no specifics ; some preparation of iron Avith liquor
potassas may be given.  When  the  liver is much  deranged, calomel and
rhubarb"; when the urine  is scanty, colchicum. As  tonics, quinine and
iron, alone or combined, may be given. Quassia, with an alkali, suits remark-
ably well.   Wine is the best and most efficacious tonic in Aveakly habits ;
an opiate at bed-time is sometimes necessary.  Warm fomentations are the
best local applications.                               Part xxxiii., p. 40.
  Sidphur externally in the cure of  Rheumatism.—Dr. Fuller orders the
whole of the affected limb to be incased in flannel, thickly sprinkled with
precipitated sulphur; a bandage is applied over this, and the Avhole covered
wdth oiled silk or  gutta percha, Avhich has the  effect of increasing the
warmth  and confining the vapor of the sulphur, and also obviating the
disagreeable odor.  This bandage should be constantly applied—absorption
takes place, the breath, urine, cutaneous  exhalations, unmistakably attest
its presence.  If the pain be  situated Avhere the above  cannot be readily
applied,  substitute the compound sulphur ointment, which must be rubbed
in for tAventy minutes night and morning.  When there is feverishness,
acute pain, even when the limb  is at rest, and the skin dry and inactive,
no relief results from this treatment; but where there are no symptoms of
active disease,  and the pain is of a dull aching character, felt chiefly ivhen
the limb is in motion, and the skin acts freely, no  external  application
proves so serviceable.                                Part xxxv., p.  23.
   Treatment of Gout and Rheumatism  by the Silicate  and Benzoate of
Soda—combined with  the  Preparations of Aconite and Colchicum.—
MM. Socquet and Bonjeau have proposed, in gouty and rheumatic affec-
tions, the employment of the silicate of soda and benzoate of soda.  Sili-
cate of soda facilitates the elimination of uric acid, and its influence may be
extended so far as to render the urine alkaline.  This salt, moreo\rer, by its
tonic action upon the digestive functions and its diuretic properties, is said
to be far superior to the carbonates  of soda or  potash,  Avhich are so con-
stantly  employed  in the  rectification of the  uric  acid diathesis.  The
benzoate of soda transforms uric acid into hippuric acid, the combinations
of which are extremely soluble, while those of uric acid are hardly soluble
at all.  This medicine, in thus modifying the part  of the acid which may
have escaped the action of the silicate of soda, will thus  contribute also to
diminish its quantity.  Colchicum Avill rapidly carry away, by the urinary
passages, the remains of the uric acid which the blood may still  contain.
Aconite  is used to act specially upon the painful part.   Part xxxv., p. 25.

   Treatment of Acute Rheumatism.—The treatment of acute  rheumatism
by one or other of the salts of  potash  has now become  the estabhshed
practice of the leading London physicians.  Dr.  Barlow has lately been
trying the bicarbonate, but does not find it  so effectual as  the  acetate
which he had previously been in the habit of using. A combination of the 
RHEUMATISM.
461
  nitrate, bitartrate, and acetate, given well diluted, is a good form of admi-
  nistration.

    Lemon-juice and Acetate of Potash.—If the portal system is congested,
  as shown  by arrest of the biliary and urinary secretions, exhibit a brisk
  mercurial alterative and purgative, repeating  this if necessary during the
  attack.  Then prescribe  lemon-juice  in  proportion of a teaspoonful or
  dessertspoonful, according to the age and size of the patient, every second
  hour.   This of itself tends also to keep the bowrels free.  A little morphia,
  the dose being carefuly regulated, may be given at bed-time.  Dr. Sand-
  with, of the Hull Infirmary, has recently treated ten cases Avith acetate of
  potash, Avith unusual success.   It should, be well diluted, and may be com-
  bined Avith lemon-juice.                              Part xxxvi., p. 30.
     Chronic Rheumatism and Gout.—Apply thin sheets  of gutta percha
  over the parts;  this produces great  local transpiration, and the pain is
  generally considerably relieved.                       Part xxxvi, p. 31.
    Rheumatic Pericarditis.— Dr.  Todd  treats this and other forms of
  rheumatic inflammation on a stimulant plan throughout, not  with a view
  of cutting short the disease, but of supporting  the patient under it,  and
  rendering  convalescence more rapid.  In a case lately under treatment,
  alkalies were given alone, till the appearance  of  the pericarditis, ivhen
* opium in gra,in doses, every four hours, and eight ounces  of brandy daily,
  were administered.  Pneumonia of both lungs came  on, and the brandy
  was ultimately increased to thirty-five ounces daily. No leeches or blisters
  were throughout employed.  He left  the hospital to all appearance quite
  Avell at the end of a mouth.                          Part xxx\d., p. 50.
     Acute Rheumatism.—After having procured free evacuation by means
  of senna and salts, begin the administration of equal  parts of vin. colch.
  and spt. tereb., in  doses of ten drops  every tAvo or three hours.  After  a
  day or tAvo, give in connection with these (only at different intervals,  say
  of five hours each), tr. ferri chlor. ten drops,  using as  much opium as  may
  be necessary to quiet pain. AHoav a free use of coffee of average strength.
  If the patient's appetite remain, alloAv a moderate use of his usual food at
  the customary intervals.   (Dr. Gordon.)

    In acute articular rheumatism give  large doses of  iodide of potassium
  in conjunction wdth morphia.   When  more than one  joint is affected do
  not use local means.   (Dr. Hauschka.)                Part xxxvii., p. 22.
    Rheumatism, Chronic.—A case of most obstinate chronic rheumatism,
  for years resisting  every form of treatment adopted, yielded to the use of
  the sulphurous vapor-bath.   A bath ivas  given  every  other  day,  the
  patient being Avell  steamed for twenty minutes, and  then, before leaving
  the bath, showered with cold salt water, to prevent a  too  relaxing action
  of the vapor.  In  the course  of six weeks, the man stated himself to  be
  " perfectly cured." Artificial sulphurous water may  be made  by addiig
  a drachm  and a half or twro drachms of sulphuret of"potassium to a galhn
  of common Avater.                                  Part xxxviii., p. 22.
     Rheumatism  and  Chorea.— Probably there is .no fact  in pathology
  better established  by experience than the connection between rheumatism
  and chorea ;  the former being the cause, the  disease in fact, the latter only 
462
RICKETS.
a symptom.  Ahvays carefully examine Avhether  there  be a  rheumatic
history ;  in some cases, of all symptoms there may be only one  leading to
this  suspicion, viz., urine highly loaded  Avith lithates.   If there be no
febrile state to account for this state of  urine, though not in itself actual
evidence, it is in most cases highly presumptive of  the  existence of the
rheumatic state.   In one case Ave have seen chorea and loaded urine the
only symptoms leading  to the detection  of  acute pericarditis.  (Ed. of
Retrospect.)                                        Part xxxix., p. 72.
  Hypodermic Injections.— In many cases of rheumatism, says Mr.  Hun-
ter of St. George's Hospital, great relief wdll be obtained by the use of
narcotic  injections, to relieve the pains when  severe.   Of course the  usual
constitutional treatment must be employed.   In one  case a man could not
move his arm after acute rheumatism, on account of pain in the shoulder.
The pain was removed by a single injection.              Part x\.,p. 279.

                              ---•-*-*—

                           RICKETS.
   Rickets—Treatment of.—Mr. A. W. Close states  that the softened state
 of the bones in  this affection  is OAving  originally  to a deficiency in  the
 supply of the nutritive  nitrogenized substances.   The affection is seldom
 seen during suckling, because the milk  contains those elements which are
 exactly  suited to the wants of the  system.   After Aveaning, the diet often
 adopted among the poor consists chiefly of potatoes, oatmeal, gruel, tea,
 coffee, and rice.  Now proteine is  only found in the two first in  small
 quantities, and  none in the  rest.  Among the middle and upper classes
 the  diet after weaning  is often  sago, rice, or  arrowroot,  Avhich  certainly
 fatten the little children, but do not convey a sufficient quantity of nitrogen
 to the  system.   The  diet  ought to  consist  more of" the nitrogenized
 substances Avhen there is this disposition in  the system, such  as beef-tea,
 eggs and wheat ground and made  into  bread  Avithout the separation of
 the  cuticle of the grain, in which is contained the  phosphate  of lime, to
 wdiose absence the softened condition of the bones is usually attributed.
                                                        Part viii., p. 78.
   Mollities  Ossium.— [This disease,  depending immediately  upon the
 want of the mineral constitutents of bone, may arise either from a want
 of powrer in the organs of  assimilation and  absorption  to take up the
 phosphate of lime contained in the food, or from the food itself not con-
 taining enough  phosphate of lime  to furnish  the required supply.   It  is
 well known that when  common fowls  are prevented from getting lime,
 their eggs will be without shells, but on restoring the lime, the  eggs  regain
 their earthy covering.   On  the same  principle Mr. Cooper  proposes to
 treat mollities ossium.  He says:]
   I  have on two or three occasions certainly  had reason to believe that
 great benefit ivas derived from giving bone powered and mixed Avith  bread,
 and at the same time draughts containing phosphoric acid, which converts
 phosphate of lime into a. biphosphate, a more  soluble salt than  the phos-
 phate, and probably  much more readily assimilated.  The result of this
 treatment  was  certainly such as Avould  wTarrant  the just expectation of
 facilitating the nutrition of bone. 
RICKETS.                           463
  I have demonstratively proved to you, I think I may say, over and over
again, the advantages of applying phosphoric acid to exfoliating  bone, to
produce its rapid removal upon a principle precisely similar.
                                                    Part xvii., p.  124.
  Treatment of, by Proteine.— Vide Art. " Caries."
  Rickets.—In diseases arising from insufficiency  of earthy phosphates in
ihe food, give calcined bones in powder;  and when there  is too rapid
elimination of phosphates by the urine, combine Avith the calcined bones a
targe proportion of sugar, or add the  latter to the food.  The sugar  will
diminish the activity of the nutritive changes  which take  place in the
tissues, and so lessen the amount of matter excreted. But "when a child
at the breast is affected wdth this disease, OAving to the  poverty of the
milk, the mother should take the  calcined bones, but without  the sugar,
in order that the elimination of the phosphates through the milk may not
be interfered wdth.  (Dr. Bocker.)                     Part xxi., p.  147.
   Observations on Rickets.—The indications are, not to cram the patients
with preparations of earthy salts, for these are not deficient in  the blood,
but to correct disorder of the digestive system, and to invigorate the body
by light nutritive diet, fresh  air,  cold  ablutions, and the  use  of some
medicinal tonic, such as quinine or iron.  In some cases steel  supports are
proper.   (Dr. Humphry.)                              Part xxi, p.  184.
   Use of Tannic Acid.—Give tannic acid in  doses  of half  a grain  or a
grain, night and morning, in sweetened water or any simple vehicle, and
continue its use for a long time.  It acts, in all probability, rather  as a
tonic and " histogenetic," than by arresting the excretion of lime by an
astringent action on the kidney.  (Dr. Alison.)         Part xxi, p.  326.
   Use of Phosphate and Oxalate of Lime.—In all chronic diseases Avhich
are distinguished by wasting,  emaciation, ulcerations of the  skin, etc. (as
scrofula,  especially  rickets),  a much  larger quantity of phosphates  is
removed from  the economy by the urine than ought to be in the normal
state; indeed, in some cases, to an almost incredible extent.  The phos-
phates of lime and magnesia are held in solution in the urine by its acidity,
and directly precipitated  by the addition  of alkalies, or  when the urine
becomes ammoniacal by putrescence.  This precipitation is more complete
by heating or boiling  the urine, and by adding a solution  of soda to boil-
ing urine  the Avhole may be precipitated;  and by always using the same
solution of carbonate of soda, say, one to tAvelve ounces of distilled Avater,
the degrees of turbidity may  be readily recognized, and  the quantity of
phosphates ascertained.  There is scarcely any disease in ivhich at one
time or another an increase in the quantity of phosphates does  not  take
place ; but as  the times are quite uncertain, there is necessity for almost
daily examination.   The mcrease, however, does not  depend so much upon
the nature of the  disease as upon the individual affected. (Dr. Beneke.)
                                                    Part  xxiv., p.  310.
  Superphosphate of Iron.—A sirup of  superphosphate of iron is  par-
ticularly applicable to rickety and wreak  children;  it is very  pleasant to
take.  It contains five grains of iron and five of  phosphate  of lime to an
ounce of the sirup.  (Dr. Routh.)                   Part xxxvii., p. 242. 
464
SALIVATION.
                       SALIVATION.
  Salivation by Small Doses of Mercury.—In a discussion respecting the
salivation of patients by  minute doses of mercury, in the Westminster
Medical Society, Mr. SnoAv  offered an  ingenious explanation.   He said :
He did not believe that the salivation which Avas occasionally produced by
a very small  dose  of mercury depended on any idiosyncrasy of constitu-
tion, which continued during the patient's life, but Avas the result of the
presence of an excess  of acid in the first passages.  He had been led to
this conclusion by having frequently seen patients salivated by  a  very
small quantity of calomel or blue pill, taken at the same time ivitb mixtures
containing dilute  sulphuric  acid.  Very lately, a man who was taking
sulphuric acid freely for epistaxis, was severely salivated by tAvo grains of
calomel in a dose of cathartic pills.  The acids naturally  contained in the
stomach were the muriatic and the acetic,  and the mercury contained in a
grain or tAvo of calomel, or  a few grains of the blue pill, would, of course,
be  sufficient to produce the most serious consequences, if changed  into
the bi-chloride.  If the vieAV he had  suggested Avas correct,  the means
of  preATenting untoward effects would  be  to give corrosive sublimate at
once, Avhere a course  of mercury was indicated, and to give it in suitable
minute doses.                                            Part l, p. 45.
  Leeches—Poidtices—Gargles.—Dr.  Watson,  in  his  lectures  on the
Treatment of Inflammation, makes the  followdng remarks respecting the
Treatment of Salivation: There are two expedients wdiich I am confident
are often of very great use in checking the violence of  the salivation, and
iu removing the most distressing of its accompaniments.  If there be much
external SAvelling, treat the  case as being, wdiat it really is, a case of local
inflammation: apply  eight or ten leeches  beneath the edges of the jaw
bones, and wrap a  soft poultice  round the  neck, into which the orifices
made by the leeches may bleed; and I  can promise you that, in nine cases
out often, you wdll receive the thanks  of  your  patient for the great com-
fort this measure has afforded him.  When  the flow  of saliva,  and the
soreness of the gums, form the chief part of the grievance, I have found
nothing  so generally useful as a gargle made of brandy and ivater; in the
proportion of one part of brandy to four or five of water.   Part \\l,p. 33.

    Use of Tannin.—Mr. Druitt considers it the best of all local means of
making the mouth comfortable in cases of severe salivation, and for all cases
of relaxed sore throat attended with superabundance of mucus. It coagulates
the mucus, and enables the patient to get rid of it easily.  Part x., p. 139.
  New Remedy for Ptyalism.—Dr. Robertson has discovered that one of
the commonest plants of  his  district, the  Ambrosia trifida, has more
prompt remedial powers in cases  of excessive ptyalism, than anything he
had previously tried.   The  patients  are described  as  being generally
relieved in  six or eight hours of the  more urgent symptoms, and  com-
pletely cured in two days.   The preparation employed is an infusion of the
green leaves used as a gargle.  Dr. Robertson suggests that the plant may
also be found useful in other profluviae, as leucorrhoea.  The plant is knoAvn
under the popular  term of horseweed—horsemint.  Dr. Robertson was
induced to try it from observing that it completely cured a horse affected
 with slabbering.  The effect is simply local.              Part xv.,p. 252. 
SALIVATION.
465
  Treatment of Salivation by Sulphur.—Dr. H. Smith says a good prepara-
tion in these cases is a mixture of alum  and chlorinated soda; 3ij. of
the former Avith §j. of the solution of the latter to fviij. of water;  but the
strength must vary according to circumstances; if there is much ulceration,
a strong solution  will give unnecessary pain.   Oak-bark, nutgalls,  and
tannin are also  serviceable remedies, and particularly the latter, as it is a
powerful astringent.  If there is inability to open the jaws, and the mouth
is clogged  with a viscid  secretion, the lotion should be injected with a
syringe, and warm wrater should  be frequently  thrown  in,  in  the  same
manner to clean this away.  But local measures alone will not suffice: the
constitutional symptoms,  which are severe and  in some cases  alarming,
should be attended to, and we must endeavor to  get the poison excreted
from the system by the various depurative organs.
  [Mr. Smith, after just  referring to the use of tartar  emetic, acetate of
lead, and opium, which he thinks may sometimes be useful, observes :]
  There  is  one remedy, however, Avhich appears to possess considerable
influence in removing salivation,  and one which I think is not universally
known ;  I mean sulphur;  by referring to Mr. Colles' works I find that he
recommended it several  years ago. Iu what manner it acts we are not
able exactly to tell, but it is highly probable that it enters into combina-
tion Avith the mineral, and forms a sulphuret, which is an inert preparation;
moreover, it acts as a purgative, and also goes off by the other secretions,
particularly the  skin.  I have had opportunities  of  using sulphur for
ptyalism, and I have seen it used by others, and certainly, in the majority
of cases, decided benefit  occurred.   The only objection I have noticed, is
the fact that it sometimes irritates the  bowels Arery much.   I used it in a
case lately, Avhen I was  obliged to suspend it for this reason.  I Avould
strenuously recommend it to those Avho  may meet Avith a troublesome case
of salivation.   Mr. Allison  has found  out that  chlorate of potash has a
most beneficial influence over  mercurial salivation,  and he has tried it in
numerous cases.                                      Part xvi, p. 218.
   Use of Creasote in Salivation.—Dr.  Faulcon relates a case of profuse
mercurial salivation, in ivhich,  after the unsuccessful employment of the
usual remedies, he employed with  great advantage a gargle  composed of
creasote  3ss., sage tea a pint,—the affection quickly yielding.
                                                      Part xx., p. 93.
  Salivation treated by  Nitrate of Silver.—Dr. Kirby applies a solution
of nitrate of silver  (3j. in  an  ounce), to the gums,  three or four times daily
with  a hair-pencil.  The teeth  will be discolored,  but  the stain may be
removed by a Asav apphcations of a solution of cyanide  of potassium  (one
part of the salt  to two of distilled water.)                Part xx.,p>. 147.

  Belladonna  in Salivation.—A woman  treated by mercury,  internally
and  externally, for  diarrhoea,  Avas affected with profuse salivation.  Dr.
Erpenbeck treated this latter complaint Avith belladonna in divided doses,
of two  grains  and  a  half,  taken in emulsion every twrenty-four  hours.
Next day  the salivation  had subsided, and the mouth Avas quite dry.   On
stopping the belladonna,  the salivation returned, and again ceased ivhen it
was resumed.   The author  believes that after this fact and  some similar
ones, belladonna is the best  treatment for salivation.    Part xxx., p. 301.
   Chlorate of Potass in Mercurial Salivation.—Encouraged by the success
     vol. n.—30 
106
SARSAPARILLA.
of Hunt, and others, in the employment of the chlorate of potass in the
treatment of gangrenous affections of the mouth, M. Ilerpin has repeatedly
employed it with the  best effect in mercurial salivation, giving  it in the
dose of 3ss. to 3j. per diem—the cure, when the case is taken early, being
completed by the fourth day.  He has long been accustomed to the employ-
ment of this substance, as recommended  by Odier, in jaundice,  Avhether
simple or complicated, w ith engorgement of the liver.  Odier carried the
daily dose as high as 150 grains.                     Part xxxi, p. 235.
  Mercurial Fetor and Salivation.—The best remedy for instantaneously
and safely removing fetor of the breath, in the opinion of Dr. Nunn, of"
the Middlesex Hospital, is a strong solution  of  the chloride of zinc, made
by  mixing one drachm of Burnett's solution ivith seven drachms of dis-
tilled Avater.  This must  be applied by the  medical  attendant wdth a soft
brush  to  the  gums, and  betAveen the teeth, the mouth being frequently
Avashed wdth water.  The solution acts by immediately entering into com-
bination Avith the rotting epithelium and forming an inodorous product,
which  the brush removes, at the same time it  powerfully constringes the
enlarged vessels, and tends to restore a healthy state of the local circula-
tion.                                               Part xxxv., p. 190.
   Quinine in the Salivation of Pregnancy.—Dr. Mauthner relates that he
has found sulphate of quinine, given in two grain doses, prove completely
efficacious in cases in Avhich various other means  had been tried without
success.                                           Part xxxvii., p. 233.
                              ---•-*-•---

                        SARSAPARILLA.
   Powder of Sarsaparilla.—[Sir Francis Smith, speaking of this medicine
says:]
   I have long been engaged in observing the effects of different prepara-
tions of sarsaparilla, and I am persuaded that of all  the forms in which it
can be given, that of powder is in most instances the most valuable.   The
advantages which it  possesses, in my opinion, may  be stated as follows,
viz.: 1, we can make use of it  in many conditions  of the stomach where
a large quantity of fluid would prove inconvenient or injurious; 2, it may
be taken in more certain and definite quantities; 3, its effects are, so far
as  I have observed, more durable.   Of course certain conditions  of the
skin wdll occur, Avhere the use of the domestic  decoction will be more ser-
viceable, especially if it  be taken warm; and in  a slimy or foul condition
of the  primasvias the infusion in lime Avater (recommended by Dr. O'Beirne
of Dublin, not as made in the Pharmacopoeia) wdll present special advan-
tages.
  Mode of Preparation and Administration of  the Powder.—The mode
made use of in one establishment where I have superintended its prepara-
tion is as follows :^ A quantity of the roots of sarsaparilla, either split or
not, but not cut into  short portions, is  either subjected  to the vapor of
steam for a feAV minutes,  or if time admit, left in a damp cellar for tiventy-
four or thirty-six hours, and subsequently introduced for  an  hour  into a
stove  or oven,  moderately heated, which processes  have the  effect of
loosening  the  connection  betAveen  the  bark and  the ligneous portion,
when  the  former  may be easily stripped off,  and  poAvdered finely in  a 
SCALP.                            467
mortar, and the powder may afterward be taken simply in a spoonful  of
any bland  fluid, or may, in  cases Avhere  quinine  is indicated, be united
Avith a suitable proportion, and the flavor be covered with a little oil of
cinnamon—or the powder either simply, or combined with S. of quinine,
or in gouty habits, with capsicum or ginger, may be made into  ptils, and
administered in the proportion of from twro to four scruples daily.
                                                       Part ii., p. 68.

                              ---»-•-•---

                            SCALP.
   Wounds of the Scalp— Contusion of the Bones.—[Severe cases of this
kind, Avhere the scalp is extensively separated and the bone denuded, some-
times run a very rapid course to  a fatal termination;  but whenever this
does occur, it is much more owing to the contusion of the bone  than the
denudation.  Prof. Hewett says:J
  In the flat bone of the skull, with its compact  tables and intervening
cancellous tissue, the contusion seldom reveals itself on the surface ; it is
in the  diploe' that the  Woav produces its effects.  Examined as to its com-
pact tables, such a bone, externally, may be to all appearance  perfectly
healthy ; but the contusion manifests itself in the  diploe by an extravasa-
tion of blood within its cells or in breaking down of the delicate fibres of
their Avails.  In such a condition,  the bone has hidden within itself all the
seeds of the future mischief, if inflammation should arise in the bone—and
arise, in all probability, it will, if  the  diploe has been much injured; and
the great tendency will be, in certain  habits of the body, to produce sup-
purative inflammation, and suppuration in such a situation is fraught w ith
the utmost danger.
   The intimate connection of the  bone to the membranes of the brain : the
large and numerous venous channels in its cancellous tissue,  render diffuse
suppuration in the diploe not only one of the most formidable complaints
the surgeon can have to  deal Avith, but one which but  too  often sets at
naught all  his resources.
  Let  us look to the train of evils which may arise in the membranes of
the brain,  after a contusion of  the  bone, followed  by mischief  in the
diploe.
  For days, for Aveeks e\ren,  there  may be no appearance Avhatsoever of
the mischief Avhich is smoldering.   Soon recovering from  the  effects of
the accident, if it ivas a slight one, the patient appears to be  in perfect
health.   For a time, all wears a favorable aspect; but generally, within a
fortnight or  three weeks, the first symptoms begin to  show themselves—
pain in the head, feverishness, and soon an unhealthy aspect in the Avound,
it there be one; a spontaneous secession of the periosteum from the bone,
Avhich, if ^denuded, becomes dry, and  may be seen gradually to lose  its
natural color, being first of a dead  white, then of an  opaque yellow, a
greenish, or it may be of a broAvnish hue.  Matters go on thus for a longer
or shorter period, that is, as long  as the inflammation does not  spread to
the inner table of the  bone; but, as soon as this is reached, the dura mater
becomes involved; inflamed in its turn, and it may be in a sloughy state,
this membrane secedes from the bone, lymph or pus is  poured out  on its
external surface, and  as long as the inflammation is limited to  the dura-
mater  itself, generally only that portion of the membrane corresponding 
468                          SCARLATINA.
exactly to the inflamed bone is diseased;  but wdien  the  inflammation  has
once passed on  to  the parietal arachnoid, matter is thrown out into the
cavity of this membrane, and then the visceral arachnoid, the pia mater,
and the brain itself, soon present all the appearances of severe  inflamma-
tory action.  The symptoms are in keeping with the progressive stages of
the disease.  As long as the inflammation is confined to  the bone they are
few, and not strongly marked;  but as soon as the dura-mater is reached,
then decided symptoms of the cerebral mischief soon manifest themselves;
increased feverishness, repeated rigors, intense pain  in the  head, sickness,
droAvsiness, occasional wTandering, coma, and sometimes  paralysis.
  Such cases as these strongly resemble those which, of late years, have
so much occupied the attention of the profession.   I allude to the diseases
of the ear, where the bone is affected, and where the inflammation mani-
festly spreads from the bone to the membranes  of the brain.  In these
cases the disease may lay smoldering for years.  I have known it to do
so for upward  of twenty;  and as long as the mischief is  confined to the
bone, the symptoms are trifling ones ; but suddenly, without any apparent
cause, it spreads to the dura-mater, and then folloAvs the train of cerebral
symptoms.
   [Mischief so  insidious in  its course, and  so constantly and  rapidly fatal,
when  once fully developed, naturally led  surgeons to  bleed largely and
repeatedly as a preventive; but Ave may fairly  question  whether we
ought to bleed  patients without a symptom of serious  disease.  We are
told to  do so to prevent inflammation  of the  dura-mater, but it is only
one case in seventy where we find mischief in the dura-mater after death.
As a general rule, blood ought never to be draivn Avithout a clear indication
of its necessity.   In the majority of cases of severe wounds and contusions,
patients recover, if kept perfectly quiet,  and Avith an occasional saline pur-
gative ;  but whenever inflammatory symptoms begin to  make their appear-
ance, then is the time to have recourse to  antiphlogistic treatment, Avhich
must be more or less strict  according to  the nature of the case.]
   Failing in our antiphlogistic remedies, ha\'e we any other  means of re-
lieving the patient ?  The only chance left is in the trephine.  But are Ave
to trephine all cases of blows on the head, Avith bare bone and symptoms
of suppuration ?.
   A close examination of cases, under such circumstances, will show that,
in many instances, we really have no indications which could lead us to ap-
ply the trephine.
   The dura-mater, Avhen  laid bare by the trephine,  is so often found to be
perfectly healthy, that its use has  of late years been abandoned, although
the  symptoms  of suppuration may have been very evident.
                                                   Part xxxiii., p. 234.
   Scalp— Wounds of.—In spite of any treatment, erysipelas too commonly
comes on about the third or fourth day ; whenever such does happen, says
Mr. F. C. Skey, the tonic treatment by quinine, steel and  ivine is the best.
                                                   Part xxxiii., p. 235.
                                  , •,—

                       SCARLATINA.
   Chlorine in  Scarlet Fever.—[In scarlatina maligna, every practitioner
is aware that frequently all his efforts are vain to check the disease.  There 
SCARLATINA.                         469
seem to be tAvo sources of danger—one arising from the primary impression
of the contagious  poison" upon the body, and especially upon the nervous
system, which is overwhelmed by its influence.   In this case, the patient
often sinks without any affection of the throat, and our  chief dependence
will be upon wine and bark to sustain the  poAvers of the system till the
deadly agency of the poison has exhausted itself.   Another source of dan-
ger arises from the gangrenous ulceration of  the throat—the system seems
to be re-inoculated Avith the poisonous secretion from  the  throat.  Wine
and bark will here also be of great benefit;  gargles composed of chloride
of soda Avill be found efficacious, and if the child is too young to gargle, it
may be injected into the nostrils and against the throat by means of a
syringe.  This will be found superior to capsicum gargles.  But we  think
one of the most efficacious methods is that recommended so strongly by
Velpeau, of blowing powdered alum  up the parts by means of any tube
long enough  for the purpose, as two or three  quills  inserted into each
other,  so  as  to make one continuous tube.  Dr. Watson seems to think
highly of chlorine.  He says:]
   From several distinct and highly respectable sources, chlorine has  been
strongly pressed upon my notice, as a most valuable remedy in the severest
forms  of scarlet fever.   I will  give you  the   formula  for its prepara-
tion.
   Tavo drachms  of the chlorate  of  potass are  to be dissolved in two
ounces of hydrochloric acid, previously diluted Avith tAvo ounces of distilled
Avater.  The  solution must be put tinmediately into a stoppered bottle, and
kept in a dark place.
   Tavo drachms of this  solution, mixed Avith a pint of distilled water, con-
stitute the chlorine  mixture ;  of which a tablespoonful, or tAvo, according
to the age of the patient, may be given for a dose, frequently.
                                                       Part vl, p. 36.
   Belladonna.—On the  Protective Influence of Belladonna in Scarlet
Fever, Dr. Watson says :
   You are probably aware that belladonna is believed by many to exert a
preventive and protecting influence upon the body against the contagion
of scarlet fever.  I knoAV nothing, by my own experience, of the alleged
conservative property of this vegetable, but in the small quantities, recom-
mended, there can be no harm hi trying it, provided that  its  employment
does not lead to a neglect of  other precautions. Three grains  of the
extract of belladonna are dissolved  in an  ounce of distilled water; -and
three drops of the solution are given twice daily to a  child under  tAvelve
months old,  and  one drop more for every year above  that age.   It is
affirmed that if this remedy does not prevent the disease, it will render it
mild;   and  that  if it  be taken four  or  five days  before exposure to
the contagion, the resulting scarlatina never proves fatal.  Part yi., p. 37.

   Carbonate  of Ammonia in Scarlatina.—The value of  carbonate of
ammonia in  scarlet fever has been attested by several observers, by Dr.
Picken, of Dublin,  and  Dr. Rieken, of Belgium ;  wditie at  St. Petersburgh
it is said to have  been employed by the German physicians without any
evident advantage.  Mr. H. Freke suggests that  it may act by taking the
place of urea, and thus supply the natural stimulus to the renal functions;
and Messrs. Ilerdenreich and Heim have observed, that in cases of  scarla-
tina an ammoniacal alkali is deposited on the skin, and hence offer another 
470
SCARLATINA.
explanation of its efficacy.  Whatever the theory, the amc- -*j of practical
evidence preponderates in favor of the administration of ammonia in scarlet
fever.                                                  Part xii., p. 27.
  Treatment of Malignant Scarlatina.—Since bleeding was abandoned
in the treatment of this disease, stimulants have formed the usual reme-
dies.  They were employed by Dr. Coley, in connection with proper local
applications, at  the commencement of the epidemic in Dec, 1847 ; but
finding that he lost the first four patients in succession, and observing that
the state of the  fauces was  identical wdth that which was  found in
the late epidemical diphtherite, he ivas  induced to try the effects  of  small
repeated doses of calomel,  at the very commencement of the  disease.
  It should be  given in doses of  one or two grains every four hours ; and
thus given does not affect the mouth.   Acetate of ammonia may be given
in conjuction Avith  it; or in the latter stages, if there  are hemorrhages
from the mucous membrane, or petechial spots, quina wdth sulphuric acid
may be exhibited.  The best local application is a lotion Avith nitrate of
silver, a scruple to the ounce, applied tAvice or thrice a day to all the parts
which are ulcerated,  or covered wdth diphtherite.  If abscesses form in
the glands  of the neck, they are  to be  opened freely  as soon as there is
fluctuation or external redness.                        Part xviii., p. 34.

   Scarlatina—Some Points in the Treatment of.—The state of the throat,
says Dr. West,.must be carefully Avatched in every case of  scarlet fever ;
and when there is much swelling of the tonsils, if the child  be too  young
to gargle, a slightly acidulated lotion should be injected into the back of
the throat, by means of a syringe, every few hours, in  order  to free it
from the mucus Avhich is so apt to collect there, and to be  the  source of
much discomfort.   If there be much deposit of lymph upon  the tonsils,
it  is generally desirable  to apply the strong hydrochloric acid,  mixed
with honey, in the proportion  of" about one part of the former to six of the
latter, by means of a dossil  of lint, or a camel's-hair pencil, two or three
 times in the twenty-four hours;  but the strength of the  application must
 be increased if the tonsils be ulcerated, or if. any disposition to sloughing
 should appear. The  coryza, ivhich is so distressing and so ill-omened a
 symptom in  cases  of severe scarlatina,  is best treated by throwing a
small quantity of a solution of gr. j. or gr. ij.,  of  nitrate of  silver in |j. of
distilled Avater up the  nostrils every four or six hours.  The  glandular
swellings are very difficult to relieve.  When considerable, they do not
seem to be benefited by leeches ; the employment of which is also, in many
cases, contra-indicated by the  feeble state of  the patient's poAvers;  while
they show very little  disposition to suppurate, and consequently  are not
relieved by lancing ;  so  that the constant application of a Avarm poultice is
often all that can be done to  afford ease to the patient.  Children, in
whom  the  local affection is  severe, or in whom the  disease assumes a
malignant character,  require  all  those  stimulants, and that  nutritious
diet, which we are accustomed to give  to  patients in certain stages of
typhus fever;  though, unfortunately, the best devised means will, in many
such cases, prove  ineffectual.
   [A still more easy and efficacious application in some of these cases is a
solution of crystallized  nitrate of  silver, (5ss. or Bij. to the  §j.)  applied to
the diseased parts by means of a sponge tied to the end of a bit of w hale-
 bone, as described by Dr.* Horace Green.]              Part xviii., p. 3j 
SCARLATINA.                          471
  Treatment of Scarlatina by Hot Water Applications.—Mr. Bulley,
surgeon te'Berkshire Hospital, directs to apply a thick flannel pad, Avrung
out of hot water till almost dry, upon the pit of the stomach and over the
region of the heart, and then wrap the patient carefully in several blankets.
At  the  same time wrrap  another  flannel, Avrung out of hot  vinegar and
water, round the throat.   After the patient  has persjrired profusely foi
three or four hours, remove the flannels carefully, and give Stevens's saline
powder  (to  an  adult half a drachm) every four hours: and let him  use a
gargle containing  Bij. of burnt alum, Bij. of Armenian bole, and  3j. of
brown sugar in  Svtij. of Avater.                           Part xx., p. 30.

  Use of Acetic Acid in Scarlatina.—Dr. Webster, consulting physician
to St, George's and St. James' Dispensary, has great faith in the use of
frequent sponging Avith tepid vinegar and Avater, especially in  the  early
stages, when the skin  is  hot and the pulse accelerated.   This measure is
very efficacious  in preventing the spread of the disease.  Part xxi, p. 350.

   Yeast in, the Treatment of Malignant  Scarlet Fever.—Mr. Bennett
states that he has found the administration of fresh yeast of the most inva-
luable advantage when the  symptoms are of a malignant character.  He
says:
  After ammonia, the mineral acids, chlorate  of potash, etc., have failed,
and  the application  of  nitrate  of silver besides, one or  tAvo  table-
spoonfuls of fresh yeast frequently given (according  to the age and malig-
nancy of the case) has, in my practice at least, been quickly  efficacious as
an  antiseptic and stimulant.                           Part xxiii, p. 29.

  Scarlatina—Delirium and Coma of—Prof. Bennett gives  the folloAving
case:  A boy, aged 14, entered the clinical ward on the third day after
experiencing distinct rigors.  There Avas restless delirium,  and constant
moving of the head from side to side upon the pillow.  He Avas apparently
conscious when spoken to, but could not answer questions—the tongue Avas
protruded with difficulty, dry, and of bright red color, studded with  florid
elevations—deglutition  Avas much  impeded—bowels  open—pulse   130,
weak—urine voided Avith difficulty, and  diminished in quantity—sp. gr.
1025—not  acted on by  heat and nitric acid—skin hot and  dry, covered
with the  bright red scarlatinal eruptions.— Ordered salines and slight
diuretics.  He  continued in the same condition, the angina, coma, and
alternating delirium, however, being more pronounced until the sixth day.
  R. Sp. aether, nit., 3hj; pot. acet., 3ij ;  tr. colchici, §ss: aquas, §iij.  Ft.
mist. A teaspoonful to be taken every four hours.
  On the folioAving day all coma and delirium had disappeared.  He an-
swers questions when  put  to him—skin  cool—eruption faded—pulse 96,
weak—passed 30 oz. of urine, which is turbid, with small flakes of a  mem-
braneous character floating in it.  On the 8th day  the quantity of  urine
excreted Avas 50 oz., and it was  still more loaded with sediments Avhich
being analyzed  were found to consist of urate of ammonia. Next day the
urine was only slightly  turbid, and on  the folloAving  one, was perfectly
clear.  From this time the boy gradually  recovered.
  Commentary.—This Avas a very severe case of scarlatina.   The angina
was intense, occasionally  rendering deglutition impossible.  There Avas
delirium on  the third day, alternating at night  Avith coma, which was often
profound.  The Avorst  result was apprehended.   It recurred to me that 
472
FCABLATlSrA.
the head  symptoms in this as in several cases of typhus, might probably
depend not so much upon inflammation of the brain, as is generally sup
posed, as upon absorption of, and poisoning by urea, an idea that appeared
to me supported by the diminished quantity of the renal excretion, as well
as its freedom from all deposit.  Remembering the alleged virtues of col-
chicum in increasing the elimination of this excretion, I ordered it, in com-
bination with  diuretics, and the result Avas  remarkable.   For on the next
day, not only had  the  fever  diminished, but the urine Avas increased in
amount and loaded with urates to an extent and in a form I had never pre-
viously seen.                                         Part xxix., p. 31.

   Scarlatina.—Dr. Bennett remarks, that great watchfulness is required
on the part of the practitioner, especially wdien the crisis is expected, that
if the pulse at all falters, and prostration comes on rapidly, he may be pre-
pared to meet it.  When death does occur in a primary attack of scarlatina,
it is from the  same  cause as in death from typhus—it is from congestion
of the brain, as indicated by delirium, passing into coma, and followed by
prostration of the vital powers.
   All the eruptive  fever., strictly so called, invariably run a natural course,
and cannot be cut short.  It follows that—
   The treatment of febrile eruptions has for its object conducting these
cases to  a favorable termination.  To this end exactly the same general
rules  are  to  be followed as  in continued  fever, and the same indications
exist for the use of salines and laxatives, cold to the head, wine and stimu-
lants, and regulation of the diet.
   Dr. Andrew Wood, physician to Heriot's Hospital,  Edinburg, recom-
 mends the production of diaphoresis.  He considers that the most efficient
 and  safe  method of treatment consists in acting powerfully on the skin,
 with a view of thereby assisting nature to eliminate the scarlatinal poison
 from the system.  As ordinary diaphoretics frequently fail, he has recourse
 to the folloAving method :  Several common beer bottles, containing very
 hot water, are placed in long wrorsted stockings, or long narrow flannel
 bags, Avrung out of Avater  as hot  as can be borne.  These are to be laid
 alongside the patient, but not in contact w ith the skin.  One on  each side,
 and one  between  the legs, will generally be sufficient;  but more may be
 used if deemed necessary.  The patient is to lie between the blankets (the
 head of course being  outside) during the  application of the bottles, and
 for several hours  afterward.   In the course of from ten minutes to half
 an hour, the  patient is thrown into a most profuse  perspiration, Avhen the
 stockings may be  removed.  In mild cases, the effect is easily kept up by
 means of draughts of cold water, and if necessary, the use of two drachm
 doses of sp. mindereii every tivo hours.  In severe cases, where the pulse
 is very rapid—the beats running  into each other—where the eruption is
 either absent or only partial,  or of a dusky purplish hue—where the sur-
 face is cold—Avhere there is  sickness or tendency to diarrhoea—where the
 throat is  aphthous or ulcerated, and the cervical glands swollen, then he
 folloAvs up the use of the vapor-bath by four or five grain doses of carbo-
 nate of ammonia, repeated every three or four hours.  Should this be
 vomited, then biandy may be  given  in doses proportionate to the age of
 the patients.   Carbonate of ammonia he considers to act beneficially : 1st,
 by supporting the poAvers of life ;  2d, by assisting the development of the
 eruption ;  and 3d, by acting on the skin and kidneys.    W here the vapor 
SCARLATINA.                          473
bath was used early in the disease, and its use continued daily, or even tAvdce
or thrice a day, according to circumstances, he  has found  that the chance
of severe sore  throat Avas greatly obviated.   In  regard to supervening
dropsy, he  considers  that, by the use of the vapor bath, Avith the other
necessary precautions as to exposure, diet, etc., its recurrence is rendered
much more rare.  In the treatment of the dropsical cases,  it was  also very
useful, and even might be trusted to entirely  in some cases.  Dr. Wood
also  condemns  all depleting treatment, and  even purgatives, during the
first  ten days, as not only not required, but positively dangerous, as tending
to interfere with the development of the eruption.  In the later  stages, as
well as in the dropsy, however, he thinks purgatives are .often beneficial.
                                                    Part xxvi., p. 22.
   Treatment of Coma, attending.—Dr.  Murphy says  that when coma
exists after or during an attack of scarlatina, the electro-galvanic battery
has been found successful, the s&me as in cases of poisoning by opium. At
the same time a flexible tube may be passed into  the stomach,  and port
wine and ether introduced.                          Part xxix., p. 314.

   Treatment of Scarlatina Anginosa.—[Mr. P. H. Chavasse has had great
experience of practice among children.  The result  of his treatment of
scarlet fever has been so uniformly successful that he has not lost a single
case for upAvard of seven years.  He says:]
   The system I adopt, in a case of scarlet fever, is to keep the bedroom
 cool—I may say cold—and to have a thorough ventilation through it;  I,
 therefore, throw open the windows, be it winter or summer, and have the
 curtains and valances of the bed removed.   If it be wdnter time, I allow the
 patient to have one blanket and a sheet; if it be summer time a  sheet only
 to cover him.  If the throat  be not seriously affected, I merely order  a
 narroAV strip of flannel once around the throat.  If  the  tonsils be much
 enlarged, I apply a barm and ^oatmeal  poultice to the throat, changing it
 night and morning.   I prescribe  an  acidulated infusion of roses mixture,
 that is to say, infusion of roses, wdth an excess of acid, made palatable Avith
 an additional quantity of sirup, to be taken every three or four hours. This
 is the only medicine I give.   Where the child is old enough, I find roasted
 apples, mixed wdth raw sugar, very grateful to the patient.
   Here let me pause, to advise my medical brethren ahvays to make medi-
 cines for children pleasant.  I avoid purgatives in scarlet fever.  I never,
 on any account Avhatever, give a particle of opening medicine for the first
 ten days at least.  It is my firm conviction, that the administration  of pur-
 gatives in scarlet fever is a fruitful source of dropsy, disease and death.
 When we take into consideration the sympathy that  there is between the
 skin and mucous membrane, I think that Ave should  pause before  giving
 irritating medicines.   The irritation of purgatives on the mucous membrane
 may cause the  poison of the skin disease to  be  driven  internally to the
 kidneys,  throat,  pericardium,  or brain.   You may say, Do  you not
 purge  if the bowels be not opened for a iveek ?   I say emphatically,

   Now with regard to food.  If the  infant be at  the breast,  keep him
 entirely to it.  If he be weaned, and under tAvo years old, give him  milk
 and water, and cold water to drink.  If he be older, give him toast and
 water, and plain water from  the pump, as much as  he chooses; let it  be
 quite cold—the colder the better.  Weak black tea,  or thin gruel,  may be 
474                          SCARLATINA.
given, but caring little if he lake nothing but cold water, unless he be an
infant at the breast.  Avoid broths and stimulants of every kind.
  Now, you must warily watch for  a change  of  temperature of the
skin.  As long as the skin is hot, the above plan I steadily follow ; but the
moment the skin of the patient becomes cool, which it Avill do probably in
five or seven  days, instantly close the A\dndow, and immediately put more
clothes on the bed.   But still do not purge.
  You will find the acidulated infusion of roses most grateful to the little
patient; it wdll abate the fever, it a\ ill cleanse his tongue, it a\ ill clear his
throat of mucus, it will, as soon as the fever is abated, give him  an appe-
tite.   I  believe, too, the acid  treatment has  some peculiar properties  of
neutralizing the scarlatinal poison.
  When the appetite  returns, you  may consider the patient  to be safe.
The diet must now be gradually improved.
  Within the last feAV  years, I have had some fearful cases of scarlet fever;
but, relying on this plan of treatment, I have given, even in very bad cases,
a favorable diagnosis.   I have had cases where there have  been violent
headache and delirium ;  ivhere there have been immense SAvellings  of the
parotid and  submaxillary glands;  Avhere  there  have  been enormous
enlargement  and ulceration of the tonsils ; Avhere a  great portion of the
fluid  that has been taken by the mouth has  escaped doAvn the nostrils;
where there has been a purulent discharge down the nose, which discharge
has in many instances  quite excoriated the skin over which it has travelled
—and yet in  such cases the patients have invariable recovered.
  Another very important regulation is never to allow the patient to leave
the house under a month in the summer, and under six Aveeks in a\ inter.
                                                    Part xxxiii., p. 29.

  Hematuria after Scarlet Fever.-—In  those  cases  where we have con-
vulsions, coma, and death, there is no hesitation in  attributing the symp-
toms to urasmic poisoning, any more than if the mischief Avere limited to
renal disturbance.  The congestion  of the kidneys, the hematuria, which
form the incipient stage of the disorder leading to  this uraemia, arise unde-
niably from the imperfect elimination of the original virus.
  According to Dr. Basham, we must endeavor to bring into activity and
act  upon those functions and emunctories which are not,  or only in  a
moderate degree, implicated in the morbid  disturbance,  and  by their
agency relieve, if possible, the  oppressed and  impeded  organs.   Thus,
though the surface of the body is anasarcous, ive must endeavor to promote
its exhaling poAver; and as the intestinal mucous surface gives no indica-
tion of sharing in the  morbid state of the kidneys, Ave must bring its se-
cretions into activity  to purge the  system of the accumulated fluid, and
vicariously, for  a time, relieve the kidneys of their office.   The intimate
sympathy betAveen the kidneys and skin, and  betiveen the latter and the
bronchial mucous membrane, Avhen the latter is the seat of inflammation,
would entitle us  to expect the most beneficial results  by vigorously pro-
moting the cutaneous function ; but unhappily, in these cases, the dropsical
state of the surface of the skin precludes  our obtaining much efficient aid
in this direction.   Warm baths effect oftentimes great temporary relief to
the lungs; the breathing becomes less oppressed, and the  secretion from
the bronchial tubes more free; but the hot-air bath appears to be the most
 efficacious; there is not that  exhaustion which is induced  by a succession 
SCARLATINA.
475
of warm baths, and, to my observation, the amount o~ relie  felt by the
patient is greater.   To  aid these external appliances,  ammoniacal salines
may be given internally with advantage.  Active purging, however, yields
the best results.  It is, however, of importance to select appropriate means
to obtain the greatest amount of relief, for it is not every purgative of the
Pharmacopoeia,which  answers the purpose equally well.  That purgative
which acts most directly as a hydragogue is the  best adapted, but which,
at the same time, is not folloAved by any disproportioned exhaustion, or by
any torpid reaction.  The combination of jalap and cream of tartar is most
admirably suited to these ends.  It  acts quickly, wdthout depressing the
system, is not followed by inactivity,  and induces copious watery  dejec-
tions.
  The appearance in the urine, revealed by the microscope, of that peculiar
pigmentary condition observed in combination with albumen, indicates an
advancing stage of degeneration, and if spread through  both kidneys, must
be quickly followed by an imperfect  elimination  of the chief urinary con-
stituents ; and  this was evident by  the  singularly  Avatery  state of the
urine, its specific gravity not  exceeding 1.005, but containing abundance
of albumen, and this latter, associated Avith a peculiar pigmentary matter,
rendered visible after boiling by the addition of nitric acid.
  It Avould be out of place here to enter into an investigation of the nature
of the pigments that are occasionally met with in  the urine, cyanurin,
melanurin, etc.  Experience tells me that the development of this pigmen-
tary condition,  in combination with albumen in the urine, is of the greatest
import.  It  is  always associated with the most  advanced stage of renal
degeneration, and in every instance in which  I have seen it, it  has been
quickly folloAved by fatal results.   Lehman, in his  "  Physiological Che-
mistry " (vol. ii., p. 428), says, as far as his experience goes, it is only Avhen
urasmic symptoms have manifested themselves, that this peculiarity of the
urine is  generally observable, and this entirely coincides Avith  my OAvn.
We should not, then,  be unprepared for the development of unfirvorable
symptoms whenever this peculiarity of the urine is observed.   Hence the
value and importance  of frequent examinations of the urine in such cases.
  You may learn an important point  here—namely, the suddenness and
abruptness Avith Avhich the symptoms  of urasmic poisoning oftentimes com-
mence.   In some cases,  particularly in adults, the indications are progres-
sive; but here  all  other things being promising, convulsions  suddenly
supervene ; they intermit, but coma characterizes their remission, and the
patient dies forty hours after the first indication of  the urinous poison
acting on the nervous centre.   You  may very properly ask, Can nothing
be done in this crisis ?   Are there no  remedies available for such a state ?
These cases of convulsion are not always fatal; sometimes in the intervals
consciousness returns.   Such cases offer a better prospect for  remedial
agents than Avhen the  patient remains comatose.  In either state, however,
an effort  should be made to excite the boAvels to active excretion. Enemata
containing, according to the age of the  patient, half a drop, or a drop, of
croton oil, should be administered, and Avhere the ability to sAvalloAV is un-
impaired, you  may expect some benefit from the chlorine mixture, the
agency of which, according to the hypothesis of Frerichs, depends  on its
union Avith the  carbonate of ammonia, into wdiich the urea in the blood is
converted, and  Avhich  he considers to be the poisonous  agent in these cases
of fatal uraemia.                                     Part xxxvi, p.  25 
476
SCIATICA.
  Scarlatina.—Some pathologists think that there is a most intimate con-
nection between the materies morbi of erysipelas and that of scarlatina, as
well as other acute diseases.  During a late epidemic of scarlatina at Brad-
ford, Dr. Meade being much struck w ith the  analogy between the symp-
toms of this disease and erysipelas, very successfully applied the tincture
of iron treatment, so useful in the latter, to the former disease, giving five
to fifteen minims, according to the age of the  patient, every three or four
hours.  He has only lost  one  case  during the Avhole of last spring and
winter, and almost all the  cases in which he employed this  treatment  re-
covered with unusual rapidity.
       *        *       *       *       *       *      *       *
  Scarlatina and Measles.—Mr. Witt looks upon the treatment of scarla-
tina and measles by ammonia as a specific.  The dose given is from three to
seven grains of the hydrochlorate every hour, for the  first twenty-four
hours, and  every second hour for the next day.  All acid drinks  are care-
fully avoided.  This is a matter of interest, iioav that the power of ammonia
in retarding the coagulation of the blood has been established.
                                                    Part xxxviii., p. 17
  Scarlatina.—Dr. E. Bishop says that the use of tonics, either the citrate
of iron, or  the tincture of the sesquichloride, not\rarying the plan of treat-
ment, even when serious complications present, will be found very success-
ful  in the treatment of scarlatina.  One gratifying result is, that wdth  few
exceptions the children escape that serious and frequent sequel—anasarca.
                                                    Part xxxix., p. 19.
  Scarlatina.—Dr. Fountain says that  chlorate of potash must not be given
in scarlatina, Avith  the idea that in chlorine something like a specific  has
been found for the disease—if so given it Avill fall into disrepute.  It is a
very valuable remedy for meeting particular  indications in the treatment
of disease, by arresting the ulcerative inflammation of the fauces, and by
its  arterializing  properties, supporting  the restorative powers of nature,
Avhen aided by other appropriate treatment. It may be combined w ith  car-
bonate of ammonia, Avith the best effects.                Part xl., p. 296.
  Scarlatina.—In the early stage, if  attended with high fever, burning
heat of skin, thirst, etc., try full doses of nitrate of potash with mucilages.
                          SCIATICA.
  Treatment of Sciatica and Lumbago.—[Dr. Graves justly remarks that
in acute sciatica and lumbago, one of the most powerful remedies consist?
of morphia, calomel, and James' powder, given in the following way.
Three grains of acetate of morphia, six grains of calomel, and tAvo grains
of James' powder, divided  into eight portions, and one to be taken every
third hour till the gums become affected.   This is to be  assisted by anti-
phlogistic measures,  as blood-letting, general and local, etc., but Avhen the
case becomes chronic, and the patient must of necessity continue his occu-
pation, if possible, he strongly recommends, from personal experience, the
hydriodate of potass.  He experienced, in  his OAvn person, a se\'ere attack
of this disease; against Avhich he struggled for some time, obtaining relief.
He  states as follows :] 
SCIATICA.
477
  Mr. Ferguson recommended me to try hydriodate of potash, of which he
was good enough to send me a drachm dissolved in a pint of decoction of
sarsaparilla.   I  took a quarter of this daily, and may literally apply here
the common phrase, that I  felt  each dose do me good ; in  four  days all
traces of the lumbago were gone, and my lameness had quite ceased. I did
not take more than one bottle, i. e. one drachm of the hydriodate, but the
good effect continued after I had ceased taking it, and in less than a Aveek
I was perfectly wrell.   Subsequent experience enables me to recommend
this medicine strongly, in subacute and chronic lumbago and sciatica.
  In spite of the best-directed means, sciatica is very apt to become chro-
nic, and then spirit of turpentine,  carbonate  of iron, arsenic, extract of
stramonium, corrosive sublimate, blue pill, and iodine internally, blisters to
the loins, thigh, and calf of the leg, acupuncture, croton oil  frictions,  and
other stimulating applications must be successively  tried.  On a former oc-
casion I recommended a combination of opium, Avith spirit  of turpentine
internally, and  ivhen that fails,  Dover's powder, combined Avith  sulphate
of quinine.  I am sorry not to have it in my poAver to lay doAvn any gene-
ral principle, which would enable us to judge in what cases  each  of these
remedies is  peculiarly indicated,  for experience has not confirmed any of
the rules generally relied on, and therefore Ave must content ourselves Avith
treating these diseases empirically.                        Part ii., p. 70.

   Treatment of Sciatica by Irritation of the Foot.—This consists in apply-
ing an olive-shaped cautery, heated to a Avhite heat, betwreeu the little toe
of the diseased limb and the one next to it.  This cautery ought to be ap-
plied to that  part  Avhere  the  nerve  bifurcates  to furnish its collateral
branches to the last two toes; and ought to be  kept there for five or six
seconds.  The  wound should then be dressed with simple cerate, and al-
lowed to cicatrize. A Capuchin monk, affected with sciatica, carried Avith
him in his travels through  various tOAvns,  an  instrument for this  purpose.
Professor Quadri  has often repeated this  operation  at Prati, in Tuscany,
with great  success.   These  circumstances were  brought  to M. Caffe's
memory, by reading an article on the treatment of sciatica,  in Avhich men-
tion avus made of a woman of Cassano Avho had a great reputation for her
success in its cure.  The means Avhich she employed  consisted in the appli-
cation of a certain herb to the foot, Avhich produced a sore.  Various phy-
sicians, astonished at the results produced, took the trouble to find out  that
the remedy  in question was the leaves of the ranunculus sceleratus, Avhich,
as every one knoAvs, is a powerful vesicant.  Dr. Fioravante has employed
common blistering plaster to the same part, with the happiest results.
                                                       Part ix., p. 85.

  Sciatica, treated by Blisters and Morphia.—This patient wras under Dr.
Taylor's care in University College Hospital.  It appears that in lifting a
heavy weight, he had strained his back, and that a few months afterward
he Avas suddenly seized Avith  pain in the right hip—striking into the loins,
and down the leg. On his admission he had still this pain,  but there was
no increased heat of  skin ;  he  Avas ordered to take, three times a  day,
two ounces of guaiacum mixture, with fortyminimsofam.tr. of guaiacum,
and have a good diet; three days afterward he was to increase  the dose
of the tincture  of guaiacum to one drachm three times daily; a blister to
be applied to the  right hip, and the blistered surface  to be dressed twice a 
478
SCIATICA.
 day with one grain of the hydrochlorate  of morphia.  Repeat the blister
■ and morphia Avhen necessary.
   Whether sciatica be rheumatic or not in its  nature, it is certain that the
 seat of the disease is in the sciatic nerve.  In the treatment of this case, Dr.
 Taylor attributes the  cure to the blistering and morphia.  M. Yalleix has
 published an excellent work on neuralgia.  He also recommends the appli-
 cation of blisters, but  Dr. Taylor remarks that:]
   The plan of blistering advocated by M. Valleix is the application of flying
 blisters, as the French term  them.   This consists in having the blisters
 very small, allowing them to heal immediately, and in applying fresh  ones
 as the seat of pain changes.  This  is the treatment  which he has himself
 put in practice, and which he finds more efficacious than any other.  After
 the application of blisters, the  next best remedy in the treatment of this
 disease seems to be the internal administration  of the oil of turpentine.
 Opium given internally generally has very little effect on the disease.
                                                       Part xiii., jo. 61.
   Moxas.—Dr. Thomson  gives a case of sciatica wdiich was treated Avith
 moxas.   Tincture of  guaiacum and aconite Avas  prescribed and  the dose
 increased.  Aconite plaster over the seat of pain.  Cupping over the  part
 and afterward two grains  calomel and one grain opium; then a mixture of
 vin. colchici and tinct. aconite; lastly, six moxas; since which the case has
 done well.
   The  best moxas are prepared by dipping a piece of bibulous paper in a
 solution of diacetate  of lead, drying  it, and rolling  it up in the form  of a
 cylinder. It burns wTell and steadily, leaving an ash of yellow oxide of lead.
                                                       Part xiv., p. 59.
   Bisulphuret of Carbon in Sciatica.—A patient, who, for five years,  had
 suffered at times under a  very painful sciatica, w ith commencing emacia-
 tion of the limb, loss of appetite  and  sleep, and against  which a great
 variety of remedies had been employed, ivas at  last put under alcohol of
 sulphur (the bisulphuret of carbon), used both internally and externally,
 after the method of Wutzer.  At the end of five  days, there was  complete
 removal.
   From the Memoir of Lampadius, it appears to  have been internally em-
 ployed with advantage in rheumatism, chronic gout, j alsy, and cutaneous
 eruptions, and  externally  against  burns: the latter use being dependent
 on its energetic property of producing cold.              Part xv., p. 67.
   Diagnosis of Sciatica  from  Morbus Coxarius.—[Mr. Corfe states
 that  the  folloAving simple  method  enables  us  readily  to distinguish
 betAveen sciatica and inflamed or diseased hip  joint, in those cases where
 difficulty arises.]
   Place the thumb of the right hand firmly on the  great trochanter, and
 the third finger on the tuberosity of the ischium;  then drive the forefinger
 into the space that exists midAvay, and a little above, these two points, and
 if sciatica is  present,  the  patient will certainly ivince. The fingers here
 describe a triangle, the apex of which,  Avhilst it  points toward the sacro-
 illiac symphysis,  also  rests upon the precise exit of the nerve from  the
 pelvis,  and the base  is formed by the line from the trochanter to  the
 ischiatic tuberosity.  But in order to ascertain  if.disease of the hip-joint ia
 present, reverse this triangle, and place the thumb of  the left hand upon
 the great  trochanter,  and  the third finger upon  the tuber ischii, and let 
SCIATICA.
479
the forefinger be driven into the apex of that triangle, of Avhich the two
former fingers describe the base, and it will be found to be immediately
over the articular surface of the hip joint, and which will certainly cause-
pain if inflammation exists in it.  It will be observed that the apex of this
triangle looks downward toward the lesser  trochanter.   These directions
apply to the detection of the seat of pain on the left side;  but  wdien the
right hip is examined, the hands of the operator should be reversed to the
above description.                                   Part  xvdii., p. 104.
   Sciatica Cured by  Cauterizing  the  Ear.—[However  singular  it may
appear, M. Malgaigne did actually apply the red-hot iron to the anterior
part of the right  helix  in a case of sciatica, and  his patient  was cured
forthwith.  Similar success is stated to have resulted on more recent occa-
sions at the Hospital St. Louis, and]
   Dr. Lucciana of Bastia relates in the " Journal des Connaissances Medico-
Chirurgicales," 1st May, 1850, a radical  mode of curing sciatica, popularly
practised in Corsica, and consisting in the application of a red  hot iron to
the ear, and exactly on its helix.  The cauterization cures the sciatica in-
stantaneously, or at least effects immediate improvement.  The operation
is in Corsica uniformly performed by the farrier, and the inhabitants, when
affected with sciatica,  lose no time in applying for his assistance.   In confir-
mation Lucciana adduces some cases of sciatica which he had in vain attempt-
ed to cure in the hospital  of Bastia by other therapeutical  methods, and
which yielded to the  farrier's cautery, as if to a charm. Part xxii., p. 86.
   Sciatica.—Sciatica, not connected wdth mechanical causes, as tumors,
accumulation  of faeces, etc., may be  cured  in fourteen  days by rubbing
along the affected nerve, from above downward, 3ss. of veratria ointment
(gr. v.  to  §ss.), every night at bed-time.  The friction to  be performed
with a horse-hair glove until severe tingling is produced.
        ********
   Sciatica and Neuralgia.—Some cases recorded by Dr. Belcombe Avere
entirely cured by the insertion of a needle just at the seat of pain, to some
depth, and another tAvo inches loAver in the same direction. These were
kept in for tAvo hours, and then  wdthdrawn.   In cases of sciatic  lumbago,
give acetate of potash in compound infusion of senna, the patients finding
much relief from, the movement of the lower  bowels, and pressure being
taken off the kidneys.  In the neuralgia of the upper extremity, carbonate
of iron in full doses was given.                         Part xxv., p. 74.
   Use of Croton Oil.—[Mr. Hancock is of opinion that mechanical irri-
tation of the nerve Avithin the pelvis is the most frequent cause of sciatica.
This may be from loaded colon or caecum, or from tumors formed within
that cavity.]
   In cases where sciatica depends  on local irritation of the nerve wdthin
the pelvis from accumulation of  faeces  in  the  colon or caecum, the follow-
ing pills generally produce a good effect;  the  patient, however,  should be
warned of the activity of the  remedy.   Croton oil, one minim; blue pill,
extract of hyo»yamus, each four grains;  compound extract of colocynth,
eight grains; to be divided into four pills, twTo to be taken at night, and
repeated as the case may be.                           Part xxix., p. 71 
480
SCORBUTIC AFFECTIONS.
                  SCORBUTIC  AFFECTIONS.
  Extract of Monesia— Suggested in the form of pills,in scurvy.  Dose,
from 12 to 36 grains during the day.                     Part ii., p. 77.
  Tincture of Cantharides.—Mr. Irven has introduced a neAV remedy for
the cure of this disease.  He administers tincture of cantharides ; at first,
in doses of from ten to twenty drops, three times a  day, inc. easing the
quantity taken in  the  twenty-four  hours, according to circumstances, to
about eighty drops.  At the same time that an improvement in the gene-
ral  health becomes perceptible, the urine  becomes clear, and is found to
contain albumen, which is said to be uniformly absent from the urine of
scorbutic patients.                                      Part vii., p. 13.
  Purpura,  or Land Scurvy.—Scurvy is the old name for purpura hemor-
rhagica, and  land  scurvy for purpura Avithout hemorrhages: the tAvo dis-
eases are alhed; they are only varieties of  the same disease.
  [It consists in a  lesion of the capillary system and of the blood, wdiich is
deficient in fibrin.  Dr. Laycock observes that if not checked, the disease
will assume  as formidable an appearance as marine scurvy; there wdll be
spreading ulcers, the gelatinous fungus on the skin and gums termed by
sailors "bullock's liver," and finally death.   He says:]
  The explanation of the symptoms is not difficult.  The morbid condition
of the blood has  impaired  the contractility of the vascular system.  In
the depending portions of the body the  capillaries  give  Avay from the
mere  gravitation of their contents;  thus giving rise to the vibices in the
legs, and  in  the  under surfaces of the thighs.   The petechias  are really
small inflamed or congested  papillae,  or the mouths of sebaceous glands.
The muscular pains are those of fatigue; there is not enough fibrin in
the blood for the nutrition of the muscles and the maintenance of their
action.
  Let the diet be  varied, and consist partly of  vegetables, which contain
acids: rhubarb, cabbage, potatoes, sorrel, water cresses, nettle tops, lemons,
oranges, etc.  Give  citric  acid four grains every four hours; or  give
nitrate of potash.                                       Part xv., p. 39.
  Deficiency of Potash in the Blood, a Cause of.—Dr. Garrod points out
many objections to the opinion that a deficiency of any of the organic con-
stituents of  the food  produces scurvy; and states that from minute re-
searches into the composition of scorbutic or antiscorbutic articles of diet,
and into the  state  of the blood in scorbutic patients, he has been led to the
following conclusions:
  1st. That in all  scorbutic diets, potash exists in much  smaller quantities
than  in  those which  are capable  of maintaining health.   2d. That all
substances proved to  act  as anti-scorbutics contain a  large  amount of
potash.  3d. That in  scurvy the  blood is deficient in potash, and the
amount of that substance thrown out by the kidneys less than that which
occurs in health.   4th.  That scorbutic patients will recover Avhen potash is
added to their  food,  the other constituents remaining as uefore, both in
quantity and quality, and without the use of succulent vegetables or milk.
5th. That the theory which ascribes the cause of scurvy to a deficiency of
potash in the food, is also capable of rationally explaining many sjmptoma
of that diseas?. 
SCORBUTIC AFFECTIONS.
481
    If medicine is to be prescribed, give 10 or 15 grains of the phosphate,
  chloride, or tartrate of potash tAvice or three  times a day either in water
  or wdth food.                                         Part xvii., p. 23.

    Treatment of Sea Scurvy.—The whole treatment of sea scurvy may be
  summed  up  in a few words.  Supply the system freely wdth protein, by
  giving patients freely those vegetables in which it most abounds.   Many
  English  naval surgeons maintain that vegetable acids alone are not suf-
  ficient to cure scurvy, and that a portion of fresh  animal food is necessary
  for a cure.                                            Part xviii., p. 53.
    Scurvy.—It would appear from  experiments made on board convict
  ships by Dr. Bryson, R. N., that the remedial powers  of citric  acid  and
  lime-juice, in scurvy, are about on a par;  and that the good effects of both
  of them  are probably increased by the addition of sugar.  As a prophylac-
  tic, citric acid has not been fairly tried, but lime juice, with sugar, is un-
  questionably of the greatest advantage.  Nitrate of potash  Avould appear
  not to possess antiscorbutic properties, and not to be adapted either for a
  prophylactic or a curative agent.                        Part xxi, p. 33.
    Purpura  Hemorrhagica.—Mr. Budd, physician to Bristol Infirmary,
  says:
    Although purpura is certainly a disease connected Avith a dissolved and
  thin condition of the blood, yet it is also more than probable that weakness
  of the vessels themselves, from defective nutrition of their Avails, has a still
  larger share in the result; the symmetrical distribution of the ecchymoses,
  proving the correctness of this supposition.  On this ground, the very  valu-
  able properties of turpentine as a styptic, both applied locally and adminis-
  tered internally, is strongly recommended, great  benefit having been pro-
  duced by it, when all other measures had failed.   IVenty minims of the
  oil may be given  in emulsion every six hours.   A similar testimony of the
  styptic properties of turpentine is quoted from the illustrious Hunter, and
  also from Mr. Vincent, late surgeon to St. Bartholomew's Hospital.
                                                       Part xxii, p. 118.
     Case  of Purpura Hemorrhagica treated by Turpentine.—A gentleman,
  aged  22, Avhile coughing, expectorated a large quantity of dark  colored
  blood.  The respiratory sounds  were natural, but the limbs Avere found
  covered  Avith the peculiar  eruption  of purpura.  He was an  excessive
  smoker, and was generally from this cause in a state of salivation.
    The treatment consisted in an acid mixture, and a dose of aperient pills ;
  the boAvels  being sluggish.  For the following three  days  this treatment
  was continued Avithout change, except that a grain of ipecacuan was added
  to the pills.   The hemoptysis subsided.  A few days afterward, the patient
  suffered severe pain in the testicle, and on voiding his  urine, it was mixed
  with a large quantity of blood.  No material improvement following upon
  the administration of the acid mixture, aperients, and gallic acid, the treat-
.  ment was changed and replaced by turpentine in the following form:
    R Spiritus terebinthinas, 3ij.; sacchari albi, pulveris acacias^ aa* 3ij-;  tinc-
  tur. lavandulas comp., 3j-; aquas menthas piper, ad gviij.  M. Fiat mistura.
    Of this he took an ounce three times a day.  The  turpentine has  been
  continued with the best effects.   The urine  has acquired, its healthy cha-
  racter, a*hd the patient expresses himself as feeling quite av ell.  In about a
  week the turpentine was  stopped, and a few drops of the tincture of the
      VOL. II.—31 
482                           SCROFULA.
muriate of iron, tAvice daily,  prescribed in its place, with a compound
rhubarb pill as an occasional aperient.   There has been no return of the
symptoms.
  As to the cause of the diseased blood, Dr. Willis ascribes it to  excessive
smoking.  He says:
  I believe that the fumes of tobacco, if long inhaled, possessing as they do
narcotico-irritant properties, are quite as capable of reducing the consist-
ency of the blood as some other agents of the same character;  and that
the essence of purpuric symptoms is a fluid or defibrinaled condition of the
blood.                                               Part xxix.,  p. 49.
   Chlorate of Potash in Scurvy.—[Mr. Corner, the resident medical offi-
cer on board the Dreadnought Hospital Ship, always relies upon the chlo-
rate of potash in scurvy.]
  Chlorate of potash has the effect of curing the spongy state of the gums
in this disease much  more rapidly than any other treatment.  It  should be
combined wdth lime-juice.  This salt appears to be curative in all inflam-
mations  of  the mouth and gums Avhatever their cause, syphilitic and can-
cerous affections alone excepted.                      Part xxxvii., p.  29.
  Purpura Hemorrhagica.—The use of the tincture of larch bark is recom-
mended in the treatment of purpura hemorrhagica.   Four cases are related
in Avhich improvement certainly seemed to date from its use.  Dr.  Moore
remarks that the tincture is one of the most elegant forms at our disposal
of prescribing  a terebinthinate, either as  an  addition to a compatible  ex-
pectorant, or other fluid mixture, or to be given per se.  The close is from
3ss. to 3iij.; of the extract, from gr. j. to grs. v.  The ATalue of terebinthi-
nates in the treatment of purpura has  been long acknoAvledged, the diffi-
culty of their exhibition having alone restricted their employment in many
instances; Avhereas in  the preparations of larch bark, Avhilst all the valu-
able styptic qualities of the turpentine are retained, its exhibition is not
attended with disagreeable results.                   Part xxxix., p.  87.
                         SCROFULA.
  Leaves of the Walnut in Scrofula.—M. Negrier published a memoir
on  the  use  of walnut  leaves  in  scrofula,  which  he  regards,  after
numerous experiments, as one of  the best antiscrofulous remedies that we
possess.
  M. Negrier concludes his memoir with the following directions for the
preparations of walnut.   The infusion is made Avith an ounce of the lea\ es
in twelve ounces of boiling water ; it may be sweetened w ith sugar or the
sirup presently to be noticed.  Two or three cupfuls may be given daily,
or even five.  The decoction is made with a handful of the leaves, boiled
for fifteen minutes in a quart of water.   The extract may be made in the
usual manner from the dried leaves.  For the sirup, eight grains of the
extract are mixed with thirty-tAvo scruples of common sirup; infants and
young children  may take tAvo or three teaspoonfuls  in the day ; adults
three drachms.  The pills  may be made of the extract,  four grains in
each; from twro  to four in the day.                      Part iv., p. 60.
  Medicinal effect of Manganese  in  Glandular Swellings and  Cutaneous 
SCROFULA.
483
 Diseases.—Dr. Krigeler, an Austrian  practitioner, having remarked that
 many Avorkmen wdio Avere previously affected Avith glandular swellings and
 cutaneous diseases, had by degrees got rid  of those  affections Avhile em-
 ployed in a bleaching factory in wdiich oxide of manganese was used, has
 since employed the  latter substance for the cure of such complaints wdth
 the  happiest  results.   Its  administration to children  with scrofulous
 enlargements of the glands, in doses  of one to five centigrammes  (one-
 seventh  to  three  quarters  of a grain), has  been found  in  a very short
 time to be  attended by a  diminution of the  swellings,  wdiich  haA>e
 eventually disappeared altogether under the use of the medicine.
                                                       Part vii., p. 90.
   Treatment of.—The basis of a very rational plan of treating  scrofula
 consists in the administration of alkalies, and the continued use of highly
 annualized diet.   Chemistry has lately shown in an interesting manner the
 reason of this fact, Avhich is, that phosphates  are  passed  in  the urine of
 scrofulous patients to an  extent  many times greater  than  natural.  The
 reason for the avoidance therefore of vegetable  diet, which, by  forming
 lactic acid, tends to dissolve the earthy phosphates,  and the persistence in
 the use of alkalies, Avhich neutralize the acid in the system, is clearly shown.
                                                       Part xii., p. 301.
   Treatment of.—Dr. Willshire, physician to the infirmary for children, saya
 iron is very valuable in the treatment of  scrofula; to  children at the
 breast give the vinum ferri, but for older  children,  nothing is better than
 the  sesqui-oxide, from one to three teaspoonfuls daily, mixed  with treacle.
 Quinine is also useful;  but  especially iodine.  To the youngest  children
 Ave may give  a  grain of iodide of potassium in distilled  Avater, sweetened
 immediately before  administration, thrice a day.  If the child is above a
'year old, from one-tenth to  one-eighth of a grain of iodine may be added;
 and  the dose increased according to age.  For external use the compound
 ointment, or the compound tincture  of the pharmacopoeia, wdll do ; or a
 lotion  Avith  from  gr. v. to  3ij- of  iodide  of potassium to  an ounce of
 distilled Avater.  Or Avhen more counter-irritation is needed, paint on the
 skin near the affected part, a solution of a  drachm of iodine and a drachm
 and  a half of iodide of potassium to half an ounce of  alcohol.
                                                       Part xvi, p. 60.
   Scrofula.—Dr.  Graves recommends  cod-liver oil; enlargements of
 the tonsils and of the cervical glands Avill disappear  under its  use.
                                                      Part xvi., p. 62.
   Scrofula.—In addition to the usual hygienic treatment, Mr. Bulley recom-
 mends small doses of the purest sulphur, Avhich has the effect  of accelerat-
 ing the capillary circulation, and restoring the defective animal heat.  The
 following formula maybe used : R.  Sulphur, purif. gr. at. ad x.; sirup simp.
 3j.;  aquae 3vij.;  bene terendo ft. haust.  To be taken  once or tAvice a day
 iu a tumblerful  of neAV milk.  A slight  chalybeate may sometimes be
 advantageously added.                                Part xviii., p. 152.
   Treatment of Scrofula as it affects  the External Lymphatic Glands.—
 Mr.  Balman says, the best application  for almost  every kind of scrofulous
 sore is  certainly the iodide  of  lead ointment: the  ung.  hyd. nit. oxid. is
 more stimulating for some very indolent and flabby  sores; but the former
 has generally succeeded with me so Avell that I noAV seldom use any other. 
484
SCROFULA.
  The disposition to scab seems very remarkable in all these kind of sores;
and however beneficial this process maybe in other wounds, it very nearly
always tends to impede, rather than otherw ise, the healing of  scrofulous
ulcers, not only by preventing granulation from forming, but, by allowing
the ill-conditioned  materials  to  accumulate and fester  under  it, causes
further  destruction to the subjacent tissues.   I have generally, therefore,
directed a poultice  to be applied  until the sore  becomes clean, and then
endeavor  to prevent  their   reproduction  by some of  the stimulating
applications already alluded to. I have used a cataplasm composed of bran,
linseed,  and common yelloAv soap, Avith very good effect in these cases.
  We have observed, that these glandular swellings are met wdth under a
great variety of circumstances.   The patient may,  for example, present
the fine, delicate, Avhite skin, the tumid lip, and crimson hue of cheek, and
the languid, listless, and enfeebled gait  so familiar  to us in persons pos-
sessing  the well-marked lymphatic temperament;  or  all these signs of the
strumous constitution may be for the most part wanting, and Ave have the
outward characters of a sound and vigorous constitution ; or there may be
evidences of a previously acquired syphilitic taint sufficient to justify our
pronouncing this to ha\re been the  primary exciting cause of the disease.
A disease, therefore, occurring under so many and varied aspects must of
necessity require different modes of treatment.  If, for instance, the sw-el-
lings appeared for the first time after an  attack of  primary syphilis,
the iodide of potassium and  sarsaparilla wdll be found the best  remedy,
all other remedies, as far as my experience goes, being  perfectly useless.
   I have made trial of most  of the reputed, antiscrofulous remedies, and
must confess with very different results.  The  following, however, deserve
some notice : mercury, barium, iodine, alkalies, cod-liver oil, etc.
   The hyd. bichloride may be given in doses of from 1-16th to l-20th of a
grain dissolved in distilled water, or in the  form of pill, with the ext. of
sarsa. twdce or thrice a  day. In  cachectic  chlorotic,  and other  cases
attended by a languid circulation and much general debility, barium may
be used as folioavs :  R. Baryta chlorid., gr. x.;  tinct. ferri mur., 3ij- to gss.;
sir. aurantii, gss.; aq. dest., §x. Mix ;  of this gss. to  §j. may be given two
or three times a day.  Cod-liver oil has little or no influence in the great ma-
 jority of glandular tumors;  but  in some forms  it is a potent remedy, as
Avhen associated with caries of the bones or phthisis.   Phosphoric acid, as
a medicine, is also most valuable.   It may be given in the infusion of ca-
lumbo,  beginning with  five grains of the dilute acid  of the pharmacopoeia,
gradually increasing it to twenty or more.
  As regards the treatment of  scrofulous swellings,  I believe that much
harm is sometimes  done by the indiscriminate  use  of frictions Avith  the
iodine ointment and other compounds, by inducing a  Ioav form of inflam-
matory action in the skin and integuments, and the chance of bringing on
suppuration  which it is desirable in  many cases, for  reasons before stated,
to prevent.  On this account, and also from the fact  that the action  of all
such applications is very feeble in dispersing the tumor under any circum-
stances, I seldom noAV have recourse to them.
  In the absence of all signs of inflammatory action after a trial of some
of the foregoing internal medicines, I prefer, as a counter-irritant, penciling
the part Avith the solid  nitrate of silver a few times,  at intervals of a week
or ten  days. This, I think, is a milder and safer  proceeding than  the
use of blisters, the  action of Avhich is more diffusive and irritating. 
BEA-6ICKNES8.
485
  It is hardly necessary to insist upon the utmost attention being paid to
a variety of circumstances regarding the general management of scrofula ;
such as good and Avholesome food, good  air,  sea-bathing,  exercise,  and
various other hygienic means, Avhich are  known to exercise the happiest
effects in every form and variety of this disease.         Part xxiv., p. 40.
   Use of Proteine in Scrofula.—In  the  case of a boy, proteine, given in
three-grain doses, three times a  day, the dose being afterward  increased
to five grains, produced the most remarkable effects—iron and other tonics
having been previously given wdthout any improvement.
  In another patient, aged two years, an emaciated, strumous  child, with
tumid abdomen and enlarged cervical glands, and numerous ill-conditioned
ulcers on the loins," nates, thighs, legs, and arms, with symptoms  of mesen-
teric disease.  Dr. Taylor ordered zinc ointment, and occasionally a poultice
of equal  parts  of linseed-meal  and  wheaten flour, to be applied  to the
ulcerated parts; and to  take, proteine,  two grains,  soda exsiccata,  one
grain, three times a day, in sugar and water.
  First week.—The skin  has  become cleaner and more healthy,  and some
of the  ulcers have healed; several that  are  noAV open display in a very
remarkable  manner the appearance of softened tubercles ; the child looks
more lively; boAvels regular; appetite better; takes beef-tea twice a day,
and milk night and morning.   To have mutton for dinner.
  Second Aveek.—Greatly improved in every respect; has begun  to run
about again, which she has been incapable of doing for the last six  Aveeks;
nearly all the  ulcers have healed;  abdomen smaller; has gained  flesh;
appetite excellent; bowels regular;  sleeps Avell.  Ordered the proteine to
be continued in doses of three grains, soda exsiccata, one grain.   A month
afterward,  the little  patient  ivas running about in excellent health  and
spirits.                                             Part xxviii., p. 38.
  Scrofula—Anemia—Boils.—Dr. Christophers considers the liquor cin-
chonas hydriodatus cum ferro a very valuable  preparation of iodine.  It
may be given in  doses varying  from fifteen minims to two drachms.  It
does not  produce the evil effects Avhich arise from small doses of  the other
preparations of iodine.  Another neAV preparation, the liquor  cinchonas
hydriodatus, in doses Ararying  from  one to three drachms, is  equally
valuable in secondary syphilis when the usual treatment has failed.
                                                  Part  xxxiv., p. 217.

                              ---•-•-•---


                      SEA-SICKNESS.

  Sea-Sickness.—As preventives, Dr. D. F. W. Fisher  recommends active
exercise and a tonic regimen for  some days before embarkation; and Avhen
on board, keep on  deck in  the breeze,  make large inspirations,  Avear a
girdle, walk quickly till  perspiration or  fatigue is caused,  or engage in
some hard Avork, such  as helping the sailors, hard  wrork being the surest
prophylactic; and take warm and exciting drinks, as tea or coffee  Avith a
little brandy, or diaphoretic medicines, opium,  saffron,  or acetate of
ammonia.  When the  sickness  has come on, nothing will do except pal-
liatives: he  down with the head Ioav, in  a hammock or a suspended bed,
and take stimulant aromatics, lemons, etc. •            Part xvii., p. 293. 
48(3
BENSATION—8ILTER.
  Sea-Sickness.—We may often succeed in preventing an attack of this
by creasote, and the best and most convenient form is to have it made up
in lozenges, about  one drop in each, one or two of wdiich  can  be taken
when necessary.                                    Part xxxiii., p. 321.
  Sea-Sickness.—Give from ten to tAvelve  drops of chloroform  in Avater,
and if necessary repeat it.  It  is  said by Dr. Landerer, of Athens, to he a
" sovereign remedy."  The patient  soon becomes able to  stand up, and
gets accustomed to the movements of the vessel.      Part xxxv., p. 306.
                       SENSATION.
  Reflex Sensations.—Dr. R. B. Todd says : The irritation of a calculus in
the bladder will give rise to pain at the end of the penis, or to pains in the
thighs.  Irritation of the ovary will cause  pain  under the right or left
mamma ; stimulation of the  nipple, whether in male or female, gives rise
to peculiar sensations referred to  the  genital organs; ice suddenly  intro-
duced into the  stomach will cause intense p^in in either supra-orbital
nerve ;  acid in  the stomach is apt to cause a similar pain, Avhich may be
very quickly relieved by  the neutralization  of  the acid.  Phenomena of
this kind imply some  closeness of connection between  the nerves of the
sympathazing parts in the centre, probably by means of commissural  fibres
connecting the respective points of implantation  of the nerves Avith each
other.                                                 Part xx., p. 51.
   Sensation—Loss of from Hysteria.—Dr. Roivdand cites a case of this
kind in a young woman, aged 25,  which various remedies failed to relieve,
who ivas gradually cured by the  patient persevering in taking the folloiv-
ing, in the form of a draught, three times a day.  Tinct. ferri sesq.,  mxv.;
tinct. cantharid., miv.; and tincture of aloes, mxx.       Part xxix.,  p. 68.

                                  • > >—

                            SILVER.
   Nitrate of Silver— Use of, in Stricture of the Urethra—In Fissured or
Excoriated Nipples—Skin Diseases—Affections of the Mucous Membrane
of the Throat, etc.—One of the most useful remedies in medicine is the
nitrate  of  silver; whether we regard its use externally or internally, Ave
must  look upon all improvements in its mode of application  as very desir-
able; the form of nitrate  as an external application has not been improved,
neither is it necessary, as  its  qualities in the present form are  such  as we
require.  As an external application, however, nitrate of silver  has been
greatly extended of late,  and especially since some able publications on its
use in different diseases.   In stricture of the urethra it has long been used,
acting, not as is commonly supposed,  by destroying the stricture, but " by
inducing some change in the vital  actions of the part, Avhich is folloAved by
relaxation of the narroived  portion."  In fissured or excoriated nipples, it
is occasionally very useful, and  certainly superior in many cases to the
tincture of catechu, which  has  lately been  so  praised in these affections.
In porrigo, the solid nitrate of silver, by being well rubbed on the part, 
SILVER.
487
 will seldom fail in either curing the affection or  considerably improving it
 —the cauterization should be repeated at intervals  of a few days.  In
 psoriasis and impetigo, it has also been found useful;  but more especially
 in erysipelas, both when rubbed  on the sound  skin round  the inflamed
 portion so as to separate the latter from the former, and also when rubbed
 all over the inflamed surface.  In affections of t/ie mucous membrane of
 the mouth and fauces, it is occasionally an invaluable  application.  " AVdien
 the fibrinous exudation of croup  commences on the surface of the tonsils
 and arches of the palate, its further progress may be stopped  by the appli-
 cation of a solution composed of a scruple of nitrate of silver and an ounce
 of distilled  water.  The solid nitrate has been introduced through an
 aperture in the trachea and applied to ulcers on  the inner surface of the
 larynx, in a  case of phthisis laryngea with  apparent benefit.  (See Dr.
 Pereira's work on Materia Medica, p. 696.)  A  case of diphtherite illus-
 trating its good effect on the mucous membrane  of the throat is related in
 the " American Journal" of Medical Sciences, in which Dr. Gibbes applied a
 saturated  solution with benefit, to an ulcer half an inch in diameter, over
 the left tonsil and  to the fauces, by means of a small sponge, which was
 thrust  far back into  the pharynx.  Every application ivas attended A\dth
 relief, and it was repeated every two or three hours Avhen the albuminous
 accumulation Avas present.                              Part xl, p.  178.
   Chloride of Silver—Therapetitic Properties of.—The chloride of silver,
 which was formerly recommended by Poterius, as an anthelmintic  and
 hydragogue;  by Hoffmann,  as  an  evacuant of phlegm in  dropsy  and
 melancholy ; by Tachenius, as an  excellent  remedy combined  with the sul-
 phuret of antimony, for  mania, melancholy, and epilepsy; and lastly, in
 modern times, by Professor Series,  for syphilis—has been  employed iu
 various cases by Dr. Perry.
   He declares that he has found it preferable to the nitrate  of the same
 metal, inasmuch as its effects are more  certain, its application  easier, is less
 disposed  to decompose,  and  free from any disagreeable   taste.  The
 chloride of silver acts best in the form of pills; nevertheless, for young
 children, it can be  prescribed in  the  form of powders, or suspended in
 some appropriate  sirup.  The use of  this  salt  inwardly is not attende.i
 with  the risk of the green  or brown discoloration of the skin, as wdth
 nitrate of  silver.  Dr. Perry has  prescribed the  chloride for epilepsy;  he
 has also given it in chronic dysentery;  under its  influence the  number  of
 stools  and other symptoms have  diminished; he has used it also in sup-
 pressed menstruation ; and lastly,  in the secondary form of syphilis.
                                                       Part ix., p. 84.
   Oxide of Silver.—There are certain  diseases of the mucous surfaces of
 the alimentary canal, bladder, uterus, vagina, etc;., which  often baffle  our
 best attempts at relief, for example, pyrosis,  menorrhagia, and  leucorrhoea ;
 and there are endless affections wdiich probably depend  upon  some  irrita-
 tion  in  the nervous centre, either immediate  or distant, which equally
 baffle our efforts at relief.   Sir James Eyre has published a little work, in
 Avhich  he extols very highly the oxide  of silver as a  poAverful tonic, seda-
 tive, and astringent, and states that in these  tiresome cases it Avill be found
 very valuable.                                         Part xl, p. 107.
  Stains from  Nitrate of Silver, to  remove.—Moisten the spots several
times  Avith  a solution of hydriodate of  potash, and expose the part to the 
488
8ILTEX.
direct  rays of the sun.   The hydriodate converts the black stain  of the
nitrate into the Avhite ioduret of silver.  A trial of its use internally is also
recommended in those cases where the skin has been tinted by the internal
use of the nitrate.                                     Part xix., p. 254.

   Oxide of Silver.—Dr. Lane says that the conjunction of  oxide of silver
wdth confection of roses  is  injudicious, as a salt  of silver is liable to be
formed, though certainly the  tendency of metallic oxides  to be acted on
by the vegetable  acids (gallic, malic, or citric)  varies  much.   The com-
bination of essential oils with the oxide of silver is exceedingly objection-
able, for the chemical union of the  oxygen Avith  the  silver is  not very
powerful;  neither is that  of the hydrogen and carbon in the essential oils ;
the substance in question, therefore, being intimately commixed, silent or
explosive composition will inevitably ensue, the  oxygen  and hydrogen,
forming Avater, while  the silver remains in a metallic state, or is converted
into a carburet.  An  analogous, though more complicated  action, I think,
takes place where the vegetable acids are concerned.  I should not  recom-
mend any  druggist to dispense a prescription wherein the  oxide of silver
and an  essential oil are  conjoined, without communicating ivith the pre-
scriber, if possible.
   The  combinations  of the  oxide of silver which  I chiefly employ, and
should recommend, are as follows:  1. With extract of gentian or chamomile.
2. With extract of hyoscyamus or conium, to which I often add a small
proportion of ipecac.  3. With inspissated ox-gall.   4.  With the aqueous
extract of opium.  5. With  compound cinnamon powder.  The pills never
should be  rolled or kept in carbonate of magnesia.      Part xvi^p. 296.

   Nitrate  of Silver Stains.—Messrs. Smith  have advised  a process,
already suggested by others, Avhich is remarkable for its simplicity.  The
stained portion of linen is well saturated with a strong solution of chloride
of  lime.  This converts  the  silver to  a Avhite chloride, which is then
removed by ammonia, or by a solution of hyposulphate of soda.   If the
stain  be deep in the fibre  and  of old  standing, this process must he
repeated several times before it is effectually removed.

   A solution  of the  cyanide of potassium is also useful in the removal of
these stains.   The plan of converting them to iodide of silver by tincture
of iodine,  and washing out  the iodide by hyposulphate  of soda, is not
always successful.                                     Part  xxi.,p. 299.
   To Remedy the Fragility  of Nitrate of Silver Crayons.—The brittle-
ness of nitrate of silver is the source not only of considerable loss of the
material itself, but frequently of danger to the patient, as when the fauces,
ossophagus, urethra, bladder, and cavity of the uterus are being cauterized.
M. Chassaignac has  succeeded  in remedying this  evil, by having  in the
centre of the stick of caustic  a thread of platinum wire.  M. Blatin  secures
the same object by  a wick  of  cotton, Avhich is placed in  the mold before
the fluid nitrate is poured into it.   The crayon thus prepared  is rendered
more solid, and, when broken,- the fragments remain attached  to  one
another.                                              Part  xix., p. 324.

   To remove Nitrate of Silver Stains.—Mr.  Collins, in a number of the
" Dublin Med. Press," recommends to brush over the stains on the linen,
skin, nails, or teeth, wdth a solution of cyanide of potassium, eight  or ten 
SINUSES—SKIN.
489
grains to 3j. of distilled water.  If the stains are superficial, one or tAvo
applications will suffice;  if deep, several will be required.
                                                     Part xx., p. 148.
  Nitrate of  Silver Stains.— Accident  first led  M.  Martinenq  to  the
observation, which he has  since repeatedly confirmed, that  the  stains
produced by nitrate of silver  on linen, etc., may be readily  removed  by
Avetting the linen in a solution of bichloride of mercury  ( 1 part to 31 ),
rubbing it well, and then  washing it well in cold water.
                                                     Part xx., p. 294.
  Nitrate of Silver.—Mr. Ward recommends  instead of  dissolving this
salt in water, to dissolve it in common nitric ether.   The ether acts as a
solvent of greasy matter on the skin,  and from its volatility, quickly dries,
enabling us to  apply several coatings  of the solution in a short time.  The
strength may vary, but about eight grains to the ounce wdll  generally  be
sufficient.  In  erysipelas, this  will be found an  improvement.
                                                    Part xxxi, p. 236.
                           SINUSES.
  Treatment of Chronic Sinuses by strong Nitric Acid.—Mr. Skey  says,
whenever inflammation, or even redness, has attended them, the application
has generally failed;  but the large majority of  these  canals  are not
inflammatory, but chronic.
  The mode of applying the escharotic is by means of a fine glass tube of
length sufficient to reach the full extent of the sinus.  At one end of the
tube is a small glass bulb.   The air is sufficiently exhausted  by the hand,
when warm, to draw up sufficient acid to fill the tube, and  partly so the
bulb.   The instrument, thus armed, is passed into the sinus, and the acid
discharged, either by the hand, or by the aid of a lucifer match, wddle the
tube is slowly withdrawn, pouring out its contents  along the entire track.
                                                  Part xxxiii., p. 239.
                             SKIN.
  Functions of the Skin.—1st. The skin is an external lung, an aerating
mechanism spread out over  the  body's entire surface.   Both lungs and
skin abstract oxygen from the atmosphere, Avhich they replace by carbonic
acid and watery vapor.  A healthy cuticle, then, must be freely permeable
by elastic  fluids  (gases and vapors).   2d. The  cuticle is  very  profusely
perforated  by minute  valvular orifices, openings of the SAAreat-ducts; the
skin is the grand drainage pipe of the body;  and when,  on indubitable
authority, Ave learn that,  computing  2,506 square inches  as  the  body's
supernual contents, its linear  amount of drainage pipe is  about tAventy-
eight  miles—an hour's  railway ride forsooth !   (Wilson)—we  shall  arrive
at something like an appreciation of the importance of keeping this pipe-
age pervious.
  Noav, from the two just named properties,  the skin is manifestly comple-
mentary or vicarious in its functions to those two vital organs, the lungs
and kidneys; therefore an  obstructed skin throws the wdiole onus of elabo- 
490
SKIN—SKIN DISEASE.
ration  upon these latter organs, which consequently become overworked
and diseased.   3d. This is not all.  The skin is a  decarbonizing  organ ;
opening into the cuticle, in common Avith the hair follicles, are the orifice?
of the "fat glands," Avhich secern an oily matter  (for the skin's lubrica
tion) from the blood; if alloAved to collect,  this fatty matter checks the
" transpirability " of the skin,  by glazing it over Avith a sort of natural var
nish, thus throAving the Avhole Avork7>f decarbonization upon the liver; tie
fat cells become gorged, and  thus arises that most grave malady " fatty
liver," good enough in a pasty, that is, if there be any virtue iu pate de foia
gras, but no trivial calamity to any unfortunate human possessor.  Carbon
is retained, moreover, in the blood, depriving the sentient lining of the ar-
teries and left heart of their proper stimulus; and carbon thus, Avith saline
and other impure matters circulating through the brain, deranges that organ
of organs.  The connection, then, between a clear head and a clear skin is
closer  than the unlearned might suppose.  4th. Many years back, Drs.
Blackall and Osborne discovered that dirtiness ivas a great source of dropsy.
To understand this, it must be recollected, that  in  an impure obstructed
skin are checked tAvo of the skin's main  functions—evaporation and exha-
lation.  (Dr. J. Coventry.)                            Part xiv., p. 258.
  Pathology  of Ski?i Diseases.—According to Dr. Burgess, eruptions of
constitutional origin, by long standing may sometimes assume a local char-
acter.  Erysipelas and acne frequently supervene in cases of derangement
of the uterine function.   Strophulus is associated with the process of den-
tition. Urticaria, lichen urticatus, and several varieties of herpes, are often
the results of a disordered condition of the digestive organs.  Psoriasis and
lichen agrius frequently occur during the  process of gout  and urinary dis-
eases ; and the hereditary nature of certain eruptions, as lepra, psoriasis,
lichen, etc., is beyond all doubt.   Unless Ave bear in mind, in our treatment
of these eruptions, their intimate relation Avdth the organic function, Ave are
constantly liable to serious error.  If, for  example,  Ave were to look upon   #
these critical eruptions or discharges which  occur at certain period of life
as local diseases, and attempt to suppress  them  by topical applications, it
is unnecessary to add that ssrious consequences Avould result; whereas, if
they are not interfered  with, they will get wrell as soon as the equilibrium
of the system is restored.  The impetiginous eczema of infants, and those
eruptions Avhich occur at the  periods of puberty and the turn of life, are
examples of this kind.                                 Part xix., p. 197.


                               ---++-•—


                          SKIN DISEASE.

                                 ACNE.

   [Medical writers, of all ages, have found some  difficulty in curing this
peculiar form of eruption.  Mr.  Startin  has  been more successful; he first
ascertains the exciting  cause, and then applies those local and general means
which increase the cutaneous circulation,  viz., hot air bath, av ith or Avithout
sulphur;  chalybeates combined Avith mineral acids,  vegetable  bitters,  or
iodine. He considers arsenic and mercury unnecessary, unless the state of 
SKIN DISEASE.
491
the liver or other viscera indicate their use ; he recommends a mild nutri-
tive dietary, wdth  such alcoholic stimulants as the stomach may require for
producing healthful digestion ; he considers vegetable acids, antiscorbutics,
so called, and the common diet drink, Avorse than useless, nearly excepting
even sarsaparilla.]
  The external local treatment of acne  is  not  the least important, and
must be regulated entirely by the stage and condition of the disease.  In
its commencement,  when a loaded state  of  the  sebaceous  follicles is the
most prominent symptom, moderate frictions Avith the flesh-brush so as to
keep open the pores, and the extraction, by pressure, of the larger collec-
tion of sebaceous matter (the outlet of the follicle being dilated wdth some
pointed but not too  sharp instrument), will be required; whilst a weak spirit
lotion and the use  of oatmeal, instead of soap, may be  enjoined; as the
disease advances,  and the suppurating points are numerous, large and pain-
ful, the vapor douche on the face, mercurial ointment with camphor, Avhite
precipitate with camphor, or the Topique contre acne of the Hopital  St.
Louis may be recommended : the latter is  composed of slaked lime, 3j.; zinc
ointment, 3jj.; and camphor, 9j.  From fifteen to thirty grains of the iodu-
ret of sulphur to an  ounce of lard, is also a useful application, as is a weak
solution of bichloride of mercury in milk of bitter almonds, or thin quince-
seed mucilage.  The following lotion, not to be  found  in books, you will
find occasionally very efficient: hyposulphite of soda, 3j> to  3h\; sulphate
of alumnia, 3j. to 3ij.; rose water, gviiss.; cologne water, gss. for a lotion, to
be used by Avashing the part with a linen  rag tAvice or thrice daily.   Of
course these proportions are not applicable in every case, but the composi-
tion is very useful in removing the unpleasant yellow stains of the cuticle
as the acne declines, and it is perhaps more  applicable to acne rosacea and
pustulosa, than to the other varieties of the disease, as it always relieves
the attendant itching.
   It sometimes happens that we may have  succeeded in the removal of
acne, particularly acne rosacea, but that a degree of redness remains on the
end of the nose, or  on one or tAvo spots on the cheeks, Avhich, on examina-
tion, is not found to be inflammation, but a dilated  state of the minute cu-
ticular vessels; there are two ivays of getting rid of this  disfigurement,
both  of Avhich I have constantly found  successful; when the vessels  are
very small and numerous, not appearing  to be nourished by conspicuously
large trunks,  the  best plan is  to paint them over very lightly wdth nitric
acid, of the pharmacopoeia strength, wdiich is to be immediately blotted off
wdth bibulous paper; by this means a blister is raised, and the cuticle de-
tached after a few days, Avhen it will be found that the morbid state of the
capillaries has disappeared, or that they  ha\'e so much contracted, that a
second application at the end of a fortnight  is all that is required.
   The acetum cantharidis may also be used  in a similar  manner, though  it
is not so effectual. The second method has the same object in view, though
the mode of its accomplishment  is rather different, and it is only applicable
when the red portions of the  integument appear to be maintained by the
influx of several larger capillary trunks—a  morbid  condition, wdiich at the
end of the nose, is exceedingly common.  The plan I adopt in such instances
is to divide each trunk in succession with the point, of a fine lancet, and as
the blood Aoavs A'ery freely, I  restrain it by means of a small ring of steel
or silver, Avhich is mounted on a stem an inch or two in length, and fixed
mto a handle at right angles; by this means, I can, as it were, insulate the 
492
SKIN DISEASE.
little Avounded point, and arrest the hemorrhage, ivhilst the blood can be
sponged aAvay and the incision exposed, so that a piece of lunar caustic, the
size of a grain of sand, can be introduced into it, by means of a probe aa ith
a flattened extremity, on which it has been previously made to adhere; this
at once stops the bleeding, and obliterates the vessel, Avhilst it produces no
disfigurement, beyond a temporary black spot that may be  covered with
court-plaster, or the blackness maybe removed  by wetting it with a solu-
tion of iodide of potassium; I can assure you I have cured  numerous red
noses by this simple procedure—Avhich  1 may mention  is applicable to the
removal of small naevi  and the congenital red marks called  araneas  (from
their resemblance to a red spider, Avith its legs outstretched).
  The small mounted ring alluded to, you will find a most useful agent in
arresting bleeding from leech-bites, until a grain of caustic can be accurately
applied as already mentioned.  I have  also used it Avith advantage  in re-
moving cutaneous tumors of various kinds, for surrounding a troublesome
bleeding artery till it could be secured ; the size of the  ring may be varied,
but I prefer it not larger than a quarter of an inch in diameter, for general
purposes; but I can imagine such a contrivance useful under a variety of
circumstances requiring surgical interference, Avhich it would be quite out
of order to discuss at this moment—amongst  such are deep wounds of ar-
teries, whether  the result of accident, injury, or surgical operation.
                                                      Part xiv., p. 240.
   This disease,  says Dr. Burgess, arises from so many causes, the  treat-
ment can only be  successfully conducted by taking these into account.
 Exclusively local, or exclusively general treatment, are equally erroneous.
                                                       Part xx., p. 170.
   Acne of the Face.—Apply a saturated solution of gutta percha in chlo-
 roform over the spots, enjoining the patient not to rub off the pellicle by
 washing.   (Dr. R. J, Graves.)                       Part xxxi, p. 281,
   Acne and Boils.—These, depending on similar states of the constitution,
 may be treated alike.   Great success has been obtained at the Hospital for
 Disease of the  Skin, by the  combination of ferrugincus satis Avith saline
 aperients.  In  acne simplex and punctata,  Mr.  Startin prescribes ferri
 sulphat.,  gr. ij.;  magnes. sulphat., 3j-; ter die sumend.: an ointment of
 ammonio-chloride of mercury gr. x. ad §j.; to be applied every night.
 For acne indurata, the iodide of iron in doses of gr. iij., three times daily.
 For the furunculous epidemic, so ripe  of late years, full doses  of iron Avith
 saline purgatives—mist, ferri acid., 3iij. ter die.        Part xxvii., p. 161.
   Acne Rosacea.—Smear  the folloAving over the face  with the finger
 every night; camphor, a drachm ; milk of sulphur, twdce as much, or  the
 sulphur sublimatum.   AfterAvard  as  much Avater as  Avill render it suffi-
 ciently liquid.  The camphor must be  powdered by the usual addition of
 a little spirits of Avine.   (Dr. E. Wilson.)             Part xxxi, p. 195.
    Use of the Acid Nitrate of Mercury in Acne.—A very minute drop of
  the acid is placed, by means of a finely-pointed glass brush, on the apex of
  any indolent tubercles, whether suppurated or  otherwise.  It has the effect
  of opening the pustule, if matter have formed, and if not, induces  the dis-
  appearance of the induration.  The application is folloived only by a tittle
  smarting pain,  and if it have been carefully made,  leaves no scar.
  (Dr. J.    Startin.)                                   Part xxxi., p. 240. 
SKIN DISEASE.                        493
  Treatment of Acne.—After arsenic has been given for a long time with-
out improvement, try cod-liver oil in teaspoonful doses three times a day ;
it will often have a marked beneficial effect both upon the health and the
disease.   Lupus  is equally benefited by the same treatment, but there is
no cutaneous affection in which cod-liver oil has proved more effectual than
in sycosis menti, or mentagra.   (Dr. T. Hunt.)        Part xxxii., p. 184.
  Acne.—Cazenave has recently recommended ammoniacal lotions, which
form with the fatty matter of the follicles a soluble soap with an ammonia-
cal base ; the hydrochlorate or acetate of ammonia answers equally well.
                                                   Part xxxii.,/). 187.
  Treatment of the Different Forms of Acne.—In acne  rosacea, and acne
simplex, the acid solution of iron in half ounce doses is usually ordered,
while for the tubercular form Mr. Startin places more confidence in, the
iodide of iron.   The  latter is generally given  in from one  to two grain
doses.  Malt liquors  are strictly prohibited in all cases.  In almost all the
local use  of the red lotion is directed, and any larger pustules or tubercles,
Avhich may be  observed from time to time, are touched on their apices
with the acid nitrate of mercury solution.  In addition  to these remedies
the direction is  mostly given to be particulcr in squeezing out the contents
of the distended follicles as soon as they become perceptible.
  The " acid solution of iron" is made by dissolving  three ounces of  Ep-
som salts, and two drachms of sulphate of iron, in half an ounce of dilute
sulphuric acid, and  a pint of infusion  of quassia.  The " red lotion" con-
sists of two scruples of the bichloride  of mercury, one of the bisulphuret,
and* ten minims  of creasote, in a pint of Avater ; each ounce containing two
grains of the bichloride.                    •       Part xxxviii., p.  174.

                              ECZEMA.
  Some Local Forms of Chronic Eczema.—Chronic  eczema assumes dif-
ferent forms as it attacks different parts of the body, as the scalp, face,
ears, tongue, anus, etc.   Chronic eczema of the face usually is of an im-
petiginous  character ; it is generally met with in children, rarely in adults,
and Avhen it does occur in the latter, it is in consequence of extension from
the scalp.
   Chronic Eczema  of the Face.—Mr. Erichsen mentions  the case of a
lady's maid, who caught cold Avhilst  travelling  outside  of  the  carriage;
her face became stiff and inflamed,  and pimples with watery heads came
out on the  forehead and cheeks.   The disease continued for three months,
without interruption, in spite of treatment, when she w7as admitted under
Mr. Erichsen's  care,  into the Westminster Hospital.
  Mr. Erichsen commenced by ordering three drops  of the liquor arseni-
calis three times a  day, and  directed that the affected  parts should be
preserved day and night from the action of the atmosphere, by covering
them up  Avith lint spread well with zinc ointment.
  Feb. 13.—Much better.  The skin is softer, not so glazed, and the feel-
ing of tension is less.   The liquor arsenicalis  was now increased to four
minims  for a  dose,  and ungent.  hydrarg. precipitat. albi  was substituted
for  the zinc ointment, it being thought that a light stimulant might be of
service.   Febrile symptoms arising, the  arsenic was omitted for six days,
when it ivas  again resumed, and on  the  25th of March, the disease was
perfectly cured. 
494                         SKIN DISEASE.
  When the disease depends on irritation of the skin and mucous surfaces,
it can  be  soonest  relieved by carefully regulating the diet, avoiding all
stimuli, and using  one of the  most efficient remedies that we possess in
affections of this class—the HarroAvgate waters.  Where the temperament
of the  patient is irritable, arsenic, cantharides, etc., would decidedly ag-
gravate the disease.  Chronic eczema  of the ears, which usually proceeds
by extension from  the scalp, is a very painful as well as obstinaie affection.
Mr. Erichsen observes that :
  The  ears, when attacked by the eczema, become exceedingly red, tense,
hot, and shining ; a number of small vesicles then appear, Avhich contain a
clear transparent  serum, of a reddish or pale yelloAv color ;  when these
give way, the  fluid that is effused forms  thin  scabs  or scales, which are
usually cracked in all  directions, and  which are frequently curled up or
project from the surface of the skin.  If the disease continue, the pinna at
tains a very large size, becoming hypertrophied, and often fissured ; some-
times,  indeed, the  swelling goes on to such an extent as to block up the
external meatus, giving rise to temporary deafness.
  When it occurs  in young children, it can easily be cured : it  is generally
in females from fifteen to twenty-five, or in women  about the change of
fife, Avhere it proves so obstinate.   It is generally associated Avith irregular
menstruation, or may be  noticed from the fact, that it is aggravated at
those periods wdien the uterus ought to act. Mr. E. describes a case which
came under his care, a female, twenty-one years of age ; menstruation was
irregular.
  Both ears Avere  found, on examination, to be affected nearly to an equal
degree.  They were red, glazed, much swollen, and chapped, covered Avith
thin, flimsy, scaly  incrustations, from  under which a serous fluid occasion-
ally oozes, and are very hot and tense. The integuments of the  mastoid,
temporal and parotidean regions are likewdse involved, being inflamed and
covered with thin  furfuraceous laminae.
  She  was ordered to apply  bread-and-water poultices to the ears every
night, to cover them up in rags spread Avith zinc ointment during the day ;
to take ten grains of the pil. aloes c. myrrha every second night at bed-
time, to abstain from all stimulants, and to adhere as strictly as possible to
a milk diet.  The  ordinary means, such as mustard-and-Avater to the feet,
etc., were likewise directed to be adopted for reestablishing the menstrual
function, and were attended with success in the course of a week.  At the
end of a fortnight she was much  better, the ears were  less tense, and not
so red  or SAvollen.   She Avas now ordered  to apply an ointment composed
of equal parts of a ceratum plumbi comp. and  zinc oiutment,  and to take
five minims of tincture of cantharides, and thirty of liquor potassae twice a
day.  This plan of treatment was continued until the end of April, when
she Avas perfectly cured, the ears  presenting their normal appearance, and
having lost entirely their hypertrophied condition.
  Eczema of the Scrotum, Penis, and Anus.—Eczema of the scrotum and
of the inside of the thighs  of young children is of a more active character,
and is by no means 60 troublesome as that which occurs in more advanced
life.  In many cases it appears to be owdng to the urine being alloAved to
dribble over the thin and delicate skin  of these parts.
  The  appearance  presented by chronic eczema of these parts in children
is very remarkable.  The  scrotum  and integuments covering the pubes,
the inside of the thighs and penis, are of a vivid red color, inflamed and 
BKJN DISEASE.
495
oozing ; occasionally covered w ith soft, moist, greyish, or yellowish scabs,
from  under and between ivhich  a  serous fluid exudes in tolerable abun-
dance.  At other times they are dry, glazed, and chapped in all directions,
being merely covered here and there Avith thin flimsy scales.  These two
conditions, the moist and the dry, alternate with one another, being evi-
dences of the greater or less activity of the disease.
  Some local forms of Chronic E zema.—When occurring m individuals
past the  middle period of  life,  eczema  attacking  the scrotum  usuatiy
presents the ordinary characters of that disease in its chronic furfuraceous
or squamous condition.  The scrotum is much  wrinkled, red, dry, rough,
and glazed, or covered with thin,  peeling,  curled, laminated,  and  dry
furfuraceous incrustations  of a Avhitish or greyish color, which rub off in
considerable abundance, exposing cracks and fissures, from which  a thin,
ichorous, or bloody discharge, oozes.  The itching,  which is  intolerable,
and is more complained of than anything else, is much aggravated by any
excess in diet, or Avhen the patient is warm in bed.  Every noAV and  then,
uuder the influence of some exciting cause,  the  disease assumes  a more
active condition, revealing  its vesicular elementary  character,  and  thus
enabling it to be readily distinguished from prurigo of the region affected.
Eczema involving  the anus  is always a most troublesome affection.  It
may be either an extension of the disease from the scrotum and perineum,
or it may be confined exclusively  to the anus and loAver part of the rectum.
It is occasionally seen in young children accompanied  by intertrigo, or in
consequence of the extension of  the disease from the neighboring parts,
wdien occurring in  adults.   It  is  characterized by  occasional vesicular
eruption, excoriation, fissures, and chaps,  which bleed, and are excessively
painful on the passage of  the fasces, more  particularly  if these be  hard or
lumpy.  There  is always excessive pruritus;  more  especially, when the
patient is Avarm in bed, or after standing for any length of time.
   Eczema of the anus is  more  commonly a disease  of individuals who
have passed  the middle period of life, and is not uncommonly connected
with  piles.
   Treatment.—Cover the parts with lint, wet with lead lotion, and inclose
them wdth oil-silk, in order to keep off the air, and to prevent urine get-
ting upon the part.   Give a small dose of hydr. c. creta at night, and a
dose of cantor oil in the morning : in a few days substitute zinc ointment
for the  lotion, and  give small doses of liq.  potassas, and five grains  each of
calomel and magnesia, tAvice  a day.   If it  be of long standing, enjoin  a
strict diet, abstinence from fermented liquors, salted  and heating articles
of food, and give 20 minims of liq. arsenici et hydrarg. iodidi twice a day,
Avith 5 grains of Plummer's pill at bed-time, and apply a mixture of zinc
ointment and the ung. plumbi acetat. to the parts by  means of a piece of
lint cut to the proper shape.  The  treatment must be persisted in for a
length  of time.  A little extract of belladonna rubbed down with the
ointment, often succeeds in allaying the irritation.
  Eczema of the Scalp.—[ Eczema of the scalp, hoAvever, appears  to be
the most commonly met Avith;  for of all cutaneous diseases seated in  this
locality, as many  as forty-three per  cent, are cases of eczema.  It  is
exceedingly difficult to remove :  it  occurs mostly in children, very rarely
in adults.   Mr.  E. observes that,]
  Chronic eczema of the scalp, although presenting considerable variety in its
characters, seems to resolve itself naturally into the three following species. 
496
SKIN DISEASE.
  1. Simple chronic eczema, which may assume either a moist or  a dry
form.  2. Eczema furfuracea, corresponding to the  porrigo  furfurosa of
Willan.  3. Eczema amiantacea, which is an  extreme  condition  of the
last variety.
  Simple chronic eczema of the scalp may, as has just been stated, assume
either a moist or a dry form.  In the moist variety  of the  disease there
is always a A'ery copious discharge of a thin serous fluid from a number of
small openings, the remains of former vesicles, that lie closely scattered
on the inflamed and tender surface of the scalp ;  this discharge,  Avhich is
of an acrid and irritating nature, is apt to increase the inflammation in that
part of the skin over Avhich it Aoavs.   If it be very abundant  the hair looks
as if it had been soaked in a thin solution of gum arabic, being matted to-
gether in locks, which have a dirty yellowish  grey moist appearance, and
between and under Avhich the inflamed scalp may be  seen pouring forth the
discharge.  As this lessens in  quantity, soft yelloAvish-grey  scabs  will be
formed,  which gradually losing their moist appearance  will be  found  to
resemble those that characterize the dry wariety of the disease.  In the
midst of this, acute attacks of eczema, attended by a great evolution of
vesicles, by  increased heat  and redness of  the  scalp, frequently  occur,
adding very greatly to the severity and obstinacy of the disease; and the
distress  of the patient is Arery often  greatly increased by a chronic  inflam-
mation  of the eyes and ears, which is a common complication  of this
form of eczema.  As the discharge lessens,  and the inflammatory action
 subsides, the moist passes, in many  cases, into the dry variety of  chronic
 eczema.
   Treatme/tt.—If occurring to a child, otherwise healthy, about the period
 of dentition, be careful how you check the eruption.  Cut the hair, apply
 bread-and-water poultices, and subdue irritation by  the application of rags
 dipped in olive oil, or smeared wdth zinc  ointment; or  sprinkle the part
 with the nurse's milk.   Give small  doses of hydrarg. c. creta and castor
 oil, and  lance the gums, if necessary.  Fluid magnesia is  often useful.  If
 it becomes inveterate, Avean the child on beef-tea, broth, and  a nutritious
 diet, and give mild tonics, a few drops of tincture  of ammon-chloride of
 iron, or iodide of iron, twice a day (from half a grain to two grains of the
 latter) ; a great part  of the treatment consists in keeping the scalp 60
 covered as to prevent the access of air.
   When it becomes chronic and inactive, and presents a furfuraceous ap-
pearance, have recourse to gentle stimulants ;  a lotion composed of from
one to two drachms of sulphuret of potass, either alone or combined Avith.
an equal quantity of the carbonate  of the same alkali, in a  pint of plain,
or of lime Avater ; Avash the head with this lotion three times a day ; at the
 same time, every night after the last application of the lotion, apply an
 ointment composed of from a  scruple to half a drachm of carbonate of
potass to an ounce of lard, or of creasote  in the same proportion, or of
wditie precipitate; or use the ung. hydr. nit. dil., or the sulphur ointment,
 or a mixture of this and tar or of creasote ointment. Do not use the oiled-
silk cap ; it confines the perspiration and  soddens  the  skin, producing a
Btate of passive congestion Avhich we Avish to get rid of.
   Chronic Eczema of the Hands.—[This generally arises from the direct
 application of irritating substances  to the parts, as lime  in bricklayers,
 sugar in grocers, potass or soda in  washerwomen,  mordants in dyers,  or
 minute  particles of steel in smiths,  weelwrights, etc.] 
SKIN DISEASE.
497
  The characters that this disease presents when attacking the hands are
those assumed by chronic eczema in its worst and  most inveterate forms.
There is, in the first instance, an eruption  of vesicles, which are most gen-
erally small and pointed, projecting but slightly above the level of the skin,
and which are at first confined  to  a small spot,  usually on one of  the
knuckles, or on the  back of one of the fingers, Avhencethe disease gradually
creeps on until the greater portion of the back of the hand may be involved.
In some rare cases, however, these Aesicles are large and prominent.
  [ The diagnosis is of importance, particularly if there has been  no local
hrtiant, as it leads to  suspicion,  more especially in the better classes of
society ; it may be  confounded Avith scabies and psoriasis.^
  From scabies  the diagnosis is not  always easy, though in the majority
of cases it is not attended Avith any difficulty.  In eczema the vesicles  are
usually  small, agglomerated, and collected in clusters on the back of one
or two knuckles, or in patches about the dorsal  aspect of  the hand;  and
occasionally we  see a raw, excoriated, oozing surface, Avhich  is never met
with in scabies.   In scabies, on  the contrary, the vesicles  are generally
large, more  distinct,  not  clustered;  and  situated  chiefly  between  the
fingers at their roots, and not on the knuckles or back of the hand.  In
scabies  -also  there  is  a  peculiar pruritus,  giving  rise to  an irresistible
propensity in the patient  to  scratch himself.  In eczema  this is  not  the
case, and the morbid sensation is of a smarting  or burning character.
  The vesicular character of the disease is a sufficient guide in diagnosis,
and when it becomes chronic, and assumes a furfuraceous appearance, it is
of little practical importance, as the treatment is directed by the condition
of the part, and the causes of the disease.  The treatment is the  same as
when occurring in other parts, only the hand must  be kept perfectly at
rest.
  Treatment.—In the early stages apply Avater-dressing by means of oiled-
silk gloves or finger stalls, and at  a more advanced period, a solution of
nitrate of silver (grain j. to the ounce), instead  of  the water-dressing ; or
a solution of carbonate of soda (grain ij. to iv. to  the ounce) ; or the fol-
lowing  lotion: acid, hydrocyan., 3ss.; zinci oxidi,  3j-; aquas rosas, §viij.;
or cover the hand wdth the ung. hydrarg. precip. alb.,  either alone or mixed
Avith citrine ointment.
  If the disease only occupy a small  patch, coiner it Avith a slice  of lemon.
Its spreading may be checked by applying the solid nitrate of silver around
the  part. Constitutional treatment must also be adopted:  remove any gas-
tric, intestinal, or uterine disturbance, and give vegetable bitters, nitric
acid diluted, or small doses of bichloride of mercury; the tAvo latter may
be given in infusion of bark.   If the  disease be of very long standing, give
Fowler's or Donovan's solution.  The hands should be kept at rest.
                                                     Part xiii., jp. 297.
  Chemical Reaction of Discharges in  Eruptive Diseases.—In eczema
and  all  eruptive diseases attended Avith more or less exudation, ascertain
the  reaction  of  the discharge upon test paper.  If it is alkaline, apply
nitric acid lotion (5*s.  ad aquas Oj.) and give small  doses of the same acid,
in the compound  infusion of orange,  internally.   If the discharge has
an acid reaction, adopt the reverse of the above  treatment.  (Dr. J. Corfe.)
                                                    Part xviii., jo. 222.

  Eczema.—Apply  a lotion containing bichloride of mercury, three grains
     VOL. II.—32 
498
SKIN DISEASE.
to the pint, five or six times a day.   Or, apply water as warm as it can be
borne.   CM. Trousseau.)                             Part xviii., p. 223.
  Eczema.—In acute cases, says Dr. J. H. Bennett, the constitutional treat-
ment is most important, and must depend upon the kind of constitutional
affection; the  disease  being usually associated with either  the  oxalic,
lithic, or phosphatic diathesis, or  Avith a scrofulous taint.  The local treat-
ment here is of very subordinate  importance.  But in chronic cases, the
local treatment is by far the most'important, and should consist in  the ap-
plication of  a solution of 3ij. of the subcarbonate of  soda in a pint and a
half of water ; lint  saturated Avith this solution being  applied  over the
affected parts, and the whole covered Avith oil-silk.

  Dr. Burgess  would direct the  treatment chiefly to the constitution, giv-
ing  mild  tonics and alteratives.   Keep the parts  cleanly,  and when it  is
thought the discharge may be safely arrested, apply mild  lotions contain-
ing  carbonate  or  bicarbonate of potash,  and let  the bath be frequently
used.   If these remedies are not  sufficient, give active  purgatives if the pa.
tient is strong; or  Avhere these  are not indicated, give sarsaparilla and
hydriodate  of  potash ; and employ lotions of nitrate of silver or bichlo-
ride of mercury.   If there is inflammatory tendency in the parts, apply
a feAv leeches behind the ears.  If  there is much smarting, wdth abundant
serous  exudation, give sulphuric  acid internally, beginning with  a  small
quantity, administered  in barley water, and a little cold water after each
dose.

   Chronic  of the Legs.—This  disease, according to Dr. Burgess, is very
difficult to manage, but is best treated by the application of the vapors of
iodine and sulphur, assisted during the interim of the application  by ban-
daging from the  foot  upAvard.  The best way to apply the vapor is the
folloAving: get a tin case or a common jar, large enough to hold the limb,
and place a heated iron at the bottom of the apparatus, and a grating above
it, to protect the limb.   Place one of the powders, about to be mentioned,
on the heated iron, put the  limb instantly into  the bath, and cover the
mouth over to prevent the vapor from escaping; and continue the bath
fifteen  or twenty minutes.  The  poAvders consist  of, sulphur, 3iij-; hydr.
sulph. rub., 9ij.; iodin. gr.  x.; divided into six powders.  In a few days
the  proportion of iodine may be  increased.

   When  this  affection is connected with a scrofulous constitution, give
col-liver oil.                                           Partxx^p. 168.
   Acetate of Potash.—Recommended by Dr. Easton in half-drachm doses,
three times a day, in eczema.                          Part xxi., p. 245.
   Local  use of Alkalies in\Treatment of Eczema.—A remedy which has
been found more  extensively applicable  and more uniformly serviceable
than any other, says Prof. Bennett, is a solution of  tAvo drachms of the
sesquicarbonate of  soda in a pint and a half  of water;  but it is necessary
to place lint saturated Avith the solution over the affected part, and to cover
the whole with oil-silk, in order to prevent evaporation. In these cases there
is an  increased exudation from  the skin,  both of  sebaceous  and  purulent
 matters; and alkalies, we knoAV, have the property of dissolving these, and oi
 actino" as a  calmative and emollient to the irritated parts. Part xxii., p. 243. 
SKIN DISEASE.
499
  Empyreumatic  Coal Oil used in Eczema.—M. Lafont-Gouzi highly
extols the virtues of the oil obtained by the distillation of pit-coal in the
manufacture of gas, as a remedy in certain  eczematous affections, and in
itch.  He has used the oil in  the treatment of eczema impetiginodes, of
itch, of prurigo,  of psoriasis,  of purulent ophthalmia,^ of keratitis,  and
of otorrhasa dependent on cutaneous eruption {otorrheas  de nature dar-
treuse).   M. Lafont mixes eight parts of empyreumatic oil ivith thirty parts
of axunge, and spreads the ointment  over the parts affected with eczema;
he asserts that it is the most active of siccatives.   In cases of prurigo  and
of psoriasis, he replaces the axunge wdth an oil  of henbane  containing
opium (huile de jusquiaume opiaciee).   If the disease proves obstinate, he
uses the undiluted empyreumatic oil.                  Part xxiv., p. 257.

  Eczema.—Make an  ointment as follows :  Oil of juniper, §iss.; suet, |ss.;
lard, §iss. It should be applied locally to the part.    Part xxxii., p. 186.
  Eczema, etc.—According to Dr. Godfrey, internal remedies are most
useful, ointments  are injurious.  The tincture of the muriate of iron given
three times a day he  has  never known fail.  The  parts should  be daily
Avashed  Avith oatmeal gruel.   Occasionally a little powdered starch with
oxide of zinc will aid  the cure.

  Professor Malmsten, of Stockholm, has used cod-liver oil externally very
successfully in  intractable skin diseases.  If the  'whole skin be affected
the patient must lie  in  bed,  all the body and bed linen being  saturated
wdth  oil; an alkaline bath may be allowed  once a week, but no other
washing or change of clothes  until the skin is restored to health.
                                                    Part xxxii., j!?.  186.
   Eczema,—The value  of cod-liver oil in this  obstinate  disease is  now
almost universally conceded;  it should  be  used in conjunction Avith other
remedies.                                           Part xxxiii., p.  236.
                                                               '■*#
  Eczema Infantile.—[The great, the urgent symptom  of this disease is
the teasing, the intense itching, especially  during  the night; the child is
often frantic with itching, it scratches  wdth all  its force, digging  its little
nails into the flesh, Avhile the  blood and  ichor run  doAvn in streams.]
  For elimination, says Erasmus Wilson, you may give one grain of calomel
with a little white sugar to the youngest infant; Avhen older, give it in  such
a dose as will produce an efficient relief  to the alimentary canal; this  may
be  repeated once, tAvice, or three times  a week, but generally once is suf-
ficient.   To alleviate  the local distress, apply freely night and morning the
benzoated oxide of zinc ointment over  the whole of the inflamed skin ;.this
should be alloAved to remain as a permanent coating until the skin is en-
tirely healed; it w ill prevent  the formation of crusts by the exclusion of
atmospheric air.   It  is very important not to disturb the ointment, but at
the same time it must not be alloAved to  accumulate too thickly.  Washing
is quite  unnecessary, indeed it is  injurious,  and must be  avoided.  In
chronic  eczema infantile,  that  is, pityriasis capitis, the  nitric oxide and
nitrate of mercury ointment of various strengths are almost specifics.  For
the restoration of power the great remedy is arsenic.   As an  effective,
harmless tonic, it stands alone and wdthout its peer in this vexatious disease ;
indeed,  it is specific, it  cures rapidly, perfectly and unfailingly.   Two
minims  of FoAvler's solution  may be given three times a day to an infant 
500
SKIN DISEASE.
from two months to a year old.   It is very useful combined with iron as
follows:
  R Vini ferri, sirup, tolutan, aa.  gss.;  liq.  potassae arsenitis, m xxxij.;
aquas anethi, §j.  M. Give one drachm three  times a day after meals; if
it appears to disagree  it should be given less frequently or suspended.
Cod-liver oil, in conjunction Avith arsenic, is a valuable addition.
  The following formula wdll be found convenient:
  R Olei jecoris  aselli,  §ij.; vitelli ovi, j.; liq. potassas  arsenitis, mlxiv.;
sirupi simplicis, 3ij.; aquas  fontan. q.s. ad |iv.   M. ft. mist.   A drachm
three times a day.                                  Part xxxiv., p. 199.

   Chronic Eczema in  Children.—Dr. Behrend  directs, first to get the
scabs or crusts separated, by means of poultices, if the spots are limited,
and are not settled on the head, face, and neck,  where these applications
are not  suitable.  Before  applying  them, it is a good plan to moisten the
surface  with a solution  of carb. of soda (3ij. to |viii.)   When the surface
is large, a water dressing is to be preferred;  a little sub-carbonate of pot-
ash  being added  to the water.  If situated on the head, face, or  neck,
paint the scabs over with a mixture of carb. of soda and cod-liver oil, re-
moving the crusts carefully next morning, and moistening the surface Avith
the alkaline lotion.   This must be repeated as often as necessary, till crusts
cease to be formed, and a red, inflamed, but painless surface is left.  Next,
we must remove this condition of the skin.  One of the best means to this
end, is the application of a solution  of 3j. of  acetate of  zinc, and the same
of acetate ofhead, in gviij. of distilled water, adding to this, at the time of
using it, an equal quantity of strong chamomile infusion.  The last indica-
tion is to restore the activity and healthy tone of the skin, by such hygienic
measures as fresh country air, free  exercise,  a well  regulated  and Avhole-
some diet, and such local applications as  weak solutions of alum and sul-
phate of zinc.                                      Part xxxvi., p. 187.
   Eczema  of  the  Face in Children.—Dr. Behrend recommends the fol-
lowing   application for the crusts  which frequently cover  the faces of
children :   Cod-liver oil, fifteen, and bicarbonate  of soda, tAvo parts.
                                                   Part xxxvii, p. 182.
  Eczema—Acute.—Mr. Startin says,  that the irritation of acute eczema
will frequently subside most rapidly  on slight  ptyalism  being induced.
The bichloride of mercury is a good form  for  administration, and five
or ten minims of colchicum may be  given Avith each dose.
                                                   Part xxxviii, p. 174.
  Eczema of the Scalp and Face in Children.—A  fair-haired, blue-eyed
ehild* aged  two years,  Avas admitted wdth that so common and so trouble-
some form of eczema in which  the whole face and scalp are involved, but
the rest of  the surface free.   It had suffered since the age of six months,
but excepting the irritation of the eruption its general  health was not in-
terfered Avith.  Mr. Startin ordered as follows:
  Misturas potash iodid. §j., aq.  §v.  capt. 3j. ter die.
  The surface to be washed with the yolk of egg and water, and smeared
with the nitric  oxide of mercury ointment.   Rapid  improvement ensued
in this individual case; and  it may be taken as a fair  illustration of the
treatment usually adopted.   In obstinate cases the compound iodide mix-
ture, which contains arsenic, is often employed. 
SKIN DISEASE.                         501
  The formulas for  the  above-mentioned preparation are:  of the mixture
 —a drachm of iodine, an ounce of liquor  potassa;, and a pint of distilled
 water, each drachm containing half a grain of iodine.  Of the liniment—
 olive  oil, two ounces ;  lard, tAvo ounces;  powdered  nitric oxide of mer-
 cury, a drachm ;  oil of bitter almonds, half a scruple ; and  glycerine, 3j-
                                                  Part xxxviii, p. 174.


                              HERPES.

  Dartres of the Perineum.—Dr. Barosh,  of Lemberg, was consulted by
 a young  man, about twenty-eight years of age, for  a dartrous  eruption
 affecting the perineum and scrotum, Avith wdiich he had been afflicted from
 his sixteenth year, and the irritation from Avhich was such as to cause him
 to be continually applying his hands there,  so that he Avas obliged to avoid
 Bociety.   He had consulted  the most famous physicians in Hungary, but
 the only  thing that seemed at all to  relieve him was the cold water hip-
 bath.  When he consulted Dr. Barosch, he Avas exhausted by suffering,
 insomnia, loss of appetite, and despair ;  the skin  wras dry; the entire
 perineum, scrotum, and internal surface of the thigh, Avere covered with
 deep brown, hard crusts, surrounded by bleeding fissures, caused by the
 nails of the patient.  BeloAV these crusts the skin Avas bard and thickened.
 The fall of  the  crusts alternated  Avith an  acrid discharge.   Kaschlin's
 liquor having failed,  Dr. Barosch prescribed the external application of
 iodine as folloAVS : Fifteen grains of iodine  and tAvo scruples of hydriodate
 of  potass dissolved in five ounces  of distilled wTater and one  ounce of
 spirits of Avine ; make a lotion.   The topical application of this solution
 continued for several hours,  caused  at first a burning  sensation, which
 was, hoAvever, very tolerable, and Avas soon followed by a relief such as
 the patient  had not  experienced for  two  years.  The use of this lotion
 was continued for three weeks, the patient taking baths frequently during
 that period, at the end of which time  the cure Avas complete.
                                                      Part viii., p. 73.
  Herpes Squamosus.—The cyanuret and deuto-phosphate of mercury are
 occasionally employed.  The former is said to be preferable to the bichlo-
 ride, being less apt to disagree, and less readily  decomposed.  It is a use-
 ful external application in some skin affections, allaying the  violent itching
 and irritation of Avhat M. Alibert terms herpes squamosus.
                                                      Part ix., p. 21.
  Treatment of Herpes Zostera,—The most soothing application, according
 to Dr. Corfe is freshly  made  ungt. hydr.  ammonio-chlorid., smeared on
the  Avhole crop of vesicles, twice or thrice a day.      Part xviii, p.  222.
  Arseniate of Iron-in Herpetic and Squamous Eruptions.—Numerous
facts accurately observed authorize M. Dupare in concluding that a daily
dose of one-fifth of a grain  of  arseniate of  iron,  uninterruptedly repeated
during the necessary time, is competent in  the adult to effect the cure of
an herpetic or squamous affection, hoAvever extensive or long-established.
  An  anti-herpetic treatment  by arseniate of iron in no degree excludes
the  employment of topical remedies  of acknoAvledged utility,  and it is
 materially assisted by the internal or  external use of certain  non-sulphu-
reted  mineral ivaters.                                 Part xxx., p.  175. 
502                         SKIN DISEASE.
                          IMPETIGO.
  Devergie's Solution of  Arsenic.—Is composed of  arsenious acid, ten
grains;  carbonate of potash, ten grains ; distilled water, six pints and a
half;  alcohol, fifty minims: tincture of cochineal, as much  as is required
to color the mixture sufficiently.  Each drachm of this  solution  is said
to be equivalent to four drops of Fowler's liquor arsenicalis.   M. Devergie
employs this  remedy wdth advantage in long standing cutaneous erup-
tions, particularly those of a  squamous and  impetiginous  nature.  He
indicates, as a constant result and symptom of cure, the appearance  of
dark brown spots on all parts of the skin previously diseased, which per-
sist for some months afterwrard.                          Part ix., p. 86.
  Impetigo.,—In acute cases, says Dr. H. Bennett, treat the particular con-
stitutional state which may accompany the eruption ; the local treatment
being unimportant.  In  chronic cases, on the  other  hand, be particular
about the local treatment.   Apply lint saturated with  the solution of sub-
carbonate of soda (3ij. to Oiss. of water), and cover it Avith  oiled silk.
        *        *        *        *        #       #        *
  When this affection seems connected with the scrofulous  diathesis, give
cod-liver oil.                                          Part xx., p. 286.
  Impetigo.—Apply the saturated solution of gutta percha  in chloroform,
by  means of a camel's-hair pencil, over the patches daily.
                                                    Part xxvi., p. 128.
  Impetigo and Eczema.—Dr. Hughes Bennett keeps  the parts moist
with lint saturated with  a solution of half a drachm of carbonate of soda to
one pint of water, covering this ivith oil silk.   For favus,  first  remove
the crusts by poulticing,  then apply  oil to exclude  the atmosphere ar.d
prevent the growth  of the  parasitic fungi.  These remedies  should be con-
joined with cod-liver oil and generous diet.           Part xxxiv., p. 197.


                            ICHTHYOSIS.
  Ichthyosis Fortuita.—Dr. Thomson considers that  in  the treatment  of
these cases, there are three indications to be fulfilled: 1st. Augment the
action of the capillaries  of the skin, by giving small doses of blue pill and
emetic  tartar;  liquor arsenicalis;  cantharides in  decoction  of rum ex
obtusifolius, made by boiling an ounce of the sliced root of the  common
dock in  a pint of  soft water; dose §ij.  2d. Improve  the secretions
generally, by generous diet, as milk, vigorous exercise in the open air, etc.
3d. Aid the action of the  two former by topical  means Avhich  stimulate
the skin, and assist the separation of the diseased papillas by warm baths,
friction, etc.                                          Part xiv., p. 254.

                                ITCH.
   Treatment of the Itch in Belgium.—The following circular Avas addressed
to military surgeons by the Inspector-General of the Belgian army:
  Each patient is to be supplied, with  an ounce  or an ounce and a half of
liquid sulphuret of lime in a small pot;  this quantity he is to rub carefully
and slowly w ith his hands on every part that is covered w ith papulas.   If
there be any papulae on the back, another patient is to rub  the liquid upon 
SKIN DISEASE.
503
that part.  The operation is to be repeated three times in ^e twenty-four
hours so that each patient consumes three or four ounces of the suipnuiu,
dailv'  A bath is to be taken every alternate day;  the frictions are to be
suspended  on that day.  Fifteen  frictions (or ten days'  use) are usually
sufficient for the cure of the. disease, if the medical officer in  charge sees
that the remedy is  properly used.                        J- art x-> P- 97.
  Treatment of Itch.—Immerse the hands of the patient in an alcoholic
solution of stavesacre for half an  hour together, two or three times, and
the acarus scabiei will be destroyed.  (Dr. Burgess.)  Use a fotion made
of an ounce of  sulphate of copper to a pint of water: wash  off the scabs
before usino- it.  It is an almost certain cure.   (Mr. Lloyd.)  Use a lotion
of iodide of potassium in the day, and sulphur ointment at night; a cure
may be  expected  in seven  days.  The lotion  should be  3j- ol iodide
to Sviij., or Bxvj. of fluid.  (Dr. Ward.)               Part xui., p. 307.

   Treatment of Scabies.—{Mr. Corfe states that he rigorously pursues the
following plan Avith a patient affected Avith itch:]
   We provide him Avith old soiled linen and a Avorn out sheet; and each
morning and evening he is ordered to make a good lather of  yellow soap
in his hands, and thus  dip them wet into a basin of sifted or fine  sand,
and assiduously rub every part of the body oh Avhich the slightest  trace
of a vesicle exists.  Having performed this ablution until the skin tingles
smartly, he wipes  himself dry, and then rubs the common ung. sulphuris
 firmly into the itchy parts.   He is then enveloped  in the Avinding sheet,
 and has a pair of old gloves on his  hands,  and be is left till night, when
 the same operation is pursued, and repeated daily until the fourth day,
 when he is ordered  to indulge (and a great indulgence it  is) in a  warm
 bath, Avhere he again lathers his body in plain soap and water, puts on fresh
 linen, and is  provided Avith clean sheets, and the cure is from thence
 invariably effected.   The vesicle  of course is broken by  the friction
 of the sand and  soap; the  acarus is  exposed, and this ectozoon receives
 its  death-blow by the inunction of the sulphur, ivhich  is oftentimes  not
 accomplished by the mere  application of sulphur ointment  alone.   The
 use of sand-soap balls is more elegant, though not more efficacious.
                                                    Part xviii., p. 223.

    Treatment of Itch.—Use a sulpho-alkaline ointment.   If there is a great
 abundance of pustules, and this excites too much pain, use frictions of lard
 and oiL  Another ointment recently tried cures in three frictions, soothes
 the itching instantly, and does  not give  rise to any secondary eruption.
 It is composed of equal parts of fresh chamomiles, olive oil, and. lard.  M.
 Bourgignon makes  an ointment by mixing  300  parts of the powder of
 staphysagria to 500 of lard, keeping it at  a temperature  of 100° C. for
 twenty-four hours.  The frictions  to be made four times a day, the cure
 being complete by the fourth day.                   Part xxiii., p. 291
    Itch—Cured in Two Hours.—In the Hospital of St. Louis, Paris, the itch
 is  cured  in two hours. The patient is first put  into a warm  bath, and
 rubbed  for an  hour with yellow soap.  He then passes  into  a clean bath,
 where he continues to cleanse  his skin for another hour.  After leaving
 this, one of his fellow-sufferers rubs him  over for half an hour Avith the
 following ointment: Axunge  eight parts, floAvers of sulphur  tAvo parts,
 and carbonate of potash one part.   The patient is then examined, and. sent 
504
SKIN DISEASE.
   away cured, though sometimes pretty numerous vesicles on the hands and
   elsewhere remain unaltered.                           Part xxv., p. 265.
     Scabies, and other Parasitical Diseases of the Human Skin.—The v.*q or
   of benzoin, or benzole, which is prepared by the decomposition of benzoic
   acid, destroys parasites,  says  M. Reynal, more  surely than  almost any
   other application.  It may therefore be used in pityriasis and scabies most
   effectually.                                          Part xxxi, p. 196.
     Itch— Cured in Half an Hour.—Sulphur applied in a liquid form, says Dr.
   E. Smith, is more  readily absorbed,  and consequently more certainly de-
   structive to  the insect than when used in the form of ointment.   To pre-
   pare a solution, boil one part of quick lime with  tAvo  parts of sublimed
   sulphur in tAvo parts of Avater, until  dissolved. The body should be pre-
   viously washed Avith warm wrater, and then this solution rubbed in for half
   an hour.  By this time  the cure will be  complete, and  it will  only be
   necessary to wash  and use clean  clothes.             Part xxxiv., p. 195.
     Treatment of Scabies by Sulphuret of Calcium.—A much more speedy
   and cleanly method of treating this loathsome disease than the filthy pro-
   ceeding of inunction, says Dr. Kesteven, is to Avash the parts affected Avith
   a solution of the sulphuret of calcium for half an hour night and morning.
   It is rarely that a third application is necessary, but it should be  enforced
-  to make security doubly sure.                        Part xxxiv., p. 196.
     Itch.—Instead of the sulphur ointment, Dr. Fischer recommends a lotion
   of caustic potass, 1 part; distilled wTater, 12 parts.    Part xxxv., p. 158.
     Bourgignon's Treatment of Itch.—After the trial and  comparison of
   the various modes of treatment,  M. Bounzignon accords the preference  to
   the folloiving  formula: Glycerine, 50 drachms; finely-poAvdered sulphur,
   25  drachms;  2 yolks of  eggs; and  tragacanth powder, q. s.; adding
   essences to mask the smell.                          Part xxxv., p. 331.
     Scabies.—The diagnosis of this disease is occasionally difficult; it wdll be
   much facilitated by the knoivledge of the fact, that the ova of the acarus
   may be readily found with the microscope, attached to the roughened and
   undermined cuticle in the neighborhood of the vesicles.
                                                     Part xxxvi., p. 191.
     Parasticides.—The following  is the formula of the Hospital for Diseases
  * of the  Skin for the " compound sulphur  ointment" which is in general
   use against scabies, favns and true ringAvorm, diseases Avhich depend upon
   parasites, wdiich it is  necessary to  kill:  R Of sublimed  sulphur, half a
   pound; of the ammonia chloride of mercury, half  an ounce;  and of the
   sulphuret of mercury, half an ounce; to these, well rubbed together, add
   four ounces  of olive-oil, sixteen  ounces of  fresh  lard, and  twenty minims
   of creasote.   It wdll be  seen  that  we  have here in combination three
   different drugs, each possessing great  efficiency in  the  destruction  of
   insect and fungus  life.  The object in viewr, that  of obtaining a vigorous
   compound, which at the same time shall not be irritating to the skin, is, we
   believe, exceedingly well attained.                  Part xxxvii., p. 315.

                                 LEPRA.
     Bark of the Ulmus  Campestris (or Elm).—Dr. Sigmond thinks favor-
   ably of the use of the decoction of elm-bark, both internally and externally, 
6KTN DISEASE.
505
in all varieties of lepra, and in other scaly affections of the skin.  Four
ounces of fresh  elm-bark, bruised, boiled in four pints of Avater, form a
thick decoction.
  The best time to gather it is in the spring, and the most desirable parts
are the smaller  branches  and tAvigs.  The  inner  bark abounds Avith a
mucilaginous principle (which disappears on boiling  too much).   Dose  of
the decoction, from tAvo to four ounces, three times a day.
  Dr. S. says: I have likewise found it very serviceable in tinea capitis,
and more especially Avhen it has been used as a Avash externally.   In those
extensive papulous eruptions, known by the name of lichen, Avhich usually
terminate  in  scurf, the  lichen simplex, which  attacks the face and skin
sometimes  periodically,  very quickly yields to the remedy ; and in the
milder cases of erysipelas, Avhen the constitution has not  in  a^y way par-
ticipated, I have been in the habit of using  this remedy wiJi  a success
that has noAV enabled me to lay the result of my observations before you.
  In those affections of  the skin where the papulas are  in a  state of high
irritation, amounting to  inflammation, I have  uniformly found  lotions  or
applications of mercurials, such as  the unguentum hydrargyri nitratis,  or
ointments  of lead, to be  rather injurious than beneficial ; in such cases it is
that I have observed so  much benefit from the bark of the elm,  internally
taken, and externally applied, and in almost  every stage of cutaneous dis-
ease.  There are likewise some states of the skin  in wdiich papulous erup-
tions and erythematic blushes are indicative of diseased states of the internal
mucous membranes,  and likeAvise of Ararious dyspeptic symptoms.  Thus
we observe where leucorrhoea exists, or where disease has  been induced
by dram-drinking, that  redness  of the  skin, and disordered functions of
the skin are visible ; in  such instances the use of the elm-bark for some
weeks, Avith attention to diet has been productive of the best consequences,
and I have had the satisfaction  of seemg some of those eruptions,  Avhich
have for years baffled every attempt of the medical men, yield  to a deter-
mined course of the elm-bark.   It is of importance to continue it for some
time, and to attend to the state of the bowels during the period in  Avhich
it is taken.  The state  of  the  urine should be carefully observed;  and it
Avill be found that, after some little time, much acid will become developed,
Avhich most probably is  determined from the blood, and would  have been
deposited in the skin and  have produced some  of  the  disordered  states
which the  elm-bark appears destined to avert.              Part l, p. 61.

  Lepra.—Dr. Ross  says :  The iodide of potassium has been used  exter-
nally in almost all cutaneous  diseases.   From  some experiments  lately
made with  regard to its destructive poAver over the  itch insect, it has been
recommended for the cure of scabies.  M. Schedel states, that the speediest
cure of this complaint is effected by an  ointment containing 3ss. to'  |j.  of
axunge.
  Dr. A. T. Thomson recommends  an ointment composed of hyd. potass.
5iss., to axunge  §iss., wdth tinct. opii  3j.,  in  lepra; this, conjoined with
appropriate  internal  treatment, has a very good effect;  but, from'a com-
parative trial, I think it inferior to  another ointment recommended by the
same author, viz.:
  R Calomelanos, 3j. ;  unguent picis, 3iv.; unguent cetacei, 3j.  M.
                                                      Partvl,p. 122.
  Lepra, Psoriasis, Lupus, Acne,  Eczema  Chronica, Impetigo, Prurigo, 
506
SKIN DISEASE.
Lichen.—In the treatment of these and all chronic  affections of the skin,
which are not venereal, nor  dependent on  local causes, Mr. Hunt advises
to first, reduce inflammatory action by depletion and antiphlogistic  regi-
men ; then administer arsenic, beginning Avith five minims of the  liquor
potassae arsenitis thrice a day, Avith  the meals, until the conjunctiva  is
inflamed ; afterward reduce the dose to four minims, keeping the eyelids
slightly sore  and weeping.  The Avhole success  of  this treatment (Avhich
seldom or never fails in any  of the above diseases),  depends upon the con-
tinued and persevering use  of the medicine, Avhich is perfectly harmless,
when administered Avith vigilance under these restrictions.
                                                     Part  xiv., p. 247.
  Lepra—Treatment of.—In obstinate cases of lepra, use fumigation with
sulphur and iodine vapors.
       *       *  •     *        *      *        *        *      *
  When the functions have  all been got into a healthy state, and the sys-
tem is  free  from inflammatory action, begin with  FoAvler's  solution of
arsenic, in four or five minim doses, taken thrice a day upon a full stomach ;
and,  without increasing  the  dose,  continue  this plan  steadily till the
system is brought under  the influence of the remedy.  Continue the me-
dicine for some  time after the disappearance of the eruption. (Dr. Griffith.)
       ********
   Let strong tar ointment (\ to i of tar) be rubbed in gently thrice a day;
while a tepid bath is used once or twice a week.  And give Fowler's solu-
tion of arsenic,  beginning with five drops daily and increasing a drop every
other day, until twelve or fifteen are  reached.   (M. Emery.)
                                                       Part xx., p. 174.
   Syphilitic Lepra.—Dr. R. B. Todd would give  five grains of blue pill
night and morning,  thus  affecting the system slowdy and gradually by a
mild and unirritating preparation of the mineral.   Iodide of potassium
favors the mercurial influence, at the same time exercising some  specific
 antidotal power of its own. Hyper-salivation, violent ioclism, irritation of
 the bowels and of the skin, and peculiar  nervous affections are produced
 when too much of these  minerals is thrown into the system, with a desire
 to produce a rapid effect.  We may Avithhold  them  for a time, renewing
 them again as occasion may suggest.   It is sometimes much more desirable
 to introduce mercury also  by  the skin than by the stomach.  Tar is also
 one of the safest remedies—the pix liquida.  It may be given internally in
 capsules, or  applied externally, or both.   Fifteen  or tAventy minims may
 be taken three or four times a day, at the same time the patient may be
 tarred over  the surface, and lie  in tarred sheets.  This is  exceedingly
 useful, though scarcely available in private practice.   Part xxiii., p. 322.
   Lepra and Psoriasis—Sesquicarbonate of Ammonia in.—M. Cazenave,
 so Avell known as a  very successful dermatologist, has published  experi-
 ments tending  to  shoAV that sesquicarbonate of ammonia may  advan-
 tageously be used as a succedaneum of arsenical preparations, in lepra  and
 psoriasis.
   Give the sesquicarbonate of ammonia in the folloAAdng manner:  Sesqui-
 carbonate of ammonia, 3ss. ;  diaphoretic sirup, §vij.;  take  one to three
 tablespoonfuls  per diem.  If diarrhoea, lassitude,  cephalalgia,  and rapid
 alternations of heat and cold Avere to occur, the remedy must be suspended.
                                                      Part xxx.,p.  265. 
SKIN DISEASE.
507
  Lepra Vulgaris.—Dr. «T. S. Taylor directs an alkaline bath once a week,
and thin oatmeal gruel instead of soup.  Give half-grain doses of iodide of
potassium, and three minims  of Fowler's  solution three times a day, and
apply night  and morning,  an ointment composed of the nitric oxide of
mercury and lard, with a  few drops of creasote added.
                                                   Part xxvi, p. 284.
  Scaly Disease of the Skin.—In these and scrofulous and cancerous dis-
eases the galium aparine is proving very valuable.  Mr. Hooper prepares
an inspissated  juice, a tea spoonful equalling half a pint of the decoction :
3j. of this juice may  be taken three times a day.        Part xxix., p.  47.
  Lepra Inveterata.—In the treatment of this most obstinate  affection,
says Dr. Willshire, much Avill be gained by a proper regulation of the diet.
Bread, milk, eggs, and vegetables, as potatoes, Avater cresses, etc., should
alone be alloAved, and all alcoholic drinks a\Toided.  A Avarm bath  twice a
week is of the greatest use.  The medicinal means principally of use are,
arsenic, bichloride of mercury, and iodine, for which the decoction of elm
bark forms a good vehicle.   An ointment containing calomel and pitch is
one of the best local applications.                  Part xxxix.,  p. 230.


                           PEMPHIGUS.
  Dr. Bennett, Mr. Skey and Mr. Startin believe that  arsenic is almost a
specific remedy in  the ivorst cases of this  disease, as it  remedies  the
unknown constitutional cause  upon ivhich the  disease depends.  It does
not prevent  the liability to  return, but it  renders the  attacks less severe
than the original one.                                Part xxix., p. 249.

                            PITYRIASIS.
   Treatment of.—Dr. Startin  recommends external  applications  of a
soothing nature ; baths medicated Avith mucilage of linseed, milk, yolk of
egg, etc.; at the same time give demulcents, diuretics, etc., to increase  the
renal secretion.  Cover the parts  over  with glycerine ; it remains fluid,
and  resists  evaporation under any  temperature to  ivhich the body is
exposed.                                             Part xiii., p. 306.
  Pityriasis, Herpes, Eczema.—M. Cazenave  uses  a lotion composed of
one part of alum, and sixty-two parts of Avater.   In the slighter forms of
acne,  lichen, pityriasis, herpes, and even in eczema, a simple acidulated
lotion.  In impetigo, after the crusts have fallen off, the folloAving appli-
cation of alumina : Alum, eight grammes; infusion of Provence roses, five
hundred grammes.  GoAvland's solution, or Bateman's mercurial emulsion,
however, ansAver very well.  M. Cazenave uses the folloAving : Bichloride
of mercury, ten  centigrammes ; hydrochlorate of  ammonia,  ten centi
grammes ; almond emulsion  250 grammes ; make  a solution.  In really
chronic eczema  he  uses the folloAving  lotion:  Acid nitric, tAventy-five
drops; acid  muriatic,  tAventy-five drops;  distilled water, three hundred
grammes.  Mix by shaking.                           Part xiv.,p. 253.
  Pityriasis.—Pityriasis is closely allied to psoriasis.   Dr. Wright says:
Psoriasis is  prone  to affect the muscular parts of the body ; pityriasis
chiefly shoAVs  itself  upon the. scalp, forehead, and face.   You saAV a very
good case of both diseases in the person of a man named Hines,  Avho came 
508
.SKIN DISEASE.
into the top ward of the hospital on the 28th of November last year.  His
arms, and hands, and legs Avere extensively covered with patches of pso-
riasis : the upper part of his face, his forehead, and scalp were completely
dusted Avith the peculiar dandriff of pityriasis.  Both,  here, occurred in
the same individual, and merely different in their relative intensity.  The
man wras a brass-founder, and had lately been out of work, and indifferently
fsd.  The disease was of five Aveeks' duration.  He was  ordered generous
diet, and half-a-pint of ale daily.
  R. Decoct, dulcamaras, §viij.; potassas, liq. arsenicalis, aa. |j.;  misce fiat
mist, cujus cap. coch. ampla duo ter die.         m
  R. Pil. coloc. c, 9ij.;  extr. hyoscy., 3j.   Misce et divide in pil. xij. qua-
rum cap. ij. omni nocte.
  This was all the general treatment the man  had, and on the 23rd of
December he left the hospital well.   Five days less than a month, he was
under medical management, and at the time of his departure there was not
a trace of skin disease  about  him.   It is probable that  the medicines ad-
ministered to  this patient rendered him some service ; but perhaps the
greater service was due to his improved mode of living.
                                                    Part xvi, p. 221.
  Pityriasis  Capitis.—Dr. Winsar recommends  the  folloAving lotion:
Fresh sulphuret of potash, 3j-> distilled water, |iij.  It may be used once a
day.                                               Part xxviii, p. 330.
  Pityriasis Versicolor Curable by Local Applications.—This common
disease known vulgarly as "Liver spots," and in the Nosology of "Wilson
as Chloasma, is one  generally acknowledged to be  of  extreme intracta-
bility.   Mr. Paget, Ave notice, among his out-patients at St. Bartholomew's,
does not adopt any constitutional treatment whatever, but simply orders a
Avash of the bichloride of mercury (gr. j. ad §j.)  He informs  us that he
has never known a case long resist the influence of this  remedy regularly
applied to  the whole  affected surface once in the day.  At the Skin  Hos-
pital, although an arsenical  course  of internal medication is always pre-
scribed at the same time, yet a  mercurial lotion is also used, and may
possibly be the chief curative agent.  In the hands of Dr. Jenner, at the
University College  Hospital, the sulphuric acid has, Ave understand, suc-
ceeded very Avell.  There can be little doubt but that the disease is almost
invariably curable by local applications solely (parasiticides ?)  In relation
to this mode  of cure,  it is important to  connect the observation of Eich-
stedt and others, as to the eruption depending on the presence of a crypto-
gamic  plant.   Another  interesting link in the same chain of evidence has
recently  been   made  out at the Skin Hospital,  namely, that it is not
unfrequently contagious.                             Part xxix., p. 250.

   Cocoa-Nut  Oil Ointments.—Use of, in Pityriasis.  Vide Art. "Medi
cines."

                             PRURIGO.

  Prurigo Senilis.—[This disease is Avell knoAvn to be very intractable, and
is indeed  set down  by many authors as incurable;  hence the treatment
usually recommended is merely palliative, and consists in the use of simple
Bait or sulphur baths, lotions containing sulphuret of potash, or corrosive 
SKIN DISEASE.
509
 sublimate, cinnabar fumigations, etc.  Dr. Bellingham thinks that a  good
 deal may be done by treatment.  He says :]
   Constitutional remedies  appear to have little effect upon purigo ; our
 principal reliance therefore must be upon local measures.   The local appli-
 cation which I have found most generally useful, both in  relieving  the in-
 tolerable itching, and in curing the disease, is  creasote, either in form of
 ointment or  of lotion, usually the former.  The ointment may be made
 wdth from ten to twenty drops of creasote to the ounce of lard, the lotion
 with from twenty to thirty  drops of creasote to the  half-pint of Avater, a
 little  spirit  of wine or acetic  being added in order to render it more
 soluble.  The ointment to  be useful should be well rubbed into the parts
 every night, and a very few applications will in general relieve the itching,
 prevent the development of fresh  papula?, Avhile the  old ones will gradu-
 ally desquamate.  If the application of the ointment is  premised by the
 warm  bath, and if the patient attends to personal cleanliness, the remedy
 Avill be more likely to prove quickly successful.         Part xvi, p. 223.

   Treatment  of Prurigo Pudendi.—Dr. Corfe says: Prurigo, Avhere it
 attacks the pudendum or scrotum, is oftentimes more effectually soothed
 by a lotion composed of two or four drachms of the terchloride of  carbon
 or chloric ether, in a pint of distilled or  elder-floAver water, than any other
 application that I am acquainted with  ; at  the same time a warm bath
 administered eveiy evening affords a calm and refeshing night's rest.
                                                   Part  xviii., p. 222.
                                                      •
   Treatment of Prurigo—Prurigo Pudendi (and other Species).—In those
 severe cases which are not  benefited by our treatment, Dr. Burgess gives
 strychnia, beginning with one-sixth of a grain twice a day, and  increasing
 the dose to one-fourth of a  grain.  Occasional doses of tincture of henbane
 may also be given.
   Senilis.—Give phosphorus internally, in the form of phosphorated ether,
 having preceded it, for a  day or tAvo,  by repeated doses  of tincture of
 hyoscyamus.  [The dose is not  stated; but the dose of the tinct. asther. c.
 phosphoro  of the French,  is, according to Pereira, from  5  to 10 drops.—
                                                    Part xix., p. 199.

   Prurigo of the Genital  Organs.—This affection (Avhich often assumes
 the form of lichen or eczema) is well known to be very painful, distressing,
 and difficult to remove.  M. Tournie has lately proposed calomel ointment,
and a  powder of camphor and starch, ivhich topical applications he has
 used Avith much success.  When the parts (genital organs, anal region, or
axilla)  are covered Avith scabs, tepid baths, and emollient  applications are
to be used first.  When the indurated particles  are removed, the affected
spot is to be rubbed tAvice a day with the calomel ointment (one or two
drachms of the calomel to one ounce of axunge), and after  each application
dredged with the poAvder (four  parts of starch to one of  finely powdered
camphor).  We mention M. Tournie's treatment as this kind of prurigo so
often baffles the remedies usually employed.           Part xxv., p. 247.

   Colchicum in Prurigo.—Dr. Elliotson gives the case of a man, laboring
under this disease in its most inveterate form, to  whom half a drachm of
vinum  colchici was  administered  thrice daily.   This the patient took for
three weeks; at the end of  which time he was completely cured. 
510                         BKTN DISEASE.
  Colchicum would thus seem to answer well in some cases of skin diseases
where the urine is of low specific gravity.              Part xxv., p. 264.

  Prurigo—Starch in Skin Diseases.—M. Cazenave substitutes powdered
starch  for poultices, especially in  pruriginou*  affections, either  simply
dusted over the part, or applied after the latter has been Avell cleansed by
an alkaline solution and thoroughly dried.  The  starch may be used sim-
ply, or mixed with oxide of zinc, camphor, etc.  M. Cazenave treats acute
eczema,  acne  rosacea, impetigo,  and  herpes,  by  dusting  the affected
regions, night and morning, Avith the following poAvder—White  oxide of
zinc, two drachms;  powdered starch, four ounces.  Very good  results
have been obtained in prurigo of the genital organs, the groin, or the axilla,
Avith the folloAving poAvder : White oxide of zinc, two drachms;  camphor,
half a drachm ;  powdered starch, four ounces.
  Prurigo Ani et Vaginas.—Dr. Richart recommends the following: Take
equal parts of sulphate of zinc and of alum, roughly poAvder them, and
put them into a glazed earthenwrare vessel; put it on a slow fire and leave
it there till bubbles of air are no longer disengaged, and till the mixture
acquires a stony hardness;  then powder it, and throw it by small portions
at a time into boiling water.   Filter, and apply to the parts wdth a  sponge
and  on linen.                                        Part xxx., p. 228.
                            PSORIASIS.
   Psoriasis—Liquor  Hydriodatis Arsenici  et Hydrargyri.—[In a pre-
vious number of the "Dublin Journal," Mr. Donovan gave some account
of a new chemical compound,  consisting of iodine,  arsenic,  and mercury,
and the diseases in which it would be  found beneficial, namely, psoriasis,
lepra,  and lupus.  He now presents to us the experience of some of the
most eminent men in Dublin.   Mr. Carmichael states that:]
   I have tried the liquor hydriodatis arsenici  et hydrargyri, in five or six
cases of lupus, and in one case of psoriasis, wdth  decidedbenefit in  all.
   In one case of lupus, often years' standing, in Avhich great deformity had
been occasioned by the disease on the features of a young lady, on whom
all the usual remedies had  been tried, it produced  most ^decided  benefit,
and seemed to put an immediate check to the progress of the malady. She
is not yet perfectly well,  but sufficient advantages have ensued to promise
recovery.  In one of my  lectures I stated the case of a man Avho had lost
a great part of the vomer, and in whom much deformity had consequently
ensued from an obstinate attack of lupus, who in the course of a few weeks
so far recovered, as to be discharged from the hospital  apparently well.
I perceive there has been no relapse of the disease, as he Avas told to return
to the hospital should any suspicious symptoms make their appearance.
  In the case of Mr.----, affected wdth psoriasis, although the disease had
existed for years, most decided benefit  generally followed the  use of the
preparation in question, so that nothing  but  discoloration  of the  skin re-
mains  where scaly spots Avere  formerly manifested.
  [Dr. Irving's case is the most interesting, not only on account of the
virulence of the disease, but also because he had tried "in different cases the
separate ingredients of the liquor hydriodatis arsenici et hydrargyri wdth-
out their having gained his confidence.   In relating this case he says:]
  On examination, I found his legs and arms  thickly covered with large
spots of psoriasis, much inflamed, and very itchy.  He said they were in-
ci easing rapidly in number, and that some had made their appearance on
his body and forehead during the last few days. 
SKIN DISEASE.
511
  I directed that he should be blooded to twelve ounces, and ordered him
some aperient medicine Avhich he Avas to continue for a Aveek. These means
afforded him some relief; the  eruption was less itchy and less inflamed.   I
directed him to continue the aperient medicine, and to take  twelve  drops
of liquor potassae three times daily.                    #
  It would he tedious to relate  the entire history of this case ; it is suffi-
cient to say, that he took various remedies, Dulcamara and Plummers's
pill among the number, Avithout  any benefit  unless temporary relief from
itching.
  From the experience of many  cases which I had  treated without perma-
nent benefit at  the Maison  de  Sante, with FoAvler's solution of arsenic,
iodine, and mercury,  separately administered,  I was  inclined to  doubt
their efficacy ; I therefore determined to try the compound of these  three.
On the 11th of February we commenced the solution.
   He took a draught containing 3ss. of liquor hydriodatis arsenici  et hy-
drargyri three  times a day from this date to the 28th of April.   Twice
during that period I found it necessary  to  stop the medicine for tAvo or
three days, and to give an opening draught, from his having complained of
headache  and  sickness of stomach.
   On the  28th of April the disease was quite cured, nothing remaining but
a stained  appearance of the skin.
   Venereal Eruptions.—Mr. Cusack states a new and different application
of the arsenico-mercurial compound, which he employed with considerable
 success.  He found that venereal eruptions rapidly yielded to scruple or
half drachm doses three  times a day, that is to one-quarter of a grain of
protoxide of mercury, and one-eighth of a grain of arsenic, or thereabouts,
in the twenty-four hours. This indeed is a very small quantity of mercury
to effect a rapid  cure with :  no one will  deny that the less of it that will
 answer the purpose  the better for the patient: and here again we perceive
 the effect of chemical combination, assisted no doubt  by solubility.  Mr.
 Cusack writes:
   " I  have unfortunately omitted to make notes of the cases in which your
valuable remedy, the liquor hydriodatis arsenici et hydrargyri, was admi-
nistered,  and am only able to state generally, that I have used it freely in
secondary venereal eruptions, both papular and scaly.   I found the erup-
tions yield rapidly to its administration in the dose of one scruple to two,
 three "tunes each day.  In two instances  the mouth became tender, and a
 slight salivation folloAved ; but in no case have I observed  any unpleasant
 consequences, even when taken in larger doses."           Part ii, p. 50.
    Uses of some  of the Combinations of Iodine.—In the paper before us,
 by Mr. Osbrey, the effects of some of the combinations of iodine are inter-
 esting.  He begins with the  hquor hydriodatis arsenici et hydrargyri, in a
 case  of inveterate psoriasis.  The patient, Susan A., ast. 9, ivas affected
 with diffuse.psoriasis which engaged almost her whole body, the scales on
 the extremities  being continuous and remarkably thick.  The following
 mixture Avas given:
   R Aquas destillat., §viij.;  liq. hydriodat.  arsen. et hydr., gtt. 80  ; tinct.
 zingiber., gss.
   Sumat  unciam misturas omni tertia hora.
   Sickness of the stomach was  at  first produced, wdiich soon subsided on
 desisting  from the medicine for a  few  days.  In ten days the  eruption
 began rapidly to decline upon the trunk,  am  the thick scales to loosen upon 
512                         SKTN DISEASE.
the extremities. _ The separation of the scales on the head was accelerated
by applying an ointment consisting of equal parts of tar and dilute  citrine
ointments.  " In five weeks from the  commencement  of the use of these
remedies she improved in  health, but after that period her appetite  de-
clined ; she fell away in flesh, and her countenance became pallid.  The
use of the mixture was of course discontinued.  All traces of the eruption
had then disappeared from the surface of the trunk, and only a few patches
remained on the extremities."   She then went into the country, took tonic
.medicines, and soon recovered her health.  The mixture was again com-
menced, and in three Aveeks no trace of the disease remained.
   The iodide of potassium, Fowder's solution of arsenic, mercurial  altera-
tives, sarsaparilla, guaiacum, and other medicines had been previously tried
in vain.  At the same time Ave think that every practitioner ought to exer-
cise the greatest caution in  every case Avhere he is using the above mixture,
as in the case here related  Ave perceive that the patient's health Avas at first
materially injured for a time.   Three  other cases of scaly eruptions were
treated in the same Avay.    One  was affected Avith several thick scaly
patches on the extremities for twrelve months  previously.   These disap-
peared Avhen she had used the  medicine about three Aveeks.   The separa-
tion of the scales was here  also assisted by the tar and citrine ointments.
TAventy-five drops of the  mixture wrere given three times a day Avithout
producing sickness.                                      Part vl,p. 63.

   Concrete Naphthaline in Psoriasis.—Dr. Emery, of the Hospital St.
Louis, had his attention turned to  the investigation of  the different pro-
ducts of tar as remedial agents in the treatment of skin diseases, on ac-
count of the successful rssults he obtained from the use of tar, and because
of the unpleasant odor it gave forth.  Various  preparations Avere had re-
course to, the most valuable of Avhich proved to be the concrete naphthaline
which Dr. Emery tried in fourteen cases.   In tAvo cases, one of psoriasis
gyrata, and the other lepra vulgaris, it failed in effecting any good ; in the
remaining tAvelve it proved more serviceable.  In two of the cases, lepra
vulgaris of from fifteen months to tivo years' duration, arsenical and iodic
preparations had been previously tried ; in the younger patient the  arsenic
at first seemed to do good, but the improvement soon ceased. An ointment
prepared with tAvo scruples of concrete naphthaline to thirty of lard was
applied, causing the scales to fall off, leaving  the skin of a violet color, with
white circles around.  A  perfect cure was effected  in six weeks, and
although three months have passed since, there has not  been any relapse.
In four other cases the men were laboring under  inveterate psoriasis; in
one of them it  had existed sixteen years, and had resisted arsenical, iodic and
mercurial treatment.  The  tar ointment Avas had recourse to, and with de-
cided advantage, but the man becoming impatient on account of his busi-
ness, an ointment of naphthaline, twice  the strength of  that used  in  the
preceding cases, was spread on compresses, and applied  over the diseased
parts night and morning.   The man was cured in  six weeks.  When  the
ointment was applied too strong, it caused a burning heat, which was soon
removed by emollient baths and poultices.  The other six cases were also
instances of psoriasis cured by the naphthaline ointment.  Dr. Emery states
that this remedy has an unpleasant odor, which passes off", and it is apt to
irritate the skin and cause erysipelas if it be not carefully Avatched.
                                                      Part vii.,  p. 111. 
SKIN DISEASE.
613
Psoriasis:
  If dependent on strumous diathesis, Dr. Graves uses cod-liver oil,  made
into an emulsion with sirup, mucilage and orange-flower water.   Insert one
or more issues at a distance from the part affected; and let the patient use
Avarm baths Avith tAvo gallons of size added to the water,  or an equivalent
quantity of isinglass, or calf's foot jelly.
   Of the  Scalp.—Use hot-air sulphur baths for fifteen or twenty minutes
daily, and apply the following ointment at night:  R Hydrarg. biniod., 9j.;
adip. ppt. §j.; ol.limon., gtt., v. M.
  Or, give hydrarg. bichlor. gr. one-sixteenth  dissoh^ed in sp. vin.  rect.,
3ss., thrice a day Avith decoction of bark and sarza, and apply dilute citrine
ointment, wdth a third part of ung. ceras alb.             Part xv., p. 256.
  Acetate of Potash in Psoriasis.—Give acetate of potash in doses  of
half-a-drachm three times  a day.  It acts (as described by Dr. Golding
Bird) by  increasing the metamorphosis of tissue  in the system, by  which
means all  products of low vitality are likely to become decomposed and
eliminated from the system in the urine.                Part xxi, p. 245.
   Use of Phosphorus.—Dr. Burgess recommends  phosphorus  as one  of
the most  valuable  medicinal agents Ave  possess in  those  inveterate cuta-
neous diseases—leprosy, psoriasis, lupus—in which the skin seems to adapt
itself to  the  morbid  condition, which it  retains with singular tenacity
against all the usual methods of treatment.
  The phosphorus treatment of these maladies may be either internal or
external.   The best method of administering the remedy internally is dis-
solved in oil or ether, and  the  phosphorated oil or ether then mixed  up
with poAvdered gum arabic and  mint ivater.  Camphorated  lard  is the
most appropriate vehicle for applying phosphorus externally.  Its energetio
revulsive  properties may likewise be turned to account in certain diseased
conditions of the skin. Phosphorus, the iodide of arsenic, cantharides,
and the biniodide of mercury, are the most powerful internal remedies for
the skin diseases, we possess.                          Part xxi, p. 250.
  Psoriasis.—" Psoriasis,  so-called, lepra vulgaris,  psoriasis diffusa, psori-
asis gyrata, psoriasis guttata, and psoriasis inveterata, are one disease more
or less chronic."   The  real nature  of psoriasis is altogether  unknown.
There is  no exudation, properly so called; there is  considerable redness
and an increased growth, or a hypertrophy of the epidermis.   As there is
generally a deranged state of the digestive organs, Avith sometimes constitu-
tional disorder in this affection, we must correct these by suitable combina-
tions.  For the constitutional treatment, Professor Bennett advises equal
parts of FoAvler's solution  and tincture of cantharides, in doses commenc-
ing with ten drops, gradually increased to fifteen or twenty.   Most der-
matologists are agreed that the best local  application  is the pitch oint-
ment (ung. picis);  if it causes  considerable  irritation it may  be diluted
with an equal  part of lard.  Some  cases require only the arsenic,  others
the pitch ointment alone,  and a third class of cases require the action of
both.                                                Part xxii., p. 244.
   Treatment of Psoriasis and Lepra-Vulgar is.—According to M. Emery,
the arsenical preparations,  and  especially Foivler's solution, are the best
internal remedies.   Tar takes the first place as an  external application.
     vol.  u.—33 
514
SKIN DISEASE.
The combination of these is the best treatment for psoriasis.  The iodide
of mercury ointment is occasionally useful when judiciously apphed, and
next to it the iodide of sulphur.  The tar ointment is made by mixing a
third or a fourth  of a part of tar to twTo or three parts of axunge.  The
ointment of iodide of mercury is made by mixing one part of proto-iodide
of mercury wdth  eight  of axunge; and that of the iodide  of sulphur by-
mixing from one part in thirty-tAvo to one part in' eight of lard.  Besides
these, dietetical and hygienic measures must be adopted.  Diet mild, and
not too substantial, avoiding all aliments difficult of digestion, regular ex-
ercise, frequent use of baths, and having recourse again to the treatment
which had benefited them before, on the least appearance of the disease.
                                                     Part xxii., p. 245.
   Psoriasis,  Chronic.—M.  Cazenave has for many years past employed
carbonate of ammonia in squamous diseases of the  skin.   He prescribes
ten parts of ammonia to two hundred and forty of simple sirup, the patient
taking from six to twenty-four grains of the salt daily. Part xxii., p. 259.
   Psoriasis—Dr. Graves applies a saturated  solution of gutta percha in
chloroform; no woollen stockings or rough garments of any kind should
be allowed next the skin, lest the application should be disturbed.
                                                    Part xxxi, p. 288.
   Psoriasis.—Dr.  Crawford  says the diet  should  be nourishing.  R Po-
tass, acet., 3ij.; aquas, §iij.  Of this one drachm to be given in a little
wrater three times a day.   Locally, the limbs to be  placed for five minutes
in the morning into a tepid bath, containing one drachm of bicarbonate of
soda. The scales to be gently removed with a soft flesh  brush, and then
the following applied :  R Plumbi diacet. sol., 5j. 3vj-; sol. mur. morph., 3ij.;
a teaspoonful to be mixed with a tablespoonful of cream, and applied to
the limbs.                                         Part  xxviii., p. 233.
   Psoriasis  Diffusa.—When in large patches over the flexures of joints,
forehead, neck, chest, etc., says Dr. Bullar, give a quarter of a pint daily
of the decoction of the urtica dioica (common stinging nettle), made by
boiling an ounce of the leaves and stems in a quart of water, down to a
pint.  An extract may be made from this—dose, five grains three times a
day.  The same medicine is efficacious in inveterate chronic papular erup-
tions (lichen),  and in various  forms of A*esicular and scaly diseases (eczema,
lepra, and psoriasis), especially in cachectic states of the system.
                                                     Part xxxi, p. 172.
   Scaly Cutaneous Diseases.—Mr. Thomas Hunt believes that if there be
any medicine more safe and manageable in these  cases, in careful hands,
than another, it is arsenic united wdth chlorate of potass; but if there be
any medicine more dangerous and unmanageable  than another, it is the
compound of arsenic, iodine,  and mercury, known  as Donovan's solution.
                                                    Part xxxii., p.  182.
   Psoriasis—Syphilitic.—Iodide of potassium and sarsaparilla, says Mr.
Stanley, will generally cure the disease for a time;  but, as a matter  of cer-
tainty and safety, 5 grains of Plummer's ptil should be given night  and
morning, though not necessarily to touch the mouth.
                                                   Part  xxxiii., p. 236.
   Psoriasis of the Matrices of the Nails.—In cases under the care  of Dr. 
BKTN DISEASE.
515
Hare, at the University College Hospital, he put them upon the plan of
treatment which he has found to answer very well in cases of psoriasis—
viz., liq. potassae in half-drachm doses, and liq. arsenicalis  in five-mininv
djses, three times daily, in water.                   Part xxxvii., p. 308.

            SYCOSIS MENTI,  OR BARBER'S  ITCH.
  Iodide of Sulphur.—Dr. Ross says he made use of the iodide of sulphur
very successfully in a bad case of sycosis menti.  After soothing the irri-
tation by extracting the hairs from the pustules, by poultices, prussic acid
lotions,  and warm poppy-head fomentations, an ointment of gr. xv. to the
ounce Avas used by gentle friction morning and evening.  In ten days the
tuberculated indurations covering the chin were much smaller,  and  ulti-
mately a complete cure was effected.                   Part vl, p. 123.

  The Liqmor Potassae.—Given in doses of from 15 to 30 drops, three times
a day—is an admirable  remedy in many cases of inveterate skin diseases.
According to our observations,  it is far more efficacious, and perhaps, too,
less injurious, than the  potash  in  combination  with iodine.   The liquor
potassas may be giA'en in milk, beer, decoction of Sarsaparilla, etc.  With
respect  to the sulphate of iron as an external application, in sycosis, men-
tagra, etc., we cannot believe that it possesses any  curative virtues abo\re
those of the sulphate of zinc,  or of the sulphate of copper, that are in daily
use. The Avhite vitriol is our favorite, and the best Avay of applying it is by
dipping rags of soft linen in a tepid solution of the salt, and covering these
wdth a piece of oil-skin.   If  used thus, the lotion will not require renewal
oftener than night and morning.   In some cases, a little hydrocyanic acid
may be conveniently added to  the solution Avdth advantage.   (Ed. Med.
Cldr. Hex.)                                           Part ix., p. 189.
  Sycosis.—Sycosis, says  Mr.  Startin, has its site in  the sebaceous fol-
licles of the face and head, wdiich  are  perforated by the hair of the beard,
whiskers, eyebrows, or scalp, and unattended wdth any necessary derange-
ment of the general health.
  The treatment consists of plucking out the hairs  with a pair of forceps,
and the application of a mildly  stimulating ointment composed as follows:
  White precipitate of mercury, gr. xv.;  strong mercurial ointment, 3j.;
liquor of acetate of lead,  3ss.; recent pure  palm oil, 3vj.   This made a
smooth, creamlike application, which suited the parts very well.   To com-
bat the  general disorder, brisk  acidulated  saline purgatives were admin-
istered,  Avhich, ivhen the desired effect  was produced, Avere combined-with
a chalybeate.  .
  Also daily ablutions  A\dth the yolk of an  egg and  water, until the cure
is effected.
  In one very severe case the disease  had extended to the forehead, and
all the hairy parts of the face, and so  much hypertrophy existed in many
of the  diseased  parts  that the disfigurement Avas hideously great; the
upper lip was quite lobulated, and a  stiff yellow  beard grew out of the
surface, covered with  fungoid-looking granulations that  oozed  a muco-
purulent secretion. • I  had more leisure at that period than now falls to
my share, and I spent many hours at different times in removing the hairs
from this diseased mass, and  in opening  the tubercles when suppuration
could be detected, auointing  him with my OAvn hands; in short, in carry- 
516
SKIN DISEASE.
ing out the principles I have detailed.  He took iron in various forms, but
received the most marked benefit from the iodide internally administered,
and iodide of sulphur externally, in the form of ointment (15 grains to the
ounce of lard), by which conjoined means in tAvo or three months he Avaa
perfectly freed from his disease, save  that a feAv of  the ej clashes  seemed
to have been permanently destroyed.
  Mr. S. states, that as the implication of the hairs constitute the only dif-
ference between acne and sycosis, it becomes a rule, as conclusive as it is
practically useful, that they should  be  extracted  by a forceps from all
the inflamed  vari as fast as they appear; and thus the  maladies will be
rendered identical,  and require only a similar treatment.
  Fomentations of decoction of mallows or poppies, of linseed,  or of warm
water, in which a little sulphur and bran have been  boiled (in an earthen
vessel), are very serviceable, both before  and after this operation, and I
would recommend the sulphur-vapor douche as a most valuable accessory.
  This bath  can be readily applied by means of any contrivance, at the
end of the steam-pipe wdiich will exclude the  nose, or as is the preferable
mode, the whole face may be subjected to the sulphurous vapor, if the nose
be provided Avith a tube for inspiration.
  By paying  attention to the extraction of the  hairs, to the use of the
scissors instead of the razor, and  to washing and anointing the parts, after
the manner recommended for acne in my last lecture (the use of the lancet
and cauterization  being also  occasionally required), and the internal
treatment directed as then advised, I  have  often succeeded in  curing
sycosis of twenty or thirty  years' duration in as many Aveeks.
                                                      Part xiv.,p. 238.

   Treatment  of Sycosis.—[The  patient  was directed to clip the  beard
carefully, to  use no  soap in washing, but  to dab the face with a soft
towel.   Regular diet and  abstinence from stimulants Avere enjoined;
and,]
  Dr. Wright ordered the following to be applied three times a day :
   R Hydrarg. bichloridi, gr.  ij.; acidi muriatici mij-; mist, camphorae,
Sjviij.   M. ft. lotio.
  Additionally he had these medicines :
  fy Inf. gentianas, gviij.; liq. potassas, liq. arsenicalis, aa.  3j.  M. ft. mist,
cujus cap. coch. larg. duo ter die.
  R Pil. coloc. c. Bij.; extr. hyoscy., Bij.; pil. hydrarg., gr. x.  Misce et
divide in pil. xiv. quarum cap.  ij. omni nocte.
  In less than a fortnight, Ave had some satisfactoiy evidences  of improve-
ment.   The congestive and inflammatory tendency  was less, as shown
by the external appearance, and the patient's oavh remark, that he  had less
heat, pricking and pain in his chin, than previously.  Further, there Avere
fewer spots of suppuration, and in one or  two places a little furfuraceous
material had collected.  You remember my dAvelling upon this, as one  of
the best features in  the manifestations of amendment, and saying that the
fact of epidermal desquamation being successive of suppuration, Avas proof
that the local inflammatory action Avas subsiding.  Such proved to be the
fact.   In this case Ave had not  a solitary drawback.  The patient sys-
tematically improved  from  the commencement, and  before tAvo months
had elapsed he was able to shave the lower part of his face without incon-
venience. 
SKIN DISEA8E.
517
   [In these cases of psoriasis, pityriasis, and sycosis, alluded  to  by Dr.
 Wright, glycerine will prove a valuable application.]    Part xvi, p. 222,
   Treatment  of Sycosis.—In regard  to  the treatment  of  this most
 troublesome complaint, Mr. Wilson mentions that he has found the strong
 citrine ointment, the iodide of sulphur ointment, and the tar ointment, to
 be the most useful local applications ; but that it is difficult to  predict in
 any  individual case,  wdiich of these  will,  be most serviceable, one  fre-
 quently succeeding where another has failed,  or even proved highly inju-
 rious.   At the same time he gives Fowler's  or Donovan's solution inter-
 nally ;  but he mentions a case in which  a gentleman was nearly poisoned
 by two drops of the former.                        Part xxiv., p. 258.
   Mentagra or Sycosis.—Sycosis is often very troublesome and  obstinate.
 The  object of treatment is to destroy the vegetable parasite wdiich causes
 or is the disease.   An ointment cf corrosive sublimate, one grain, and lard,
 two  dr's, is  often very useful, or the Avhite  precipitate ointment of the
 Pharmacopoeia.   An ointment composed of a scruple of iodide of sulphur
 to an ounce of lard is strongly recommended by Dr. Thompson.  Warm
 fomentations  and poultices are very useful.   Epilation is sometimes abso-
 lutely necessary to effect a cure.  The  condition  of the digestive organs
 must be attended to, and purgatives,  tonics, and antacids exhibited as
 required.                                          Part xxxvii.,/). 179.
   Treatment of Sycosis.—Dr. W. Cooke says: Poultice with linseed until
 the  scabs are removed, and then apply constantly a lotion composed of
 tAvo drachms  of manganese, wdth potassa or  permanganate of potash and a
 pint of Avater.  After the ulcers are healed apply  red precipitate ointment
 every night for several weeks.                      Part xxxvii.,/). 182.


                    SYPHILITIC ERUPTIONS.
   M. Cazenave considers the best remedies to be the iodides of mercury.
 Biett gave R  hydrarg. biniod., gr. x.; pulv. glycyrrh., 3j. M. ft. pilul. Ix.
 Dose two or three daily.  But the protiodide is better ; R hydr. protiodid.
 gr. x., pulv. glycyrrhiz. 3ss. M. ft. pilul. Ix.  Begin Avith one, and afterward
 give two, three, or  four, daily.  In the more inveterate  forms,  as  the
 tubercular, give twice  the above quantity.  Do not combine with opium,
 which neutralizes the  effect.   If the bowels  become deranged, suspend  its
 use for a few  days.
  Next in value to iodide of mercury is  that of potassium, in doses of six
 grains daily, increased to ten. or in obstinate cases, and  where the consti-
 tution is not irritable,  to half a drachm in the day.   Topical remedies  are
 not of much use.  To dress an ulcerated surface use hydrarg. protiod.  Bj.
 to an ounce of lard.                                   Part xv., p. 242.
  Syphilitic Cutaneous Eruptions.—In  the treatment of these  eruptions,
Avhich may come on as exanthematous affections, vesicular, papular, tuber-
cular, pustular, and as ulcerations, Mr. Acton strongly recommends mer-
curial fumigations.
  He does not believe the condylomata  to be inoculable.  As local  treat-
ment he recommends the parts to be wa.shed  with a solution of chloride
of soda twice  a day, the parts to be well dried, and calomel sprinkled upon
them, and dry tint kept between the excoriated surfaces. 
518
SKIN DISEASE.
   Under the head of pustulas, he  includes rupia, bulks, and impetigo of
the scalp.  He finds the emplastrum ammoniaci cum mercurio an admirable
local application.
   In the local treatment of alopecia, Mr. Acton recommends stimulating
washes, as, equal parts of rectified spirits, eau de cologne, and castor oil,
or, if a stronger one be required, equal parts of vermy water and tinctura
lyttas,  some pomade being used also.
   The throat is very frequently the seat of secondary symptoms.  Patches
of erythema appear, Avhich become prominent, and then pale in the centre,
extending in  size.   They are often of a circular shape, or like the figure
8; they  frequently  ulcerate  ; their most  common  situation  is  on the
tonsils, the sides of the tongue,  or near the framum; they are met wdth
less frequently at the corner of the mouth, and on the dorsum of the
tongue.  Generally the patient has other secondary symptoms at the same
time.
   Mercurial Fumigation.—"The patient, having undressed, is seated naked
on a chair in a large box, his head being the only part exposed to the air.
This box is heated by a furnace, on which the bisulphuret of mercury is
placed, in the proportion  of three  drachms for each vapor-bath.  The
intense heat apphed soon volatilizes the mercury, which quickly fills the
well-closed chamber or box with a leaden-colored vapor that condenses on
the  body of the patient,  who is exposed  to  its influence for  tAventy
minutes, during the last ten of which he perspires profusely.   The box is
then opened, and the surface of the body is gently  wiped, so as only to
remove the drops of perspiration ;  a gown is  noiv thrown over the body,
and tOAvels  tAvisted round bis legs, and the patient laid on a bed, thus
SAvaddled up, betAveen two blankets, Avhich are tucked carefully round him,
and additional covering added.  The patient is now left for half an hour,
during Avhich he perspires freely, and a glass of  toast and Avater  may be
given.  At the end of this time, the wet clothes should be removed, and
the  patient  thoroughly rubbed  down ;  after dressing he should not at
once expose himself to the  open air, but remain a  short time in a cool
room.  The vapor, thus administered, may be repeated two or three times
a week, for a month or five weeks, and a cure of some of the most rebel-
lious forms of secondary symptoms may be attained.  It may be readily
assumed that this treatment is one that cannot be easily carried  into
effect in the country, as the necessary conveniences are not at hand.  In
these instances, the vapor-bath may be had recourse  to, and the cinnabar
may be placed on a metal plate over a  little charcoal furnace ; but, from
some experiments Avhich I haAre instituted, I find  that the mercurial vapor
is  so heavy, that  it will not usually rise more than a foot, and the good
effects of the fumigation will be slight, as compared Avith  those  arising
from the real fumigating apparatus.  The body should be covered Avith a
dark powder ivhen the apparatus is well applied, and gold leaf will detect
the presence of mercury on every part of the body.  The above remarks,
perhaps, explain why fumigations have fallen into disrepute, as the proper
means of application  are not always at hand."          Part xxiv., p. 266.

   Treatment of the Syphilides—Formulce.—The following is the prescrip-
tion for the  mistura hydrargyri bichloridi of the Pharmacopoeia  of the
Hospital for Diseases of the Skin:  R Of the  bichloride  of mercury, two
drachms; of strong hydrochloric acid, one drachm;  of spirits of camphor, 
SEJN DISEASE.
51b
two drachnis; of burnt  sugar, half a drachm ; of water, a gallon.  The
dose is from a drachm to two drachms, each drachm containing a twelfth
of a grain of the bichloride.  An extemporaneous biniodide of mercury is
also much used, the formula for the mixture being as  follows: R Of the
bichloride  of mercury, two drachms ; of  the iodide of potassium, six
ounces; of the tincture  of cardamoms,  two  ounces; and of Avater, a
gallon.  Of this, the  dose, a drachm, contains a tenth of a grain of tie
bichloride, and tAvo grains of the iodide.  Simultaneously with the use of
either  of these  mixtures,  Mr.  Startin  almost always orders the "red
ointment" to be  rubbed into  the  patches of eruption, or applied to any
ulcers which may exist.   The formula for this " unguentum rubrum," the
prime favorite of the institution, is: of the bisulphuret of mercury, half an
ounce; of the nitric oxide of mercury, half an ounce; of creasote, twenty
mininis ; and of fresh lard, sixteen ounces.           Part xxxvii, p. 316.
                 TINEA CAPITIS OR PORRIGO.

   Treatment.—Dr. Graves directs attention to the following points:
   When the disease is of long standing, always insert an issue in the arm
 before you attempt its cure.  I have seen water on the brain and other
 fatal consequences, from neglect of this precaution.
   If this disease has  clearly originated from contagion and no other evi-
 dence of derangement of the general health can be detected, we must not,
 from the mere presence of the cutaneous affection, infer a constitutional
 taint, and  must avoid the common error, of making the poor children
 undergo a course of alterative medicines.
   This affection originating in contagious matter directly applied to the
 skin, cannot, like some  varieties of lepra  and psoriasis (to which it often
 bears a great resemblance), be cured by internal medicines, such as  mer-
 cury, arsenic, and iodine, given separately or in combination.
   When it occupies the hairy  scalp, the common procedure of shaving the
 head is injudicious, for it adds to the irritation of the skin ; and the scalp
 can be sufficiently exposed hy cutting the hair as close as possible with a
 sharp scissors.
   The cure must be accomplished by removing the scales as far as that
 can be done by ddigent ablution, without using any irritating degree of
 friction : and wdien the  diseased portion of the skin has been thus exposed,
 we must next have recourse  to some  application which will  destroy the
 morbid secreting surface.  Formerly this  was attempted by means of an
 endless  variety of complicated formulas, each  of which had its advocates;
 the list may, however, be noiv reduced to a few simple remedies, and in
 truth, Avith nitrate of silver, sulphate of copper, or strong tincture of iodine,
 every case of this disease may  be cured.
  I never use the solid lunar caustic, or sulphate, but prefer a solution of
 ten, fifteen, or twenty grains to the ounce, as the  case may require.  As
to the application of this solution, it will not do to apply it, as  is generally
done, Avith a camel's-hair pencil, for it must be strongly rubbed into  each
 spot, for which purpose  a small bit of sponge, covered with fine linen, and
tied to the  end of a quill or  slender stick,  should be employed.  When a
large portion of the scalp is affected, it  will require some perseverance to
apply this lotion in an effectual manner. 
520                         SKIN DISEASE.
  An application of this nature, when effectually done, must not be re-
peated oftener than once a week.
  Immediately after it the whole scalp must  be covered wdth a spermaceti
dressing, and the spermaceti must be renewed at least four times daily, so
as to keep the head constantly moistened with it.  The head is  not to be
washed for three  days after  the  application  of the caustic, or of the
tincture of iodine, but  then it may be well but very gently washed  Avith
yellowT soap and water twdce a day, taking care to cover, as before, Avith a
spermaceti dressing after each washing.
  In 6caly diseases of the skin, it is quite surprising how much the cure is
facilitated by keeping the  affected  parts constantly smeared with sperma-
ceti, oil, melted suet, or even candle-grease.   Without this aid, the use of
caustics will often disappoint the practitioner.
  When the above precautions have  been  taken, the  cure will advance
rapidly, and each  succeeding application of  the caustic solution, or if the
tincture, may be less severe.                              Part ii., p. 69.

   Tinea  Capitis,  or Porrigo. — Dr.  Davidson makes   some valuable
remarks on the use of ioduret of sulphur in porrigo, and  other cutaneous
affections.   The following are among the cases given:
   C. B., aged 10, was admitted to  the GlasgoAV Royal Infirmary, on the
1st  Feb.   Scattered  over the whole of  the head  were  numerous  thick
greyish patches  of scabs, which, when removed, left  the surface under-
neath  perfectly bare and  shining,  but  in a day or two,  numerous  small
pustules made their  appearance, accompanied with considerable itching.
The eruption appeared in the form  of small  pustules four  years ago.  In
this case, the  scabs wrere first softened by the constant application of poul-
tices for tAvo days; the head  wras then  shaved.  An ointment, composed
of five grains of the bichloride of mercury  to  one ounce  of axunge, ivas
tried  from the 5th of February to the  12th, Avithout any improvement.
The following was then employed :
   R. Iodur. sulphur. Bij.; axungias, |ij. misce.
   This ointment Avas applied daily to the head; and in a few days a decided
amendment was remarked.
   On  the  5th  of March, the  following  report was  taken.—Pustules and
scales  are  now completely gone, but there are some bald  patches on head
in situation of eruption ; no itching;  surface of skin pretty natural; general
health good.
   He was dismissed in a few days afterward.
   James R., aged 12, ivas  admitted on the  10th Feb.  The whole of the
head and neck was covered w till thick laminated yellowish «sabs, which were
easily removed.   Some yelloAvish pretty large pustules we; e situated behind
the ears, but on  the  scalp they were not distinct, the hair being matted
together.   A fetid ichorous matter  Avas discharged, ?nd numerous pediculi
nestled everywhere on the head.  He had had the eruption for tAvo  and a
half years, but the general health was pretty good..
   A poultice Avas applied  for a  day, after which the following ointment
was applied, even before the shaving of the head, in order to extinguish
the pediculi, which it effectually did in twenty-four hours.
   R. Iodur. sulphur., Bij.;  axungias, |ij.   Misce.
   He was dismissed perfectly cured on the  29th February, or in about a
 fortnight after  the commencement of the  ointment, the  skin being quite 
SKIN DISEASE.
521
natural in appearance, without itching, and the hair growing naturally over
the Avhole head.
  D. M'L, aged 10, admitted 30th December.  The whole head, particularly
the forehead, was covered with a thick, dry, greyish white crust, accom-
panied ivith itching, but wdthout discharge.   The disease Avas of four years'
duration, and was  represented to be of a very inveterate kind.   General
health good;  bowels regular; tongue clean; pulse 80.
  R. Iodur. sulphur., Bij- 5 axungias, gj.   Misce.
  A fortnight after  the  use of the ointment, the eruption is  reported
to be quite, gone, and the skin covering the scalp natural in appearance.
  As a precautionary measure, it Avas continued till the 22d, when he ivas
dismissed.
   Observations.—Porrigo, in all its  forms, is often a very unmanageable
disease,  and  even Avhen cured is very liable to return.  In the treatment
of porriginous affections, the folloiving is a more particular account than
what  is given in the short history of  the cases.  The head is  first well
washed  with  soap and water, the hair is then cut as short as possible wdth
the scissors, a poultice is applied, and continued for a day or two if necessary,
to soften the crusts, Avhich being removed as thoroughly as possible, the hair
is closely shaved.   In general, the ointment is  not applied until the head
has been shaved ; but if pediculi be present, it is employed from the com-
mencement, in order speedily to extinguish these vermin.   The proportion
of ioduret of sulphur employed  has varied from 20 to 40 grains to  one
ounce of axunge.
   As a'general rule, the daily application of the ointment will be sufficient;
but, in some  cases, it is advisable to use it twice a day, in order to facilitate
the cure.
   Alteratives, or  any particular internal treatment, have rarely  been
resorted to, when the general health was tolerably good.  Laxatives have
occasionally been prescribed, and a mild fariuaceous or milk diet.
                                                       Part v., p. 115.

   Tinea  Capitis or Porrigo.—Topical  Application of  Iodine and its
Compounds.—Dr. James J.Ross remarks as follows,regarding the topical
use of tincture of iodine in cases of porrigo:
   The next instance Ave shall bring forward of the external use of tincture
of iodine is in porrigo, or, more generally speaking, ringworm of the scalp,
comprising all those affections, described as tinea, porrigo, eczema, impeti-
go, etc.   The diagnosis of these various forms, which run one into another,
is often  exceedingly doubtful, and,  what is  of more  consequence, their
cure is often difficult, and frequently exhausts the patience both of patient
and surgeon.  Hundreds of applications have been used in the treatment
of ringworm, and their very number proclaims their inefficiency;  av bile in
many cases, there  can be  no doubt,  that the cure ultimately effected,
ought rather to be referred  to  the natural dying-out, as it Avere, of the
disease in course of time, than to the particular remedy in use at the mo-
ment.   Iu such circumstances, then, Ave are all much indebted to Dr. Graves,
who has laid down  certainly the most  successful plan of treatment I have
yet had  an  opportunity of trying.   He  recommends  as  a precautionary
measure, that, if the disease has been of long standing, an issue  should be
inserted in the arm, before attempting its cure.  He condemns  shaving
the head, for it adds  to';, tho irritation of the skin, and  the scalp can be 
522
BKIN DISEASE.
sufficiently exposed by cutting the hair as closely as possible with a sharp
scissors.  The next object is to remove the concreted scales, Avhichlie over
and conceal the diseased skin: this is to be accomplished by diligent ablu-
tion, without using any irritating degree of friction.  We must next have
recourse to some application, wdiich will destroy the morbid secreting sur-
face, or those vegetable fungi, which, according to some  late observers,
constitute the true pathology of the disease.  For this purpose, Dr. Graves
recommends either the tincture  of iodine, or a  solution of lunar caustic, or
blue-stone, 10, 15, or 20  grains to the  ounce, as  the  case may require.
Since reading Dr. Graves' paper, I have in several instances used the tinc-
ture of iodine, and have since been far more successful than before.  "As
to the application of this solution, or the tincture," continues Dr. G., " it
will not do to apply it, as is generally done, with a earners-hair brush, for
it must be strongly rubbed into each spot, for which purpose a small bit of
sponge, covered with fine linen, and  tied to the end of a quill or slender
stick, should be employed.  When a  large portion of the scalp is affected,
it will require some perseverance to apply the lotion, or tincture, in an
effectual manner.  An  application of this nature, when  effectually done,
must not be repeated oftener than once a week.  Immediately after it, the
scalp must be covered Avith  a spermaceti dressing, and the spermaceti must
be renewed at least four times daily,  so  as  to  keep the head constantly
moistened  ivith it.  The  head is not to be Avashed for three days after the
apphcation of the caustic, or the tincture of iodine, but then it may be
Avell, but very gently, washed  Avith yellow soap and water tiviee a day;
taking care to cover, as before, wdth a spermaceti dressing after each wash-
ing."  The doctor adds, " Avhen  the above precautions have been taken,
the cure will  advance rapidly, and each  succeeding  application of the
caustic solution, or of the tincture, may be less severe."  I have been thus
particular  in transcribing Dr.  Graves' directions, as there is no disease
more troublesome to the  practitioner, and as, from experience, I can bear
testimony to the efficacy of his mode of treatment, as above explained.
The surgeon, when applying the iodine or caustic, should have his hands
protected by gloves.                                   Part vl, p. 120.

   Tinea Favosa—Treatment.—The  mode  of  treatment of this obstinate
disease, employed by the frires Mahon, although kept secret by them, has
for a long time been followed ivith unquestionable  benefit in the Parisian
hospitals.
  The hair is first cut short, and the crusts then removed by emolient poul-
tices.  The  head is now  frequently washed with soap and water, and the
inunctions  and  lotions  continued until the  scalp is completely cleaned.
When this has been effected, the second stage of the treatment commences,
the object of which is to remove the hair slowly and without pain, from
all the points of the scalp, occupied by the favus.   Every second  day the
ointment (No. 1) is applied, and its use continued according to the obsti-
nacy of the  case.  On the intervening days the hair is combed with'a fine
comb, to renurve the loose hairs.  This mode  of treatment having been
continued for about a fortnight, a depilatory powder (No. 2) is sprinkled
through the hair once a week;  on the following day the hair is  combed,
and the deptiatory ointment applied as before.  At the end of a month or
six iveeks a more active ointment is applied every day; and as  the disease
gives way the frictions are  made only once a week, until the rcduess of 
SKIN DISEASE.
523
 the skin has entirely disappeared.  Although the formulae of the remedies
 employed by the freres Mahon have  been kept secret, yet their composi-
 tion has been very nearly ascertained by experiment and are supposed to
 be as follows:
   No. 1.—Slaked lime, eight scruples ; soda of commerce, twelve scruples;
 lard, sixty-four scruples.
   No. 2.—Wood-ashes, sixty-four parts; pulverized charcoal, thirty-two
 parts.
   Lotion.—Lime-water, five hundred  parts; sulphate of soda, one hundred
 and eighty-five parts;  alcohol, twenty-four parts; Avhite soap, ten parts.
                                                     Part viii., j(?. 159.

   Scald Head, Ringworm of  Scalp, etc.—In one of the meetings of the
 Westminster Medical Society, Mr. Fisher refers to the practice of treating
 scald head, ringworm, etc., in Brussels.   This is by an ointment chiefly
 composed of wood  soot.  The  common soot of the chimney is collected,
 placed in a quantity of Avater, and macerated by a gentle heat for four
 days; the  fluid is then strained and  evaporated in an open  vessel to the
 consistence of treacle.  An equal  portion of this  and  common lard are
 mixed together and applied to the part affected night and morning.   The
 head is shaved occasionally and thoroughly Avashed every third day.  It is
 supposed that the efficacy of  this ointment depends upon the  creasote and
 pyroligneous acid which it contains :
   Dr. Sayer observes, that the ointment used in Brussels years ago, with
 so much efficacy, consisted of equal parts of charcoal, so burnt as to retain
 its pyroligneous acid, nitrate  of potash and common brimstone, worked up
 with hog's lard into  an unguent, and applied night and morning.   The
 head Avas, moreover,  Avashed  daily with soft  soap  containing a great
 quantity of alkali, and shaved e\rery fourth day.          Part ix., p. 172

   Treatment of Porrigo.—Dr. Corrigan states that nothing is easier than
 to give the appearance of having cured the  disease.   It is merely neces-
 sary to poultice the head, or part it is  on, Avhen the scab all comes off, leav-
 ing a shining red surface, then to wash it, when it looks clean, and thus
 make it look as  if cured. After many applications, a week, fortnight, or
 month, may pass over, but in all those instances AAdiere I had the opportu-
 nity of afterward observing the case, the small favi  began again to show
 themselves, and the  disease then rapidly shot up again, and spread ; indeed,
 so certainly was this the case, that I at last began to think the disease Avas
 incurable.  To reflecting on the nature of the disease, I owe the thouo-ht
 of a remedy on which I place considerable reliance—it is the local applica-
 tion of oxymuriate of mercury, which  has much  power in destroying the
 sporula of cryptogamic plants.  I have used it in the form of ointment in
 the proportion of five grains in very fine powder  to  §j. of ung. cetacei; I
 have used it in the proportion of  10 grains to §j., but it sometimes gives
 pain in this larger proportion.  A small portion of the  ointment is rubbed
 in on the part affected every day.  It  has not salivated in any instance in
 which I have employed it.                              Part xii., p. 255.

  Porrigo.—Mr. Startin submits the  following:  The first  procedure  I
Avould dAvell upon as most necessary to success (I speak of course from my
own experience)  is to avoid all unnecessary irritation ; do not use soap or
apply cold lotions, or poultices, or narcotics that by then absorption may 
524
SKIN DISEASE.
occasion fatal effects, as tobacco, etc.  Do not shave the head, but use scis-
sors, cutting the hair as close as possible, and use all applications Avithout
force or friction, following the grain of the hair, and extract  Avith the for-
ceps those hairs onlyivhich are loose, and can  be removed Avithout pain.
The directions I am in the habit of giving are as follows: Soften the crusts,
if necessary, by applying flannel wrung  out  of  wrater as steaming hot as
possible, Avithout scalding or  injury to the head, till the hair can  be cut
short Avith scissors, so that the root of every hair  may be visible Avithout
touching the parts; Avash  the head Avith half of the yolk of a fresh egg
and tepid water; dry it with  a soft cloth, and anoint w ith  an ointment
adapted to the case, which in porrigo should be  a sulphureous application ;
in impetigo the iodides  of mercury or  of sulphur; in pityriasis calomel,
white or red precipitate of mercury; and  in eczema  the bisulphuret of
mercury, and sometimes the  black  oxide of manganese ; all these ingre-
.dients may be  combined Avith  creasote,  wdth camphor, etc., as Avell as va-
riously intermingled, bearing in mind that the  proportions of each article
must not exceed Bj- to Sj. of lard, which is better than any oleaginous sub-
stance of AA'hich I have made trial.   Of course the internal treatment must
correspond to the nature of the particular affection, its stage, and the con-
stitutional symptoms manifested.  It will  also be advantageous that the
patient wear a light linen or silk cap, which is by no means to be rendered
impervious to perspiration, but to be of a kind  that can be Avashed daily;
the lining of hats, bonnets, etc., must also be frequently cleansed  and re-
newed.   If these recommendations be attended to, I can assure you from
my own experience, that a complaint which ordinarily lasts for years may
be subdued in as many Aveeks or months.               Part xiv., p. 236.

   Porrigo Scutulata ( Willan)—Herpes Tonsurans (Cazenave)—(Ring-
worm.)—Mr. Erichsen advises to shave the head, and apply one of the
stronger acids to the part.  The  strong acetic  answers best.  It  may be
applied  by means of a piece of sponge tied to a stick, and should  only he
used for a few minutes.   Nothing more should be done for  a week or ten
days, Avhen the crust produced by  the  acid should be separated with a
pair of scissors, and if there be any appearance of the disease  remaining,
the acetic acid should be applied again ; but if it present a healthy appear-
ance, let it be Avell Avashed with soap and water, and a little olive oil ap-
plied every night.   When all the vegetable organisms constituting the dis-
ease have been destroyed, then use a stimulating ointment, as the ung.
creasote, 3ss. to 3j. to the ounce  of lard; or apply tincture  of iodine by
means of a camel's-hair brush ;  or the ung. hyd. biniodid., diluted with six
parts of the ung. picis liquid.; or a mixture  of  equal parts of sulphur and
pitch ointment; or the carb. of potass ointment, 3ss. to 3j. to the ounce ol
lard.  It is often useful to alternate some  of  these remedies; the head
should  also be Avashed three or four times a day with a lotion of the sul-
phuret of potass dissolved in lime  water, or with carbonate of potass dis-
solved  in  water, or with  soft  soap and water.  Attend to the  general
health;  if the child be of a delicate  habit or scrofulous, give iron and ton-
ics, quinine with infus. quassias, and a nutritious diet.  All heating articles
of diet  are improper, also salted food;  the  diet should be  plain, but nu-
tritious.                                           '   Part xiv., p. 243.

   Porrigo Declavans.—According to Dr. Coley, we  should not remove 
*
SKIN DISEASE.
525
the hairs ; but rub solution of sulphate of copper upon the bald patches for
several minutes, three times a day ; and give a purgative  occasionally.
  And in Porrigo Favosa apply twice a-day the ung. hydr. amnion, chlo-
rid., and give a calomel and jalap powder every three days.  Treat P. lu-
pinosa in the same manner.                            Part xv., p. 254.
   Oil of Juniper in Scald Head.—The direct application of the oil of the
juniperus  communis has been already proved to be successful in scrofulous
ophthalmia, scabies, and eczema.  Dr. Sully has found besides, that dt is
efficacious in the most inveterate forms of scald head.  His formula is, oil
ofjuuiper, one ounce and a half; axunge, tAvo ounces; essence of aniseed,
six drops.   The oil  may also  be applied unmixed;  but  in either  case it
should be  applied freely over the whole affected surface.
                                                     Part xv., p. 255.

   Creasote in Porrigo.—Speaking of the treatment of Porrigo Senilis, Dr.
Bedingham says: Before  concluding, I may observe that the efficacy of
creasote, as a local application in cutaneous  disease, is not limited to cases
of prurigo.  In that comparatively rare, but very intractable form  of dis-
ease of the scalp, the favus confertus of Erichsen, Avhich is known under
a great variety of names, as the porrigo scutulata, tinea annularis, scald
head and ringworm of the scalp, which constitutes  one of the few conta-
gious diseases of the scalp, and  is one of the few which occasions the de-
struction of the bulbs  of the hair,  and  for the cure of which that most
painful application, the pitch cap, was in former times supposed to be es-
sential, creasote  in  the form of ointment and dotion will be found a most
effectual remedy, provided its use is persevered in for a sufficient length of
time, and attention is at the same time paid to cleanliness.   On the  other
hand, in the vesicular and pustular diseases of the scalp, in Avhich the erup-
tion is usually preceded or accompanied by more or less inflammation, evi-
denced by the heat, redness,  soreness, and  discharge, creasote as  a local
application will be found to disagree, and will rather aggravate than re-
lieve the disease.                                       Part xvi, p. 223.
   Ointment for Scald Head.-~- Norway pitch, 30 parts;  turpeth mineral,
15  parts; red oxide of mercury, 15 parts; lard, 100 parts.  Mix.   The
ointment to be applied night and morning.             Part xvii., p. 196.

  Favus.—By those not well accustomed to the diagnosis of skin diseases,
favus  has often been confounded wdth other eruptions of the scalp, more
especially eczema and impetigo, or the combinations of these diseases known
as the eczema impetiginodes ; but in none of these do the yellow crusts or
scales present, when examined microscopically, traces of  vegetation. This
furnishes the real diagnostic and pathognomonic character  of the disease.
There can be no doubt the disease is  inoculable,  and  capable  of being
communicated by contagion.  The pathology of favus is  best understood
by considering it essentially to be a  form of anormal nutrition, with exuda-
tion of a matter analogous to, if not identical A\dth, that of tubercle, which
constitutes a soil for the germination of cryptogamic plants, the presence
of Avhjch, as stated, is pathognomonic of the disease.  As favus is in many
eases  a  constitutional disease, and  dependent upon the causes inducing
scrofulous diseases in general, the treatment must  be constitutional, and
directed to remove  the tendency to tubercular exudation.  The internal
and external exhibition of cod-liver  oil Avith appropriate diet and exercise, 
526
SKIN DISEA8E.
has been attended by most marked advantage. As to the local treatment,
Professor Bennett directs the affected scalp to be poulticed for several
days, until the favus crusts are thoroughly softened and fall off, then the
head to be carefully shaved, and lastly, cod-liver oil to be  applied w ith a
soft brush, night and morning, and the head covered with  an oil-skin cap
to prevent evaporation, and further exclude the atmospheric air.
  Every now and then the accumulated and inspissated oil should be re-
moved by gently washing it with soap and water.  Whenever favus is re-
cent, and of limited  extent, it may be at  once  destroyed by cauterization
with nitrate of stiver.                                Part xxii., p. 238.

  Apparatus for Fumigating the Scalp, in some Chronic Diseases of that
Region.—Dr. Burgess has  recommended  fumigation of the scalp in cer-
tain of its diseases.  He thus describes the apparatus he uses for that pur-
pose :
  The vapor apparatus is extremely simple.  It consists of a tin jar, about
ten inches by four, Avith a conducting tube, on  which is placed a stop-
cock, for the purpose  of  diluting the vapor, or  turning  it off, and an
elastic cap  of vulcanized india-rubber, Avhich  fits closely to the  head, so
as to prevent the vapor from escaping.  The great majority of diseases of
the skin are constitutional,  and those of the  scalp are not an exception to
the rule.
  Favus (the porrigo favosa of Wilan), for example, which is one of the
most unsightly,  as well as  the most inveterate of the eruptions of that
region, may be temporarily relieved by tonics and fomentations,  and  the
skin even made to appear clean and  healthy ; but the virus still  remains,
and, consequently, the " cure " Avill be but of short duration.  In this, as in
other inveterate  diseases of the scalp, the  application  of vapor, simple or
medicated, as the case may require, to the  diseased scalp, Avill be found a
very efficient remedy.  Where the object is,  to alter  the  vitality of the
parts, it can be done more effectually by the repeated application of stimu-
lating vapor (the skin being previously cleansed with any detergent Avash)
than by the employment of caustic lotions or ointments.  Indeed, greasy
applications of every kind may be advantageously dispensed with in the
treatment of diseases of the scalp.
  That variety of baldness, Avhich is the result of atony, or disordered nu-
trition of  the hair-follicles and bulbs, will be materially benefited by the
use of the vapor apparatus.                            Part xxi, p. 259.
   Cachexia  Eczematosa in  Children. — This disease  is  very   common
amongst the ill-fed and neglected children of the lower  classes.   There is
a pale and sickly aspect, and on different parts of the scalp the hair is mat-
ted together wdth filthy scabs of eczematous secretion, from wdiich exudes
a thin and irritating discharge.  There are also Aveak ulcerations behind
the ears, and about the angles of the mouth,  and on the nares, etc.
  There is no eruptive disease more easily got rid of than this,  says Dr.
W. S. Oke, provided the treatment be carefully carried out.  The whole
of the scalp having been closely clipped, and the scabs removed by poultice
or fomentation, the eczematous parts are to be smeared by the ointment,
1, tAAdce a day, and Avell fomented before each application.   The alterative
dose, 2, is to be given twice a week, and the strength supported by 3.  By
these means the  removal of the disease Avili >e at once accomplished.
  J.—R  Unguenti hydrarg. uit. oxidi, oz. ss.   Bis die applicandum digito. 
SKIN DISEASE.
527
  2.—R Hydrarg. cum creta, gr. iij.; pulv. rhei, gr., iv.; pulv. cinnamo-
mi, gr. j.  Misce ;  fiat pulvis bis heodomada sumendus in theriaca.
  3^—R Quinas disulphatis, gr.  ij.-iij.; acidi sulphurici dil., gtt. aj.;  tinct.
aurantii, co. syrupi zingib. sing, dr. ij.;  aquas destillatae, ad oz. iij.  Misce
capiat cochleare largum bis quotidie.                  Part xxxi, p. 292.
   Treatment  of Favus.—After removing the crusts of favus by poulticing
and shaving the head, keep the  surface moist Avith cod-liver oil, or use Dr.
Jenner's lotion, composed of one part of sulphurous acid mixed Avith three
parts of water, in the folloAving way :   Saturate  lint with this lotion and
apply it all over the scalp night  and morning, keeping it moist by an oil-silk
cap.                                                 Part xxix., p. 248.
   Treatment  of Favus.—From the observation of about a dozen cases of
severe  favus  (diagnosis by the microscope in all)  recently treated  by Mr.
Startin  at  the  Hospital for  skin diseases, we can speak Avdth great confi-
dence of the efficiency of the  followdng  ointment.  It is the ung. sulph.
comp. of the pharmacopoeia of that institution:
   R  Sulph. sublimati, tbss.;  hydrarg. ammonio-chlorid., |ss.; hydr. sulphu-
reti cum sulph., §ss.; leviga simul, dein adde otivae olei, §iv.; adipis recen-
tis, §xvj.;  creasoti, m xx.  Misce.
  To correct the  state of  general health, Mr. Startin commonly orders
simultaneously a mild course of the iodide of potassium, but this, we sus-
pect, has but  a small share, if any, in the local result.
  In a most disgusting disease for which as yet no real cure is knoAvn, it is
much to be in possession of an almost certain means of insuring its absence.
The ointment no doubt acts as  a parasiticide.  Before  its first application
it is desirable to clear away the  crust as much as  possible, either  by fomen-
tation or a poultice.
   We may remark, that the ointment mentioned  is used by Mr.  Startin in
the treatment of scabies, and also in that of the contagious form of porrigo.
                                                     Part xxx., p. 177.
                                                      *      *
  Porrigo.—The treatment  now in vogue for this  affection in Guy's Hospb
tal is the iodide of lead ointment and alkaline lotions, Avith the internal use
of the iodide  of arsenic.                             Part xxxiii., p. 236,

                            URTICARIA.
  In  a case of this disease, says  Dr. Madagan, where the urine was of low
specific gravity (1010), and Avas found on examination to be much deficient
in  urea and uric acid, colchicum was employed with complete success.  The
urine before taking colchicum Avas of a  pale straw color, transparent, and
left no deposit on standing.
  Colchicum was then administered, and a fortnight after the urine was again
examined.  The urea Avas more than triple in his amount, and raised above
the normal standard.  The increase of uric acid was in a  tenfold ratio, Avhilst
the other organic constituents and water suffered a corresponding diminu-
tion,  the inorganic salts remaining nearly as before.    Part  xxv., p. 264.
   Treatment  of Urticaria.—It sometimes happens, says Dr. G. Budd, that
a nettle-rash  resulting from  defective digestion  is brought on not merely
by some one substance,  but by several substances in common use; and it
is then very difficult to detect the offending  substances or to prevent the
disorder by any restriction of diet to Avhich the patient will submit. 
528
SKIN DISEASE.
  Where it arises from defective digestion, give a dinner pill, containing
three or four grains  of rhubarb, and from half to one and a half grains of
ipecacuanha.  This remedy is a very valuable one in slowness of digestion.
  It sometimes happens, especially in women, that the nettle-rash, though
depending immediately  on  the  stomach, occurs only wdien digestion  is
weakened  by over-fatigue, or by anxiety or some other mental emotion,
or by profuse monthly discharges, and that remedies of a different class are
availing.
  In some such cases, where all the  means spoken  of failed, the  eruption
was known to disappear under the use of carbonate of  ammonia, alone or
in conjunction with tincture of gentian.
  Serpentaria is another remedy that has obtained some  repute in the treat
ment of this disorder.   An excellent application for allaying the irritation
of nettle-rash,  wdiatever be  its  cause, is a lotion made by mixing 3ss. of
acetate of lead and gss.  of tincture of opium Avith gviij. of water.
                                                    Part xxix., p. 106.
   Treatment of, by Quinine.—A severe  case, in which the  eruption had
come out daily for the last six months, presented  itself a few days  ago.
The patient was a married woman, of middle age, and of nervous tempera-
ment.  The folloAving was the prescription ordered :
   R Quin. disulph., gr.  xij.;  am.  sesquicarb., 5j-; magnes. carbon., gss.; aq.
pur., gviij.  Ft. mist. gss. ter. die sumend.
   The quinine in this formula is of course undissolved, and the magnesia is
added  in  order to  suspend it.  To relieve the itching  of the eruption, a
lotion containing  the dilute nitric  acid was  ordered to be used.  With
regard to the latter, it may be Avorth remarking, that Mr. Startin  believes
it quite as useful as the  hydrocyanic acid for the  relief of tingling, etc.,
while it is very much less expensive.                  Part xxx., p. 236.

   Urticaria.—This, says Prof. Budd, is generally caused by the imperfect
digestion of particular articles of food, such as crabs, muscles, pork-pie, fish,
honey, mushrooms, cucumbers, almonds,  and oatmeal.   Our main object
of treatment must therefore be to expel the offending  matter as  soon  as
possible ; this is best done by an emetic, followed by a Avarm quick purga-
tive.  If it seems rather to be referable to several  articles in common use,
it may be kept off by the administration of a  feAv grains of rhubarb before
dinner; it may occur from weak  digestion, attended Avith general debility;
in such cases the carbonate of ammonia, with the tincture of gentian, will
succeed when other means fail.  To allay the cutaneous irritation use a
lotion composed of half a drachm of acetate of lead, half an ounce of tinc-
ture of opium and half a pound of water.             Part xxxiv., p. 197.


                         MISCELLANEOUS.
   Arsenic in Chronic Scaly Eruptions.—Mr. Erichsen lays great  stress
upon the necessity of attending particularly to the constitution and tempe-
rament of the patient before  commencing the  use of the medicine.  It will
be badly borne by individuals of a plethoric habit of body, or of  a highly
sanguine or sanguineo-nervous temperamant -this  arises from the stimu-
lating properties of the  metal.  In such cases, the digestive organs become
so irritated, and the nervous  system so excited under the use of the arsenic,
that it is impossible  to  employ it in any such  dose  as can be expected to 
SKIN DISEASE.
529
produce a beneficial effect upon the cutaneous  affection.  There are other
circumstances Avhich contra-indicate the use of this remedy, namely, " the
complication of the cutaneous affection Avith other diseases," and especially
with irritative or inflammatory gastric  dyspepsia, accompanied Avith  a
sensation of heat and oppression at the epigastrium, increased by food, so
well described by Dr.  Todd.  When this form  of dyspepsia is present, the
smallest doses of  arsenic ivill do harm, as the usual effect of the remedy,
when continued too long, is  to produce  these very symptoms.  Besides
this form of indigestion, any other local inflammatory condition of the
system, or the supervention  of phthisis, Avill contra-indicate the use of so
powerfully  stimulating  a tonic  as  arsenic.  Another  important circum-
stance  to attend to is  the kind of disease, and the stage in Avhich to use it.
The indiscriminate use of this article  in certain diseases of the skin, has
no doubt frequently brought discredit upon it.
  One great principle to be held in vieAV in its use is ne\-er to administer
it in the early, acute, and inflammatory stages  of the affection.  The solu-
tion of the arsenite of potassa (Fowder's solution), and the solution of the
iodide  of arsenic and mercury (Donovan's solution), are the tAvo prepara-
tions Avhich are most frequently prescribed in this country ; and the former
is by far the most popular of the two.  Different authors vary a little as
to the dose  of FoAvler's solution Avhich ought to be  given ; but most of
them agree that we ought not to exceed 15,  or at most  18 drops in the
course of the  day.  Mr. Erichsen, however, begins Avith  tAvo minims of
the solution tAvice a-day, and increases the dose to 5, 6, or 1\ minims thre-s
times a-day, beyond Avhich, he says, it ought not to be carried, as its good
effects Avill be more evident  from small  doses continued  for some time,
than from larger  doses which  have  to be  sooner relinquished.   Some
patients, however,  are  so  excitable, that  the smallest doses are inadmis-
sible.  Another good preparation is the iodide of  arsenic introduced by
Dr. A. T. Thompson.   The  dose is the twelfth of a grain twice a day, to
be increased to the sixth or fourth of a grain  three times  a-day, although
these doses  are seldom  necessary.   It  is Avell to combine the extract of
conium with iodide of arsenic, in order to sheath its  irritating qualities,
and prevent it from exciting too powerfully the mucous membrane of the
stomach.  By the addition of the biniodide of mercury, a compound pill
may be formed, which resembles in its effects the liquor of the hydriodate
of arsenic and mercury, and which has been found by Dr. A. T. Thompson
very efficacious in lupus, and by Mr. Erichsen in some  syphilitic eruptions,
more particularly when  of a squamous kind.  A pill may be made contain-
ing one-tAvelfth of a grain of the biniodide of mercury, and two grains of
the extract of conium;  to be given twice a-day.  The iodide of arsenic
may be gradually increased to one-sixth of a  grain, and the biniodide of
mercury omitted  at the end of a fortnight, or sooner, as it might affect the
gums.   The diluted biniodide of mercury ointment may in some cases, as
in syphilitic psoriasis,  be also applied externally at the same time. Arsenic
seems to bean excitant or stimulating tonic, acting chiefly on the digestive,
nervous, and integumentary systems ; and when the dose has been pushed
so as to irritate any one of these parts, the medicine  ought to be  imme-
diately suspended,  or greatly reduced in  strength.   The time for pre-
scribing  arsenic in  a  cutaneous  affection requires,  perhaps, as nice a dis-
crimination  as can be  exercised.  Mr. Erichsen  points  out  a mode  of
practice which will he generally serviceable in these cases.  As it is in the
  VOL. ii.—34 
530
SKIN DISEASE.
chronic stages that the remedy is to be used, he first ascertains whether
the affection will bear the  topical application of mild stimulants, such aa
the ointment of the  white precipitate, or the nitrate of mercury diluted
AAdth equal parts of the spermaceti ointment, or a solution of the sulphuret
of potassium in the proportion of about a drachm to  the pint;  and if any
of these  applications can  be  borne Avithout  increasing permanently  the
severity of the disease, the internal administration of  arsenic may likewise
be beneficial.  In illustration of this  opinion he adduces as an example that
very common disease, eczema, which, Avhen in its acute stage,  in which it
wdll bear no other topical application that the most soothing poultices and
fomentations, will infallibly be greatly increased in severity by the employ-
ment of arsenic, even in its most minute doses ; but at a more advanced
period, when it can bear topical stimulants, the same disease will be greatly
benefited by the internal administration of this  medicine.  The diseases
of the skin  for which arsenic is recommended,  may be of very different
kinds, but they all agree in this, that  they are  characterized by the pre-
sence of scales or scurf; and even when they do not  belong to the order
squamm they are usually  but little benefited until  they  arrive at that
stage in which they assume a furfuraceous or scaly condition.
                                                      Part  viii., p. 10.

   Selection  from  .the Formidary of  Biett on  Diseases  of  the  Skin—
Internal Remedies.—Subcarbonate of soda, half, to one drachm ; barley-
water,  one pint.   Dose,  four  glasses daily.   Use :  Lichen;  prurigo;
chronic diseases Avith itching.
   Decoction of Dulcamara.—Dulcamara, half an ounce; Avater, a pint and
a half.  Boil doAvn to two-thirds.  The quantity of  the  remedy  may be
increased to  one  ounce, or an  ounce and a half.  Dose, half a glass at
first; then a glass,  morning and evening.   Use, lepra vulgaris; chronic
diseases.
   Decoction of Orma.—Orma pyramidalis, four ounces ; water, four pints ;
boil  down  to a half.   Dose, twro  to four  glasses  a day.  Use:  Scaly
diseases.
   Sirup of fumaria, tAvelve ounces  ; sirup  of viola tricolor, four ounces;
bisulphate of soda, two drachms.   Mix.   [M. Biett  often  employed  this
mixture in cases of eczema, lichen, and  several chronic diseases of the skin.]
Dose, twro spoonfuls a day.
   Sirup of fumaria, a pint; bicarbonate of soda, three drachms.   Dose,
two teaspoonfuls;  one  before breakfast;  the  other at bedtime.  Use:
eczema ; lichen ; prurigo.
   Pearson's Solution.—Arsenite of  soda, four grains ; water, four ounces.
Dose, from tAvelve drops to a drachm  or more.   Use: most  chronic  dis-
eases of the skin ; eczema, impetigo, lichen;  but chiefly in squamous dis-
eases, lepra, psoriasis, etc.
   Fowler's Solution.—Arsenious  acid,  and carbonate of potass, of each
seventy-eight grains ; distilled Avater a pint;  alcohol, half an ounce.  Use:
the  same as  Pearson's  solution.  Dose, three   or four drops, gradually
increased to tAyelve or fifteen.
   M. Bictfs  Solution.—Arsenite of ammonia,  four  grains; water four
ounces.  Use : same as above.  Dose,  same as Pearson's solution.
   Larrey^s  Sirup— Sudorific sirup, one pint; bichloride of mercury, hydro-
chlorate of ammonia, and extract of opium, of each five grains  • Hoffman's 
SKIN DISEA8E.
531
liquor, half a drachm.  Dose,  half an ounce to two ounces.  Use :  syphi-
litic  eruptions.  Sirup of mezereon, two  ounces; balsam  of tolu, four
ounces ; subcarbonate of ammonia, half an ounce.   Dose, a spoonful morn.
ing and evening.  LTse :  constitutional syphilis.
   Van Stcieteu's Liquor.—Bichloride of mercury, eighteen grains ;  water,
twenty-nine ounces; alcohol, three ounces.  Dose, a teaspoonful daily, in
a glass of decoction of sarsaparilla.  Each ounce contains a little more than
half a grain.  Use:  secondary  syphilis.
  Powders—Pills.—sublimed  sulphur, magnesia,  of each half an  ounce.
Make eighteen packets.   Dose,  one daily.  Use:  chronic  eczema; scaly
diseases.
  Proto-ioduret of mercury, tAvelve grains; extract of lettuce, two scruples.
Make forty-eight pills.  Dose,  one to four.  Use : syphilis.   Or,
  Proto-ioduret of mercury,  half  a drachm; extract of guaiacum, one
drachm; extract of  lettuce,  tAATo  scruples; sirup of sarsaparilla, q. s.
Divide  into  seventy-tAvo pills.   Dose, one, and  then two daily.   Use :
syphilis.
  Bichloride of Mercury.—Extract of aconite, six grains; bichloride of
mercuiw, two  grains ; marshmallows poAvder,  eight grains.   Make eight
pills.   Dose, one to four.  Use :  syphilis.
  Deuto-ioduret  of Mercury.—Deuto-ioduret of mercury,  six  grains;
marshmalloAvs  powder,  half a drachm.  Make thirty-six pills.  Use:  the
same.  Dose,  tAvo or three a day.
  M. Sedillofs Pills.—Strong mercurial ointment, one drachm ; soap, two
scruples ; mallows poAvder, one scruple.  Make thirty-six pills.  Dose, two
or three daily.  Use : the same.
  M. Bietfs Pills.—Mercurial ointment, poAvdered sarsaparilla, of each a
drachm.   Make forty-eight pills.  Use: the  same.   Dose,  one to four
daily.  Or,
  Phosphate of mercury, half a drachm; extract of fumaria,  one drachm.
Make forty-eight pills.  Dose, one to two a day.   Use: as before.
  Aconite Pills.—Extract of aconite, half a drachm; malloAvs powder, two
scruples.   Make forty-eight pills. Dose, one or two morning and evening-
Use : syphilitic eruptions ; nocturnal pains.
  Arsenic Pills.—Arsenious acid,  one grain; black  pepper powdered,
twelve grains; gum arabic,  tivo grains; water, q. s.  Make tAvelve pills.
Dose, one or two a  day.
  Arsenite of Iron—M.  Biett.—Arsenite of iron, three grains; extract of
hop, one drachm ; mallows poAvder, half a drachm ; orange floAver sirup, q. s.
Make  forty-eight pills;  each   contains  the  one-sixteenth  of  a  grain.
Dose,  one  daily. Use:  the two preceding formulae   are chiefly used in
cases of chronic eczema and lichen ; in the scaly diseases, lepra, lupus, and
psoriasis.
  Arsenite of Soda—M. Biett.—Extract of aconite, one scruple; arsenite
of soda, tAvo  grains.  Make twenty-four pills.   Dose*, one  or two daily.
Use:  as above.
  Hydrochlorate of Iron.—Hydrochlorate of iron, twelve grains; gentian,
in powder, twenty-four grains.   Make twelve pills.   Dose,  one to four
daily.  Use: employed  with success by M. Biett in scrofulous eruptions.
  Sulphate of Iron—M. Biett.—Sulphate of iron, one scruple ;  powdered
mallows, twelve grains;  sirup, q.  s.  Make tAvelve  pills.  Use and dose
the same.                                              Part ix., p. 73. 
532
SKTN DISEASE.
   Use of Tar in  Cutaneous Diseases.—[Mr. Wetherfield published, in
1845, an account of several intractable cases of skin disease Avhich Avere
cured by the use of tar, after arsenic and other favorite remedies had been
tried in vain.  As he still finds the remedy a valuable one, Mr. W. again
calls the attention of the profession to the subject.  He says :]
  Tar Avas administered in these cases in  capsules, each  containing  ten
minims  of simple Stockholm tar, and Avas first prescribed in this form by
Dr. Sutro, of the German Hospital.  This mode of administering  the  tar
removes^ every objection on the score of taste to the use of this valuable
remedy, which doubtless Avould still have enjoyed all the credit it obtained
at the  time its virtues Avere so much extolled  in  the works of Bishop
Berkeley, but for its nauseous flavor in the  then mode of administering,
viz., tar wTater.
   Acne.—Tavo obstinate  cases of this disease, of several years' standing,
wrere published in the report.  The face, neck, and shoulders were much
covered and disfigured by the eruption, Avhich had withstood all kinds of
treatment.   One capsule was given three times  a day, and continued  for
three months.  The disease entirely disappeared.
   Eczema Impetiginodes and Eczema Capillitii.—Both diseases nearly the
same in character, the former attacking adults, the  latter  children.  Two
cases of the former disease, one of  eight years', another one  year's dura-
tion.  Both  cases were treated by the internal use of the  capsule,  and
externally the ung. picis. liquid, continued betAveen two and three  months,
with perfect success.
   Eczema capillitii is most common  in  young persons, beginning on the
scalp behind the  ears ;  from thence  extending to the body and limbs.
Several obstinate  cases, of from  five to seven  years' duration, have been
treated Avith the capsules of tar and ung. picis  liq. very successfully.  In
one case a  bath of tar water Avas employed instead of the ung. picis, the
child being but three years of age.  Four ounces of tar, added to a suffi-
cient quantity of Avater to cover the child's body and limbs, is the mode in
Avhich  the  tar bath may be made, and a very efficient remedy it is,  free
from the objection ivhich might be raised against the ointment, of soiling
the  linen.  This  child  took the capsules with perfect ease, and  together
wdth the Avarm tar bath used eArery other night, recovered in five Aveeks.
Cases of this disease often run a course of five or seven years, resisting
every, even the most potent remedies.
   Lepra.—A case  of this disease came under treatment.  The patient was
covered with leprous patches.  He took the capsules about a month*, and
the  disease decidedly diminished.  He AA'as unsteady in conduct, and irregu-
lar in his habits, and did not pursue the plan so as to derive all the benefit
he might have done.  The odor of tar was perceptible in his  clothes Avorn
next the skin.
   Psoriasis Palrnaris et Nasi.—In this disease, in addition to the internal
use of the capsules, Avhich should be persevered ivith a considerable time,
the  hands should be  immersed  in a  bath of tar Avater every night for a
quarter of an hour, then  dried, and poAvdered  Avith starch powder.   In a
case of psoriasis nasi, the  cracks wdiich form  at the junction of the mucous
membrane  and  true  skin  should be  anointed  ivith ung. picis  liq.  very
slightly at bed-time, and Avashed off in the morning  wdth Avarm water.  In
a case of this kind which annoyed  the patient, Aidio was a great snuff-taker,
the disease was thus removed in a few days. 
SKIN DISEASE.                         533
  Prurigo Senilis.—Tavo  cases in men, one of 85, and the other of 90
years of age.  These gentlemen were subject to attacks of prurigo, attended
as usual Avith desperate itching and irritation.   Various remedies had been
employed in vain ;  lotions of hydrocyanic acid.  hydr. bichlorid., etc., etc.,
The  ung. picis  liq. was applied freely on  the legs, and over it an elastic
roller, occasionally bathing the legs in bran water, to remove the deposit
of tar  from the skin.  Fresh  applications were made in this  manner
every second  or third day.  This  plan  soon allayed the itching.  Both
patients suffered repeatedly  from this  disease,  but ahvays found relief
from this mode  of  treatment, and Avere often  quite free from it for months
together.
  Sycosis.—A case of this disease, Avhich  had  resisted a multitude of reme-
dies, amongst others carbonate of iron in  large doses, sarsaparilla and lime
water, arsenic, mercury, etc., was cured by the internal use of tar  in  cap-
sules, taken one morning and evening, Avhich  removed not only the mealy
eruption, but pimples, which Avere a source of great annoyance and much
pain in shaving.
  Tar acts as a diuretic and  diaphoretic.  The  odor of tar is  distinctly
perceptible in the urine of those Avho take it in capsules.  The quantity is
somewhat increased, and it is rendered clear and free  from all deposits.
A physician who took it for acne, and  who  had studied the analysis of
urine long and carefully, told me  he  had found it entirely remove a de-
posit of phosphates to which he had been long subject.   Increased per-
spiration, and the strong odor of tar on the linen of those Avho have taken
it, clearly prove its action on the skin.  In moderate doses it improves the
digestive organs, and invigorates the  general health.
   Tar certainly deserves a trial in all chronic intractable  and senile erup-
tions, Avhere, OAAdng to peculiar idiosyncrasy, arsenic cannot be  adminis-
tered.                                               Part xviii., p. 223.

   Treatment of the more Common Forms of Skin Diseases.—According to
Prof. Bennett,  of  Edinburgh, Eczema is by far the most common disease
met with, both in  its acute and  chronic forms.
   Prof. B. says: The local treatment  I  have found most  efficacious, con-
sists in keeping the affected part moist; with lint or linen saturated  in a very
 weak alkaline solution, consisting of soda subcarb. 3ss.  to a pint of water.
For this purpose it is necessaiy to cover the moistened lint Avith oil-silk,
or gutta  percha sheeting, wdiich should Avell overlap the lint below,  so as
to prevent evaporation.  The usual effect is soon to remove all local irrita-
tion, and especially the itching or smarting so distressing to the patient;
to keep the surface  clean, and prevent the accumulation of those scabs
and crusts, which in  themselves often tend to keep up the disease.   After
a time, even the indurated parts begin to soften, the margins of the erup-
tion lose  their  fiery red color, and merge into that of the healthy skin, and,
finally,  the Avhole  surface assumes its normal character.
   Herpes.—This disease generally runs its course in about  fourteen  days,
and requires no treatment Avhatever,  further than an acetate of lead lotion
to allay the smarting.  It is not very common.
   Scabies occurs very frequently, and is cured  by a host of remedies.  A
strong lather of common soft soap and Avarm water, twice  a day, answers
 very well.  The question with scabies, is  not  Avhat remedy is usefuL but
 which will cure it in  the shortest  period.  The most extensive experience 
534
SKIN DISEASE.
at St. Louis  has shown, that the su-phur and  alkaline, or Ilelmerinch's
ointment, cures  itch, on  an average, in seven days.  That sulphur, how-
ever, is not the active remedy, I  ha\-e  satisfied myself of  by experiment.
Soft soap, as we have seen, wdiich contains alkali, and even simple  lard, if
pains be  taken to keep the parts constantly covered wdth it, will cure the
disease as  soon as sulphur  ointment.  I  have tried the Stavesacre oint-
ment, recommended by M. Bourguignon, in only a few cases, but found it
to ansAver very well.
  Pemphigus.—This  is  rather a rare disease, and -when  chronic, coming
out in successive  crops, is very rebellious.  Tavo cases which entered the
infirmary last Avinter  were cured in a few weeks by the weak alkaline
wash, applied as in the case of eczema, combined with generous diet.
  Impetigo.—This affection  in all its  forms is very common,  and is best
treated by the weak alkaline  ivash, exactly the same as in eczema.   In the
chronic forms which attack the chin of men, constituting one of the varie-
ties of mentagra, the same treatment cures the most rebellious cases if the
moisture be  constantly preserved.   For this purpose the hair must be
cautiously cut short Avith sharp scissors, and the razor carefully avoided.
If the side of the cheek covered AAdth the'whisker is attacked  removal of
the hair from thence also is essential to the treatment.   A bag or covering
accurately adapted to the part  affected  must  be made of gutta  percha
sheeting, and tied on with strings.   This  may be covered  with black silk,
to  allow the individual  to go about  and carry on his usual occupations.
In this way I have frequently seen chronic impetigo  of the  chin,  of from
eight  to ten years' standing, completely removed in a few weeks.  But
then the surface must be kept constantly  moist, a circumstance requiring
very great care and determination  on the part of the patient.  When it
becomes necessary to shave, flour and warm Avater, or  paste should be
used, and not soap.   Alkalies applied  from  time to time only, as in  the
form of wash  or  soap, always irritate, although, when employed continu-
ously, they are soothing.
   Ecthyma  is not a  common disease, and usually presents itself, as the
E. cacheticum, requiring in  addition to the alkaline wash locally, a gene-
rous diet.
   Acne  is a  disease always requiring constitutional rather  than local reme-
dies.   Although not uncommon in private, it is rare in hospital practice.
Careful  regulation of the  diet, abstinence from Avine  and  stimulating
articles  of food, av ate ring-places, baths,  etc.,  etc.,  constitute the appro-
priate treatment.
   Rupia.—This disease I have  never seen occur  but in individuals who
have been subjected to the influence of mercurial poisoning.   Hydriodate
of potassium and tonic remedies, Avith careful avoidance of mercury in all
its forms, is  the treatment I  have found most successful.
   Lichen and Prurigo.—In both these affections constant inunction with
lard is as beneficial as constant moisture  in the eczematous and impetigin-
 ous disorders.  In the  prurigo  of aged  persons,  the  ung. hyd. precip.
 alb. is a useful application,  although the disease is not unfrequently so
 rebellious  as only to  admit  of  palliation.  The chronic  papular diseases
 often  constitute the despair  of the physician.
   Psoriasis, and  that modification of it known as lepra, are very common
 diseases, and are  uniformly treated by me externally wdth pitch ointment.
 I have  satisfied myself by careful trials, that it is the pitch apnlied to the 
SKIN DISEASE.
535
part that is the beneficial agent, as I have given pitch pills, and infusion of
pitch, largely internally Avithout benefit.  With  the  hope of obtaining a
less disagreeable remedy, I  have frequently tried creasote, and naphtha
ointment  and Avashes, but also Avithout benefit.  Lastly, I have  caused
simple lard to be rubbed in for a lengthened time, but without doing the
slightest good.   The  oil of cade is also very useful, especially in psoriasis
of the scalp.  Internally, I give five drops each of Fowler's solution, and
of the tr. cantharidis.  It is rare  that  the internal treatment alone pro-
duces any effect on a case of psoriasis of any standing.   If a case resists
this conjoined  external and  internal treatment,  I  have  always found it
incurable.  About a  year  ago I carefully treated a series of cases inter-
nally with Donovan's  solution, Avithout producing the slightest benefit.
  Lupus is a constitutional disease, and must be  treated by cod-liver oil,
and all those remedies useful in scrofula, of wdiich it is  a  local manifesta-
tion.  The external treatment  is  surgical, consisting  of the occasional
application of caustics, red lotion, ointments, etc., according to the appear-
ance of the sore.
  Faous is a very common disease  in Edinburgh, and  is most readily
removed, first, by poulticing the crusts till they fall off, and the  skin pre-
sents a smooth, clean  surface; secondly, by shaving the hair;  and thirdly,
by keeping the  scalp continually covered with oil, so as  to  exclude the
atmosphere, and prevent the growth of the  parasitic  fungi, which consti-
tutes the disease.  For this purpose, a gutta percha or oil silk cap must be
constantly Avorn.  A  continuance of this treatment for six wreeks produces
a cure in young persons if combined with cod-liver oil, generous diet, and
anti-scrofulous remedies internally.  I have tried  the lotion of sulphurous
acid, recommended by Dr. Jenner, and found it successful in  a  feAv cases,
but  the treatment by oil is so easy, to be far preferable to  it.  Very
chronic cases are cured Avith difficulty, but so long as the  oil is applied the
disease never returns, and mere freedom from the disgusting crusts is a
great gain.
   Scalp diseases must be treated according  as it depends on eczema,
impetigo, psoriasis, or favus, in all cases first removing  the crusts with
poultices,  then keeping the  head shaved,  and  lastly,  applying  alkaline
Avaslus, pitch ointment, or oil, according to  the directions formerly given.
Ringworm is a disease I have never seen in Edinburgh, and of what it con-
sists 1 am ignorant.   Some Avriters apparently consider it  to be favus, and
others a form of herpes.   On tAvo or three occasions I have seen a scaly
disease  of the scalp, in the form of  a ring—that is  lepra, Avhich  I  have
cured by pitch ointment, or  oil of cade.  My friend,  Dr. Andrew Wood,
informed me some time ago, that he banished it from the Heriot's Hospital
school by condensing on  the eruption the fumes of coarse brown paper,
and thus causing an empyreumatic oil, or kind of tar, to fall upon the part.
This has led me to suppose that it is a scaly disease, and a form of lepra
or psoriasis.
  So-called syphilitic  discuses  of the skin are, in my opinion, the various
disorders already alluded to, modified by occurring in individuals Avho have
suffered for periods'more or less long from the  poisonous  action of mercu-
ry. A longer time will be required for their cure, but the same remedies
locally,  conjoined with hydriodate of potassium, in  smaller doses, with
bitter  infusions, tonics, and a  regulated diet, offer the  best chance of
success. 
530
SKIN DISFASE.
  The great difficulty in the treatment of skin diseases generally consists
in their  having been  mismanaged in the early stages—a circumstance  I
attribute to their not having, until a recent period, been much studied by
clinical students.  Many chronic cases of eczema are continually coming
under my notice, wdiich, in their acute forms, have been treated b) sitrine
ointment, or other irritating applications, ivhich invariably exasperate the
disorder.   I shall not easily forget the case of one gentleman, covered all
over with acute eczema, wdio had suffered excessive torture from its having
been mistaken for psoriasis, and rubbed for some time Avith pitch ointment.
In  the same Avay I have seen a simple herpes, wdiich would have readily
got wrell if left  to itself, converted  into  an ulcerated sore, by the use of
mercurial ointment.  Nothing is  more common than to confound chronic
eczema of the scalp Avith  the favus, although the microscope furnishes us
wdth the most exact means of diagnosis.  I need scarcely say that the cor-
rect application of the  remedies I have spoken of can only be secured by
an  accurate discrimination, in the first instance, of the diseases  to which
they are applicable.
  The general  constitutional treatment in all these cases seldom demands
aperient or lowering remedies except in young and robust individuals Avith
febrile symptoms.  In the great majority of cases, cod-liver oil, good diet,
and tonics are required.   In a few instances, sedatives, both locally and
internally,  are  necessary  to  overcome excessive itching and irritation.
These the  judicious practitioner will readily understand hoAv to apply
according to circumstances.                          Part xxxi,p. 178.

    Use of Collodion in Skin Diseases.—Mr. Wilson says: the diseases of
the skin in which I have  hitherto used the collodion Avith advantage are,
chronic  erythema of the face; intertrigo ;  chapped  nipples and chapped
hands ; herpes labialis, preputialis, and herpes zoster ; lichen agrius ;  lupus
non exedens and exedens ;  acne vulgaris; and several  affections of the
sebiparous organs.   In  chronic erythema of the  face, its contracting
power wras most usefully evinced, as it Avas also in lupus  non exedens, and
acne.
   In  a  troublesome case of chapped hands  and fingers, resulting from
chronic lichen  agrius, the collodion acted not merely as a protective cover-
ing, but also promoted the healing of the cracks.  In chapped  nipples, it
was even more efficient in its protective  and curative action.  The gnptiig
cracks were instantly drawn together and almost obliterated by the con-
tracting power of  the remedy, and  Avere effectually shielded from the
influence of moisture  and the pressure of the gums of the  infant, and all
this, in consequence of the rapid evaporation of the ether, in an  instant of
time.  In another point of view the remedy is invaluable as an application
to  chapped nipples—namely, as being in nowdse injurious to the infant,
from offering nothing which can be removed by the lips during the act of
sucking, and in this particular, therefore, possessing a vast superiority over
the various forms of ointments, astringent lotions, eto.   As  it is usually
prepared, it has the consistence of sirup, and in this state is best suited for
those  cases in  which its  adhesive  properties  are principally  needed.
Where,  however, it is intended to be applied  to the surface of an ulcer  or
abrasion, or to chaps of the skin, I find it convenient  to  dilute it with
ether, and render it almost as limpid as Avater.         Part xviii., p. 227.
   Borax in Efflorescence of the Face.—Mr. Vanoye, in these cases of red 
SLEEPLESSNESS.
537
spots, or efflorescence of the face, so often seen in the young otherwise in
good  health, states  he has found Avashing them several times a day Avith
Hufeland's  formula  a most excellent remedy.   It consists of borax two
parts, orange-flower and rose-Avaters of each fifteen parts.
1                                                   Part xxiv., p. 258.

  Grease in Man—Inoculation of—In a case  in Guy's Hospital, three
grains of quinine Avere ordered three times a day; also  a lotion of nitrate
of silver, 3ss. to %]. of  distilled water, applied by a sponge pushed up the
nostrils; Avith full diet, ten ounces of  port Avine, and two pints of porter
daily.  The solution of caustic seemed decidedly to have killed the disease.
The parts around the nose, cheeks, and eyes, were much swollen, and were
punctured.  The streams and jets Avhich floAved from the Avounds  showed
the state of congestion the parts Avere in,             Part xxiv., p. 349.
  Balms for Diseases of the Skin.—Baume Chiron ou de Lausanne, em-
ployed to promote  the  Cicatrization  of chapped Nipples and  Broken
Chilblains.—Take of olive oil, ten ounces ; Venice turpentine, tAvo  ounces ;
yellow Avax, one ounce ;  alkanet root, half an ounce ;  boil together, strain
and add of balsam of Peru, two and a half drachms;  camphor, nine and a
quarter grains; stir constantly until cold.
  Balm for Chilblains.—Take of rectified spirit of turpentine, one drachm;
sulphuric acid, fifteen grains ; olive oil, two and a  half drachms ; mix.  To
be rubbed night and morning on unbroken chilblains.
   Goulard's Balm  (Oil of Saturn).—Take  of essential oil of turpentine
any quantity ; heat it  secundem artem ;  decant, etc.    Used for dressing
phagedenic ulcers, ecthyma, some chronic eczemas, and rupia.
  Plen<k"s Mercurial Balm.—Take of mercury, one ounce ; Venice tur-
pentine, half an ounce ;  lard, three ounces ;  calomel, seventeen grains and
three-quarters ; elemi ointment,  three ounces: mix.    Used for dressing
venereal ulcers.                                     Part xxvii., p 161.
   Cutaneous Affections.—When associated with  the cancerous diathesis,
are best treated at the London Hospitals, by creasote made into pills AAdth
liquorice powder.                                  Part xxxiii.,/?. 236.
  Disuse of Soap in Skin Diseases.—Mr. Startin is very emphatic in his
directions to patients suffering from cutaneous eruptions, to avoid the appli-
cation of soap to the irritated part.  In the general directions appended to
the pharmacopoeia is the following :  " Avoid using soap of any kind to the
affected part; substitute to cleanse the  skin, instead of soap, a paste or gruel
made of bran, oatmeal, linseed-meal, arrowroot, or starch and warm water,
or warm milk and Avater ; and yolk of egg and warm Avater to cleanse the
scalp."  The last named application is exceedingly useful in cases of porrigo
and eczema of the scalp in children.   Both of these affections are often.ag
gravated and kept up  by the persevering use of soap. Part xxxviii.,/?. 176.
                       SLEEPLESSNESS.
  Sleeplessness.—Vide Selections from  Favorite Prescriptions,  Article
"Medicines."                                           L
   Wakefulness—Hypodermic Injections.—Opium,  morphia,  and  other 
538
SMALLPOX.
sedatives, Mr. Hunter observes, wdll, in some cases, entirely fail in pro
curing sleep, or even cause a little delirium, Avhilst a little morphia (a third
or half a grain of the acetite) injected into the cellular tissue of any part
of the body, will act rapidly and effectually, procuring sleep and allaying
irritation.                                          Part xxxix., p. 53.
                           SMALLPOX.
  Sulphur.—It would appear from the experiments of  Dr. Midaveine,
that sulphur possesses  the same  efficacy  as mercury in arresting  the
devolopment of the small pox  pustule.  Dr.  M.  employs  an ointment
composed of two to tAvo and a half drachms of flowers of sulphur to an
ounce of lard, and Avith this rubs  lightly, thrice a day, all parts of  the
body on which pustules exist.   The nearer the pustules are to the period
of their first appearance, the greater the chances  of success ;  the papulae
then contract, become dry, and  fade aAvay.   Even in confluent smallpox
the patient quickly recovers his appetite, and asks for food.
  Dr. Midaveine employed the sulphur ointment in sixteen cases only, and
of these tAArelve had been vaccinated.
   Gold-leaf—Gold-leaf is  used for the  same purpose by the Egyptians
and Arabs as related by Baron Larrey.   They cover the parts with gold-
leaf as soon as the eruption makes its appearance.
  M. Legrand bears testimony to the efficacy of the practice, having tried
it in one case, which he relates.  The patient was a beautiful English girl,
who had a copious eruption of confluent smallpox.  On the first day of
the  eruption  the  Avhole of the face ivas covered with the gold leaves,
which wrere made to adhere by means of gum Avater.  The application  Avas
renewed morning and evening so long as the suppurative fever continued ;
and Avhen the cure was complete, not a pit or scar was left on  the  face
where the gold-leaf had been applied.   The iands,  and the rest of  the
body wdiich had not been thus protected, Avere  deeply  marked wdth  the
scars of the pustules.
  Almond Oil.—Barron Larrey says that he has found  nearly  the same
beneficial results to folloAV from the repeated anointing of the face of the
person  laboring  under smallpox  ivith  almond  oil;   a  practice  which
recommends itself from its cheapness and the facility of its application.
                                                       Part 'in.., p. 51.
  Aphorism of Practical Surgery.— It is  a well-knoAvn  fact that all
abcesses caused by smallpox exist  between the periosteum and  the bone,
with tumefaction of the latter, and subsequent formation of a sequestrum;
but in  the majority of cases, this cause  produces only a  swelling of the
bone with denudation.  It is important to distinguish  these tAvo sets of
cases.   (Dupytren.)                                   Part 'in., p.  116.
  Iodine a Preservative against Variola.—Dr.  Schreiber states  that he
has found the administration of iodine useful in  preventing  the members
of the family of a  person  laboring under smallpox from being infected
with the same disease.  The formula he used Avas as folloAvs :
  fy Hydriod. potass., gr. viij.; tinct. iod., gtt. xvj.; aquas font., |ij. S. A.
teaspoonful morning and evening.                        Part x., p.  181.
  Blisters in confluent Smallpox.—-M.  Piorry has for  some  time  past 
SMALLPOX.
539
 derived great assistance from the use of blisters as a means of preventing
 the scarring of the face by the cicatrices of confluent smallpox.   The pus,
 retained so long  in  contact  Avith  the tissues,  and  altered in character
 through the agency of the  air Avhich  passes  through the  pustules  by
 endosmosis, operates extensive local destruction, and proAes very injurious
 to the system when re-absorbed.  Various practitioners have proposed mea-
 sures for obviating this inconvenience, as by cauterization of each pustule
 (impossible in the confluent disease), the opening  them by  scissors, nee-
 dles,  etc.   Experience, hoAvever, sIioavs that over such means the blister
 has the advantage of—1, opening at one time the  Avhole of the pustules
 over  which it is applied;   2,  evacuating their  entire  contents, and
 preventing the  consequences of the sojourn, or resorption  of pus;  3,
 counteracting the attendant erysipelas, by  diminishing  the swelling: and
 5, causing the scabs to fall much sooner from the face than from  other
 parts of the body.  It has an  advantage over  mercurial plasters in not
 risking the excitement of salivation, the extent of evil which results from
 its use being a slight ischuria.  The various plasters  applied as abortives
 in this  disease,  have been reproached  with exerting a repellent action,
 and directing the morbid action upon  the brain and its membranes.   A
 blister,  on the contrary, rather acts as a derivative.       Part xv., p. 261.
   Smallpox—To prevent Pitting from.—Professor Bennett recommends
 mercurial ointment thickened Avith  starch (ung. hydrag., |j.; pulv. amyli.,
 §ij.) to  the forehead and face, night and morning.   The ointment forms a
 thick hard crust, Avhich, as it cracks and peels off, is renewed by a fresh
 application.                                           part xxi.? ^j. 262.
   Abortive Power of Collodion on Smallpox.—A case occurred  in  the
 Ayards of M. Aran, at the Bon Secours, in Avhich the good effects of collo-
 dion  was  proved to be as decisive  in  confluent smallpox as it had been
 found before in  the more simple form.   It  occurred  in the person  of  an
 unvaccinated young man, and the collodion Avas applied to all parts of the
 face but the lips and  ears.  Through this transparent covering the progress
 of the pustules  was observed to become at once arrested, ivhile those un-
 covered continued enlarging.  Moreover, a part of  the covering having
 been  destroyed Avithout being observed for some hours, the pustules thus
 exposed immediately began to develop themselves until again arrested by
 a  reapplication.  The ears, too, Avere now covered, and the progress of the
 pustules stopped there.  In a  few days the collodion peeled off, the skin
 looking as if after erysipelas, but no cicatrices Avere to be observed, though
 in other parts of the body they existed in abundance, the eruption havino
 been very confluent.                                 Part xxiii ? p 29£

   Treatment of Smallpox.—After mature  deliberation  upon the  treat-
 ment  of smallpox, Mr. Pasquin arrived at the conclusion that  the pitting
 and disfigurement of the face was dependent upon the confinement of the
 matter too long m the pocks, causing a slough thereby to form in the cel-
 lular tissue lying between the cuticle and the fascia of the face.  This  is
 not regenerated, hence the cuticle  falls into the space where the cellular
 tissue is then wanting, ami thus follows the pitting.   To obviate this, Mr.
1 asquin determined to puncture each pock previous to its arriving at per-
fection, and apply a common  poultice.  This treatment succeeded to his
utmost  satisfaction.   As the  pustules  are liable to form on the tonoue,
fauces, pharynx,  and larynx, apply a few leeches over  these regions, exter- 
540
SMALLPOX.
nally, so as to diminish the circulation and to reduce the size of the pocks.
                                                     Part xxiv.,/). 42.
  Smallpox.—In a case of smallpox, under the  care of Dr. George, at-
tended by great  SAveltihg of the throat, and painful and  difficult degluti-
tion, great relief followed the application to the throat of jeweller's cotton,
Avell sprinkled wdth poAvdered camphor.                Part xxvi., p. 290.
  Smallpox—Abortive Treatment.—Professor Bennett recommends to the
face the following plaster : Carbonate of  zinc,  three parts ; oxide of  zinc,
one part; rubbed in a mortar Avith olive oil to a proper consistence.  This
may be used throughout the case, and reneAved from time to time.
                                                     Part xxix., p. 50.
  Smallpox—To prevent Pitting in.—Dr. Crawford uses a saturated  solu-
tion of iodine in spirits of Avine.   Brush this  tincture freely over the face
once or twice daily, from the earliest period of the eruption, and continue it
during the maturation of the pustules.                Part xxx., p. 175.
  Abortion of the Variola  Pustule.—Many are the remedies Avhich  have
been recommended for the  prevention of the  pits left in  the place of the
pustule.  Mercurial ointment has, perhaps, been  most useful, though it is
very objectionable.   Trousseau's  Elastic Collodion is much more useful
and agreeable; it is formed of collodion 30 parts, Venice turpentine 1\, and
castor oil £ part.  It  must be applied over  the whole face three or four
times  a day.   The result has been highly satisfactory.
   In the Paris hospitals from 30 to 40 centigrammes of corrosive sublimate
are added to every 30 grammes of the elastic  collodion, and it is said Avith
excellent results; but of this mixture M. Delioux has had no experience.
                                                    Part xxxii, p. 188.
   Prevention of. Pitting in.—Dr. Stokes and Dr. Graves, of Dublin, have
recommended painting the face Avith a solution of gutta percha in chloro-
form.   It should be applied-immediately before complete  maturation.
The increase of swelling  after this time is moderate, and not such as to
give rise to much pain, tension, or inconvenience.    Part xxxiii., p. 228.
   Smallpox.—In confluent variola, as soon as the eruption is  complete,
the greatest benefit may be derived from a few grains of  Dover's powder,
given every night.                                  Part xxxiii, p. 308.
  Smallpox—Prevention of Pitting in.—If the  eruption be distinct, the
solid stick of nitrate  of silver should be applied to each pustule, previously
moistened with a tittle water.  If confluent, the  concentrated solution of
8 scruples to an ounce of distilled water, must be applied over  the Avhole
surface.  (If  necessary to apply it  to the scalp, the hair should  be pre-
viously removed.)  The application should be  used on the second or third
day of  the eruption.   Mr. Higginbottom relates a case of confluent  small-
pox, where no punctures  Avere made, in Avhich the strong solution Avas ap-
plied to the wdiole of the face and ears, the pustules Avere immediately ar-
rested,  and in nine days the eschar had come aivay from  the face, without
leaving pits.                                         Part xxxv.,p. 159.
   Treatment  of Smallpox.—During  the spring of  1858,  smallpox was
very prevalent in the Chatham garrison, and  only one case out of thirty
proved fatal  under  the treatment  pursued by the author.  The patient,
under the care of Mr. Mandevtile, surgeon 3d Indian Depot Battalion, was 
SNAKE BLTES.
541
directed to take a mixture composed of 2 drachms of compound rhubarb
powder, 2 drachms of tincture of hyoscyamus, and 1\ ounces of camphor
mixture, in doses of two  tablespoonfuls three or four times a day; but if
the attendant fever was very high, there Avere  added  two  ounces  of the
solution of acetate of ammonia to the above.  This mixture Avas generally
continued as  long as the fever lasted, which was  usually about the time
Avhen the pustules had fully maturated and the scabs had formed, the fever
seldom extending beyond that period.  It was then omitted, and bark or-
dered,  if there  had been  great prostration, after  a  serious attack.   A
draught containing one drachm of tincture of hyoscyamus, in an ounce of
camphor  mixture, was given  at right, as soon as the patient complained  of
any restlessness or itching, which was about  the second or  third day of the
eruption  in the confluent  form; but they sometimes complained of it on
the first day, Avhen the eruption appeared to be  retarded,  as if struggling
to force its Way through the  cutis vera.  This ivas  continued  every night
as long as the sleeplessness from the pruritus continued, and at  the same
time the  following liniment or ointment was  laid on with a large-sized
camel-hair  brush  three or four times a day over the face and  any other
p.irt of the body of which  the patient complained of being itchy—viz.,
half a drachm of extract  of belladonna, rubbed up  Avith half a drachm of
spermaceti ointment, to which were  added  3^  ounces of olive oil and 2\
drachms  of chloroform.  The cerate was added to  give it consistence and
hold the  chloroform in suspension, but the  bottle  must, notwithstanding,
be well shaken before using, as the chloroform will subside after standing
for any time.                                      Part xxxviii., £>. 28.
                      SNAKE   BITES.
  Ipecacuanha in  the  Bites  of Venomous Animals.—[A little girl Avas
bitten by a centipede;  after the usual remedies, oil,  spirits,  laudanum, am-
monia, had been exhausted without relief to the pain.]
  Mr. Collett  says:  I fetched a bottle of Avine of ipecacuanha  from the
chest, and gave it to the mother to apply locally.  To my surprise and de-
light she came out of her  cabin in tAvo minutes, to tell me it had stopped
the pain instantly.   I requested her to re-apply it if necessary.   The pain
returned once, Avhen it again immediately and entirely relieved it.  If so
minute a quantity as is contained in the Avine, could be attended with such
good effects, I think much  more might  be expected from its use in the
concentrated form of emetine.                         Part xvi, p. 331.
  Snake Bite.—Dr.  Bland recommends a ligature,  whenever practicable,
above the bite; include the bitten part between the blades of a pair of
tenaculum  forceps, raise it from  the subjacent tissues, and cut it  com-
pletely out Avith a scalpel;  apply a cupping-glass to  the wound,  or use
suction ;  give stimulants, as brandy,  wine, ammonia, or oil  of turpentine;
bleed to relieve constriction of the chest, or pain about the  heart or head;
wash the head, face, and  hands, occasionally in cold water ; and prevent
sound sleep for some time after the injury.  "           Part xvii., p. 296.
  Snake Bite.—Dr. Whitmire paints the part bitten, and the whole ex-
tent of the swelling, with three or four coats of tincture of iodine, twice
daily.                                                Part xx., p. 18Q. 
5d2
SNAKE BITES.
  Bite from an Adder.— Vide Art. "Bites."'
  Bite from a  Cobra de Capello.—Give a teaspoonful of sp. ammoniae
aromaticus in a little water every five minutes.   Dr. Mac Rae, when bit-
ten by this snake, took 13 teaspoonfuls  in this  manner;  every dose
seemed to give some relief.  In three hours he was out of danger.
       ********
  D. Cole adds his testimony to the great value of ammonia administered
internally in the cases of bite from this snake. He prefers the liq. ammon.
fort., (P. L.) in doses of ten to twenty drops.  He also states his belief
that it is exceedingly dangerous to suck the poison from the wound, as,
in his opinion, the deleterious principle of the poison is not neutralized by
the gastric juice.
       *       *       *      *      *       *      *       *
  In twTenty cases of this nature, hot brandy and water was immediately
administered along with peppermint and laudanum.   Not one  case was
lost.
        *        *        *         *        *      #        #
  The late M. Lisfranc spoke in the  most unqualified manner of the suc-
cess followdng the free application of ammonia to the wound,  and its free
administration internally.
         7T         7T       w       VT       7F        7P        W
   Suction from the  wound, or the  actual cautery, or if possible, a tight
ligature, combined wdth e\Tery means to combat torpor, ought to form
the bases of the treatment.                          Part xxvi., p. 334.
   Bites  from Serpents.—Rub the parts with the  tincture of guaco, and
give 3j.  doses  every ten minutes.  This remedy is said by Dr. Pritchard
to  be unerring in its efficacy.                         Part xxvii., p. 250.
   Arsenical Treatment of cases  of Snake  Bite.—Arsenic has been re-
cently employed for the treatment of these  cases, and it is singular that
persons having been bitten by  snakes recovered completely by this treat-
ment, without any of the poisonous symptoms of arsenic being manifested.
Mr. Ireland prescribed liquor arsenicalis, 3ij.; tinct.  opii, gtt. x.; aqua;
menthas  pip., §iss. To this quantity half an ounce of lime juice Avas added,
and the medicine taken in an effervescent form.  A grain  of arsenic every
half hour  looks formidable treatment, but it was  certainly successful in
snake bite, and maybe so in hydrophobia.  Arsenic would seem to stimu-
late specially the semilunar  ganglion and its  tributaries, presiding over
the organic life of our bodies.   Its  '• evacuant " operation is an incident
of  prime importance in cases of poison.   It should always "be given on
these occasions until the patient vomits and purges abundantly.
                                                   Part xxviii.,^. 317.
   Snake Bite.—Dr.  Loundes recommends 5 grains of bicarbonate of am-
monia every five minutes, and to administer an enema  of mustard  and
Avater, Avith tAvo drachms of tinct. of valerian, AA-hich may be repeated if
returned.   Apply a  mustard cataplasm over the cardiac  region and then
give the folioAving: Chloroform. 5j.; spirit, §ij.;  mist, camph., §iij.; M. ft.
m.  3j. every ten minutes.                             Part xxix., p. 326,
   Snake Bite.—A decoction or broth of the leaves near the root of the
common male fern, polypodium filix  mas, has been used as  a secret, re-
medy in Australia, as u specific for snake bites.  Though the experiments 
SOAPS—SOKES.
515
 hitherto made cannot be said to be satisfactory, it might be  tried by me-
 dical men in the army, if nothing better is at  hand.   Probably a tincture
 would be more powerful.                               Part x\.,p. 278.
  Alcoholic Stimuli in Snake Bites.—Vide Art. "Bites."

                              —•-»-•---

                             SOAPS.
  Medicated Soaps for the Treatment of Skin Diseases.—Sir H. Marsh
 recommends the following in the more chronic forms of skin disease, as
 chronic eczema, psoriasis, etc.:
  Sulphur Soap.—Take of white Windsor soap, two ounces;  spirit  of
 wine,  colored with alkanet root, one fluid drachm.  Pound the soap well
 in  a marble mortar, so  as  effectually to  get rid of  all lumps; add the
 spi rit  and beat into a  uniform  paste; then add sublimed sulphur two
 drachms, otto of roses, ten  drops—beat  all well together.
   White Precipitate Soap  is made precisely as the sulphur  soap, substi-
 tuting ammoniated submuriate of mercury for the sulphur.
  Red Precipitate Soap.—Take of Avhite Windsor soap, two  ounces ; rec-
 tified spirit of Avine one fluid drachm; pound the soap Avell  in  a  marble
 mortar, until all lumps have  disappeared ; add  the  spirit and  beat into
 a uniform paste; then add precipitated red oxide of mercury,  one drachm;
 otto of roses, six drops ;  beat  all well together.
   Corrosive Sublimate Soap.—Take of wdiite Windsor soap, two ounces;
 spirit of Avine, one fluid drachm; corrosive sublimate, one scruple ; pound
 the soap well in a marble  mortar until all lumps have disappeared; add
 the corrosive sublimate, previously reduced to a fine powder, and rubbed
 in a separate mortar,  Avith the spirit.   Beat all into a uniform paste,
 adding six drops of otto of rose.
  Sir  II. Marsh  states that the only  forms  of cutaneous  disease  that
 admit  of the application of these soaps are those Avhich either have passed
 from the  acute into the chronic  stage, or have not been at any period
 peculiarly irritable and tender; at the same time, he has met with several
 cases in Avhich the  tender surfaces, at first intolerant, became subsequently
 inured to them; and,  after a little  perseverance, the patients  began to
 speak highly of their soothing and beneficial effects.    Part  xxii., p. 260.

                              ---•-*-•---

                            SORES.
  Sores^ and Wounds—Sloughing.—Dr. T. S. Fletcher advises the  use
 of chlorine.  It is a poAverful antiseptic,  and prevents sloughing.   Make a
 solution of chloride of  lime, two drachms  of the poAvder to a pint of cold
 water.   Cover the Avound  with pads of tow  dipped in this solution, and
 renew  them about  twdce a day.                      Part xxxi, p. 191.
  Chloride of Potash in  Scrofulous Sores.—M. Bouchut employs Avith
great  success, a  solution  of t'ds  substance (3j. ad §iij. aquae)  as a local
application to external sores in scrofulous children.  He has also found it
highly  useful in arresting the progress of ulcers supervening upon the em-
ployment of blisters, as also in  ulcerated  chilblains.  Part xxxviii., p. 175. 
u±
SPASMODIC  AFFECTIONS.
                  SPASMODIC  AFFECTIONS.
  Spasmodic Affections of  the Larynx—Veratria.—Dr. Bushnan has
strongly recommended the ointment of veratria in the treatment of dys-
menorrhcea.  Dr. Bushnan supposes that dysmenorrhcea may frequently be
owing to perversion of the nervous action of the loAver portion of the spinal
nerves,  and found good effects from the  external application of the oint-
ment of veratria.  Dr. Tunstall suggests that if the ointment of veratria
has this effect on the lower portion of the spinal marrow, why may it not
have a similar effect on the superior portion ? and in  this latter case  it
would be supposed to be useful in spasmodic affections  of the larynx and
appendages.   Dr. T. accordingly tried it in the case  of a schoolmistress:
she Avas usually seized with a sense of suffocation, the whole of the muscles
employed in respiration were  put  into violent and convulsive action, the
loAver extremities became cold, the  face purple, the wdiole surface was be-
dewed with cold perspiration ; she Avas perfectly sensible during the whole
attack; the fit usually terminated in ordinary dyspnoea, which lasted for
hours, or even clays.  Every variety of depletion and counter-irritation
had been  employed;  also, opiates and  antispasmodics, Avithout the least
advantage.   Dr. T. says :]
   I therefore prescribed a scruple of veratria to one ounce of simple cerate,
and directed that a small portion should be applied on each side of the cer-
vical vertebras, and rubbed Avell  into neck, throughout its Avhole extent,
tAvice a day.   Although the attacks were previously rather frequent, she
had not a single attack of consequence during its use.      Part iv., p. 29.

   Opium Smoking  as a Remedial Agent.—Dr. James Johnson suggests
that the Chinese mode of smoking  opium may be made useful  " in certain
dangerous and painful maladies, where the common mode is found to be
inefficient, and attended wdth great derangement of the digestive organs."
The Chinese method induces  a profound sleep and insensibility to all mental
misery and corporeal pain, which cannot be induced by opium taken into
the stomach, and may, therefore, at some period, be used in cases of teta-
nus,  hydrophobia, tic-douloureux, and  violent spasms,  where  the  com-
mon mode  of  giving opium  by the stomach so frequently fails.  Dr.
Johnson adds, that " the various preparations of opium might he  easily
smoked by means of a common pipe, and the powerful effects induced in a
very short space of time without the possibility of their being rejected  by
the stomach, or prevented from acting energetically on the sensorium, and
throughout the Avhole nervous  system."                   Part v., p. 56.

   Division of the Muscles of the Face when affected with Chronic Spasms.
   Dieffenbach performed this operation in four cases in which the disease
had existed  for a considerable time.   The orbicularis palpebrarum was
divided, also the muscles of the cheek, from the ala of the nose to the an-
terior  border of the masseter, and lastly, the muscles at the angle of the
mouth.  The result of the operation was, that the spasmodic  affections
were cured.                                            Part v., p. 142. 
SPERMATOCELE.
545
                     SPERMATOCELE.

   Spermatocele and Hydrocele.—[In a clinical lecture upon a case  of hy
drocele which had been operated upon,]
   Mr.  Syme stated, that he had long ceased to employ port wdne for injec-
tion into the tunica vaginalis, on account of its effect proving very  uncer-
tain ;  and that having  subsequently used  a  mixture  of the  tincture of
iodine  with three  parts of water for this purpose, he had, during the last
five years, always injected the tincture  alone,  and Avithout a single case of
failure or unpleasant effect, either in public or private practice.  The quan-
tity required was about a teaspoonful, or as much as filled a common  six-
penny  pewter syringe, which was the most  convenient instrument for  the
operation, as the substance composing it allowed the nozzle to be readily
adapted to the canula of the trocar.  The fluid when injected was allowed
to  remain, and  Avhile producing the effect  desired  Avith absolute  cer-
tainty, seemed to occasion less pain than any other agent in past or present
use.
   When the tumor Avas punctured, the fluid Avhich  issued  through  the
tube, to the amount of a pint or more, appeared somewhat turbid, and this
was attributed to its probably containing the scales  of cholesterine,  which
are frequently met with in albuminous  fluid long pent up in close cavdties.
The tincture of iodine, therefore, Avas injected as usual.  But Avhen a little
of the fluid  ivas  poured  from the basin, in which it had been received,
into a  glass vessel, in  order that the gentlemen present might more readily
examine it, the absence of scales, and the  peculiar  opalescence observed,
at  once suggested the  idea of spermatocele, and an appeal to the  micro-
scope  confirmed this  suspicion, by bringing myriads  of spermatozoa  into
view.
   Had the true nature of the case been  ascertained  in the first instance, in-
jection Avould not  have appeared expedient, since spermatocele has not only
resisted the means of treatment Avhich have proved sufficient for the remedy
of hydrocele, but has also shoAvn a disposition to resent with violence even
liberties of a much slighter kind.
  The  result of this case was, therefore, watched AAdth interest; and when,
after passing through  the  usual course  of  a  simple hydrocele, under the
same circumstances, the SAvelling quickly subsided, with complete restora-
tion of the testicle  to its healthy state, it naturally suggested  another trial
of the same  kind. For this an occasion happened at the time to present
itself, in the case of a gentleman, Avho had had a hydrocele tapped about
twenty years ago,  by Sir Astley Cooper, and afterAvard injected with port
wine by another surgeon in London, but still suffered from it.  The  tumor
was in  every respect very similar to that just  mentioned; and when punc-
tured,  was found to cofitain the same sort of turbid  opalescent fluid.  The
suspicion of spermatocele was confirmed  hy the microscope, Avhich detected
abundance of spermatozoa ; but everything went on satisfactorily after the
iodine ivas injected, so that before the end of three  weeks the testicle had
very nearly regained its proper size and consistence.
  The  two cases just  related afford encouragement  to attempt the radical
cure of spermatocele by the injection of tincture of iodine, although other
means  have been found to fail.                         Part xxi, p.  236.
    vol. n.—35 
546
SPER3IAT0KK1ICEA.
                   SPERMATORRHOEA.

   Causes and Treatment of.—[A number of years ago, Mr. Phillips, at the
suggestion of M. Lallemand, first applied lunar caustic  to  the mucous
membrane of the urethra to check involuntary seminal discharges.  Mr. P.
says:]
  Involuntary discharges are, for the  most part, if not altogether, caused
by irritation set  up in or about the ducts connected wdth the testicle.
  There are particular modes in wdiich the urethral irritation is commonly
excited ; among  these, masturbation holds a prominent place:  by this prac-
tice the constant excitement of the  seminal ducts ends by establishing a
permanent irritation there: it may likewise happen from excess  in sexual
intercourse.  Next to this  cause Ave arrange gonorrhoea  or gleety  dis-
charges, which,  from  time  to time, establish chronic inflammation in  the
Adcinity of the  orifices of the ejaculatory ducts.   Then follows stricture,
which,  by opposing an obstacle to the free passage  of urine, ultimately
causes the development  of a morbid condition of the mucous membrane
between the stricture  and  the bladder.  The  same state of these organs
may result from irritation w ithin the rectum ; that irritation may be caused
by fissures of piles, or by the presence of ascarides.
   The mode in  which the  irritation, once set up around  the orifices of the
ejaculatory ducts, acts, is very much  the same as obtains upon the applica-
tion of irritation to the mouths  of other ducts; it solicits increased action
in the  organ with which they communicate.  Irritate the bladder, and the
kidneys are stimulated to increased action ;  irritate the conjunctiva,  and
the lachrymal  secretion increases ; irritate the duodenum, and it is said
bile will be supplied in increased quantity; it is unnecessary to carry the
illustration further.
   In most cases the  evidence of involuntary spermatic discharges is clear
enough, but the time comes when the ejaculation is unaccompanied by the
ordinary sensations, and the patient may then be unaAvare of  the extent of
the evil.  I have  again and again known cases where the spermatic fluid
passed out Avith the urine; others, in which the efforts  at stool caused a
pressure to be made  upon the distended seminal A'esicles, and thus their
contents Avere squeezed out; but the fluid may not pass until the process
of buttoning up is going on, and the evil may be undiscovered.   Still, un-
less the disorder be  very  advanced,  in most  cases  the person  himself is
aware  of it Avhen it passes wdth the urine, because it almost ahvays passes
wdth the last drops, and can then be  detected, and because a  certain sensa-
tion is  experienced about the neck of the bladder.  But when the medical
man is consulted, he  calls  for the recently passed urine,  or requests that it
may be passed in his  presence, and at the bottom of the vessel he perceives
small granular diaphanous particles ;  and they are seen floating even before
the urine cools; if the evil be, hoAvever, very ad\Tanced, no peculiar sensa-
tion is experienced,  and  the granular matter may  be  undetected, and
may assume  a  more uniform cloudy appearance.  In  cases where uncer-
tainty  remains  wdth  regard to the  deposit, Ave may advantageously  have
 recourse to the microscope, by means of Avhich the little long-tailed ani-
 malcules of the spermatic  fluid can readily be perceived.  Under any debi-
 litating  causes, Avhether  those causes  be found  in  frequent spermatic
 discharges, disease, or old age, the fluid becomes much thinner, and the 
SPERMATORRHOEA.
547
animalcules much less numerous, and they may be almost, if not altogether,
winting.                                                        .
  One of the general symptoms resulting from too frequent spermatic dis-
charges, which is most distressing to the sufferer, is a state approaching to,
if not at the time, actual impotency.  It is not  that the seminal fluid,
though deteriorated, is incapable of determining fecundation, but it is that
the oTgans are Avanting in the energy necessary for projecting the fluid into
the uterus; the erection of the  penis,  if it exist at all, being only momen-
tary.  The digestive functions become deranged ; the bowels constipated ;
nutrition languishes ;  respiration is troubled; the votie fails; the heart's ac-
tion  is interfered wdth, even to such an extent  as to induce  the belief of
actual disease in that organ, and hypochondriasis becomes complete.  These
things do not advance far  without causing trouble in the nervous  system,
manifested  by some  perturbation of the senses, by headache, with great
sense of weight or pressure, and they are accompanied by loss of memory;
a timidity and apprehension which  are very painful.  It must be  evident
that  as the causes  of these discharges are many, the treatment must also
be variable.   When the irritation is in the rectum, the  case Avill require a
very different course of treatment to one proceeding from stricture of the
urethra.  We will  therefore make such general remarks as are proper with
reference to the treatment of the several varieties of the affection wdiich Ave
have considered.   First, when the  cause is masturbation or sexual excess:
the  causes here are voluntary, the cure must also be  voluntary.  Lunar
caustic will be powerless, unless the patient has sufficient determination to
abstain from the practice.   But in many cases perfect  abstinence Avill not
suffice to put an end to the mischief; the voluntary discharges are got rid
of, but they were persisted in so long that a permanent irritation has been
sot up hi the verumontanum,  and that irritation may, as we have already
explained,  excite equally injurious involuntary discharges: and  here  a
remedy- must be found by the surgeon.  The first thing we have to do  is
to introduce cautiously a bougie, to pass it down toward the bladder ;  but
before it arrives there, the patient wdll complain of pain Avhich is  sometimes
very acute;  and the point at which the bougie  has then arrived is usually
a little in front  of the prostate.  The  surgeon must then carefully obseiwe
how  far the penis has been extended, and a mark must be made upon  the
bougie to indicate the depth to which the instrument has penetrated, be-
cause that is the point upon which the lunar caustic must be applied.  The
depth to wdiich we must penetrate must be marked upon the caustic instru-
ment, Avhich  is then introduced and gently passed to the proper point,
when the caustic is uncovered, and the membrane brushed over:  as soon
as that has been done, the caustic is again covered, and the instrument  ia
withdrawn.
  The point upon which the caustic is to be applied is, as near as practica-
ble, about the region of the orifices of the ejaculatory ducts. It often hap-
pens, however, that the whole or several parts of the urethra are very  sen-
sitive, and it becomes difficult to know, from this  circumstance, which  is
the most tender and irritable ; but  when, for example, it is found that it  is
seven and a half inches from the orifice of the urethra to the bladder, which
is knoAvn by the urine passing along the catheter, and Avhen it is further
seen  that an acute  pain is felt at a little more than  six inches, Ave may con-
fidently cauterize the space betAveen the sixth and seventh inches, satisfied
that  the oriities of tee ejaculatory ducts will not escape. 
543
8PERMAT0ERHCEA.
   In some cases the patient complains of a little heat when the caustic is
 applied; in others, the sensation spoken of is a coldness. I have more than
 once known some discomfort almost amounting to spasms at the anus, but
 altogether it is astonishing how rarely any complaint is made.   At the next
 time of passing the urine, more  smarting is usually experienced; it may
 continue through the day, but it is very bearable.  In all cases it occasions
 a discharge, which is sometimes considerable, and at first is thin and waterv,
 but gradually becomes thicker, and in the course of a feAv days ceases.  In
 a few cases the discharge is at first streaked with blood ; and in a few rare
 instances there may be trifling hemorrhage.
   It is always necessary to guard the patient against  impatience, because
 four or five weeks will, in some cases, pass, before the beneficial effects of
 the remedy become  clearly evident; and this is the more necessary, because
 he looks with intense anxiety to the result; and sometimes it happens that
 a single discharge, after the application of the caustic, wdll dash the cup of
 hope from his lips, and induce the most gloomy forebodings.  I may again
 repeat what I ha\Te said before, that I have never applied too much caustic,
 but I have more than once failed by using too little ; and much experience
 is necessary to apply the proper dose.   HoAvever, it is better to err on the
 safe side, until experience shall have given confidence in the use of  the
 remedy.  I have  scarcely ever had recourse to a second application until
 five or six weeks have passed, and given  the assurance that the first  has
 been insufficient.
   If the affection has been  caused by a gonorrhoeal or gleety discharge, the
 treatment must be the same as in the former instance.
   If it has been caused by  stricture, Ave must first restore the canal to its
 natural diameter; the obstacle to the passage of the urine may be removed,
 but the morbid condition of the posterior part of  the canal, which has re-
 sulted from it, may persist; so may the specific discharges. Then the effi-
 cacy of the lunar caustic can be at once demonstrated; and a single proper
 and sufficient  application of the remedy, with the precautions already indi-
 cated, will, in most cases, promptly cure the disease of the urethra as well
 as that of the spermatic organs.
   If the discharge be determined by irritation of the  anus, or the rectum,
 appropriate means must be used to cure the intestinal disorder; and it may
 be that when that has ceased the spermatic disorder will also cease.  BuV,
 it may persist, because a distinct irritation may have been determined it
 the urethra by the long-continued action of that of the intestinal canal; and
 to dissipate that, recourse must be had to the lunar caustic, under the same
 restrictions as have been already pointed out.
  The space which M. Lallemand usually cauterizes, is from the neck of
 the bladder to the membranous part  of the urethra; but sometimes he
 brushes over the internal surface of the bladder itself to a greater or less
 extent.  He cautions us strongly against repeating the operation too soon;
 and advises us to ivait two or three weeks  before we re-apply the caustic.
Many of his cases appear to have been cured by a single application. Pain
and a slight discharge of blood, but never amounting to hemorrhage, seem
to have followed some of his operations ; but these consequences disappear
at the end of from twelve to forty-eight  hours.   In one case they are de-
scribed as lasting three Aveeks, but this is  mentioned as  a rare exception.
When the emissions have been diurnal, M. Lallemand regards the conver-
 sion of them into nocturnal, and the fact of the emissions being once more 
SPERMATORRHOEA.
549
accompanied Avith erections and Avith pleasurable sensations, as a sign of
the favorable effects of treatment and prospect of cure.
  We shall now, Avith great brevity, advert to other  modes than  cauter-
ization, of treating involuntary seminal  discharges, depending solely on
chronic inflammation of the prostatic portion  of the  urethra and  of the
vesicuke seminales.   The daily introduction of a bougie, and the retaining
it for a longer or shorter time in the  urethra,  may first be mentioned.
This, as our own observation enables us to testify, is often useful.  Leech-
ing of and blisters to the perineum are by no means of slight efficacy, es-
pecially where the prostate is tender and. enlarged.  We have also pre-
scribed tartar emetic frictions of the perineum with excellent effects.  A
total abandonment of masturbation, and a moderate use, or even an entire
though temporary disuse of coition, are, of course, indispensable measures.
One of our correspondents states that he has found opiates extremely use-
ful.  They are so in most cases, though not in all; since they sometimes
seem to augment the disease.  Conium  is safer: and both it and  opium
may be used both constitutionally and as a suppository.  Cold clysters are
often of benefit.  As regards general  means, alcoholic and malt  liquors
must be abandoned.  M. Lallemand's opinion of these is exceedingly hos-
tile ; and Ave believe he is right in this.  The food  should be nourishing,
light, andunstimulant; the bowels  should be of course attended to,  and, as
a general rule, country air and exercise prescribed.   Among medicines and
articles of diet, tea and coffee in excess, tobacco, camphor, nitrate of potass,
aloes, must be abstained from.  .                      Part vii.,  p. 119.

  Involuntary  Seminal Discharges. — Since  the  publication  of Mr.  B.
Phillips' paper on this subject, in Avhich the application of the  nitrate of
silver to the prostatic  portion of the urethra, as  first  recommended  by
Lallemand, is shoAvn to be very efficacious, the subject has been taken up
by other writers.
  Mr. James Douglas, of Glasgow, publishes a case in which the cauteri-
zation of the  urethra, though very  beneficial, did  not  cure the affection,
and for which an injection composed of  one  grain of opium, three  grains
of acetate of lead, and one ounce of mucilage, used three times a day, and
doubled in strength in ten days, Avas  remarkably efficacious.
  Another paper on the same subject is published by Mr. Allnatt, in which
He hesitates to believe that these discharges are always seminal. He thinks
that they are often more of a mucous character, and unattended Avith the
pleasurable sensation accompanying the emission of semen.  An abundant
secretion of mucus may be afforded by the prostate, the glands of Cowper,
and by the internal coat of the bladder when diseased. Mr. Allnatt has before
directed the attention of the profession  to the effect  of creasote  on the
mucous membrane in fluor alhus, gonorrhoea, and  purulent otorrhasa,  and
thinks that it may be useful in these mucous discharges resembling  semen.
In the case of otorrhasa he used an injection composed of a drachm of crea-
sote, the same quantity of liquor potassas, and six  ounces of water; to be
frequently thrown into the tube.  Mr. Allnatt  accidentally discovered the
value of the same remedy to restrain the bleeding from piles.
                                                   Part viii., p.  163.
  Spermatorrhoea.—In the treatment of this affection, M. Lallemand ob-
serves, it is more important  that our  attention should be directed to the
present condition oi the spermatic organs, than to  the original  cause pro- 
550
BPEEMATORRHCEA.
ducing this; and there can be no  question that, in many cases, until this
great source of irritation be removed, all the efforts of the practitioner and
resolutions of the patient will be in vain.  To the chapter which directs the
suitable treatment, when this diseased condition arises  from irritation oc-
curring in the vicinity, wre need not advert; seeing the remedies employed
against ascarides, eruptions, or fissures at the margin of the anus, diseased
conditions of the prepuce, stricture of the urethra, constipation, etc., are
those in ordinary use.
   When arising simply from debility,  as it may do in persons of lymphatic
temperament, and who have suffered  in  childhood  from incontinence of
urine, give tonics, as the ferruginous waters, use the local douche folloAved
by friction, or transmit galvanic shocks through the penis and perineum ;
warm aromatic baths, ergot of rye, 4 to 20 grains night and morning, or
small doses ofcopaiba or turpentine  are sometimes useful.  When  from
great nervous susceptibility of the organs, give narcotics and sedatives, as
camphor in 5 or 6 grain doses, and introduce every feiv days  a medium-
sized gum catheter, and allow it to remain for an  hour  or more, or practice;
acupuncture of the perineum. When dependent upon sub-inflammatory con-
 dition of the orifices of the ducts, use  tepid baths, give milk diet and light
 regimen, apply nitrate of silver to  the parts,  sec. art.,  and let all exercise
 of the organs be abandoned.                           Part xvii., p. 181.
    Spermatorrhoea and Impotence.—Let the patient sit in the hip-bath of
 Priessnitz for five minutes three times a day,  the water being brought to
 the temperature of  65°.  The time may he increased and the temperature
 lowrered, until the  patient sits for  tAventy  minutes, three times a day, in
 water at 50°.  In some cases the  spine may be sponged for three  or four
 minutes before leaving the bath.  A  shoAver-bath may be  used after the
 first daily sitting-bath, the head being protected by a conical cap.—(Rev.)
                                                      Part xxiv., p. 248.
    Treatment of.—Mr. Adams, surgeon to the London Hospital, recommends
 the application, locally, of caustic,  and the  internal exhibition of conium
 and soda in  the  infusion of gentian, cold-bathing, fresh air, and the almost
 entire abstinence from alcoholic fluids.  After the secretions of the patient
 have been got into good  order, give  small  doses of tinct. cantharides and
 the sesquichloride of iron in a bitter infusion.           Part xxv., p. 216.
    Spermatorrhoea.—\*S\r. Milton offers the following observations on the
 treatment of this disease.  He says:]
    It consists—
    1.  Of Quinine in Solution, in  the following form :
    R Quin. disulph., gr. ij.; acid sulph. dil., 5j. ; tinct. cardam. co., 3hj.; aq.
 cinnam., §vss.  M.   Sumat cochl. duo am pi. bis die.
    Used in this way, one grain seems  to have much more effect than  larger
 doses with less acid.
    2.  Of Local Baths of Cold Salt Water.—I generally direct the patient
 to buy a pound of common salt, break a piece off as large as a walnut, and
 dissolve it in half a basin of Avater.  The  scrotum and perineum  are then
 bathed A\dth this by the aid of a sponge for five minutes  every morning,
 and the water thrown away, so that  nothing remains to excite suspicion ;
 those patients who  are under no restraint may use a hip bath of cold solu-
 tion of salt Avater wdth the greatest  advantage.
    3. Some  Gymnastic  Exercise every Day.—The  application  of this 
SPERMATC RRGCEA.
551
remedy must naturally he modified by the  patient's  position _ in life;  but
even those most restricted can take a walk early in the morning and  ^st
thin"- at ni^ht.  When this trenches on the hours of sleep it may he re-
garded rather as an advantage than otherwise; the less sleep the patient
has the  sounder it will be ; the earlier he rises  the better, the erections
bein<r generally most forcible aftid recurring most regularly in the morning.
  When the weather does not admit of out-of-door exercise, I advise read-
ing for a fixed time, as an hour or so every night; and if the patient be
restless and unsettled, reading aloud, even when he is obliged to walk to
and fro to accomplish his task, will often soothe  down this excitement  and
dispose him to sleep.
  4   Of Cltecking the Erections.—-It will often  be  remarked, that the pa-
tient has erections two or three nights successively.  When these awaken
him, I find it best to treat the case like one of chordee, and direct  him to
rise, take a teaspoonful of spirit of camphor in water. This will generally allay
the priapism, and prevent its recurrence.   On  those nights when  he ex-
pects the emissions, a dose may be taken last thing at night.
  The bowels should be kept loose;  and, for this purpose, five  grains of
blue pill may be taken occasionally, in conjunction with rhubarb. _ When
this does not act, the sulphate of magnesia may he added to the mixture.
  5.  If these measures do not suffice to cure the disease, I Avould  advise
blistering.  If  applied on the perineum, it acts most efficiently;  but, in
some instances, I have seen this followed by a troublesome crop of boils;
this I have never seen from a blister on the penis, where it can  be  applied
and dressed  much more easily, and where it occasions much  less soreness
and difficulty in Avalking.  If the  patient objects to this, it may be laid on
 the groin.
   Those cases in which I tried steel failed.   In  place of acting beneficially,
it seemed to heat and over-stimulate the patient, and even to dispose more
to erections.  In that  shattered  state of  the  frame in  which  the semen
passes away involuntarily, and  almost without an  erection,  it may be
useful, but I am inclined to rely more on the measures I have laid  down.
   Some surgeons, considering this disorder, in  many instances, as  merely
an effort of nature to throAV off an accumulated secretion, recommend  con-
 nection.  I would neither recommend nor  forbid  it, unless I found  it
 acting injuriously.  In some cases the patient takes it for granted that  if
 this be the remedy, medicines, gymnastics, etc., can do him no good, and
 shaking off all restraint, gives Avay to the Avorst excesses.  This plan, too,
 is not free from danger to  the surgeon's reputation.  Only very recently,
 a patient  placed  himself under  my care  for seminal emissions.   He had
 suffered under them for a long  time, and  had consulted a surgeon, who
 advised him to have connection.  The result was a gonorrhoea, which  took
 two months to cure ; and this mistake unsettled all  his former confidence
 in his medical adviser.
   When self-pollution or excessive connection  is indulged in, I only know
 of one remedy, and that is, the employment of some  irritative ointment  to
 tLe penis,  such as that of bichloride of mercury, 3ss. to §j.; deutiodide  of
 mercury, Dj. to §j.; or of the ung. ant. pot.-tart.
   The only wray to break him of  it, is to make  the penis so sore, that he is
 at once awakened by the smarting as soon as he commences any attempts
 at friction.  When once the habit is  fairly broken off, he rarely recurs
 to it. 
552
BPERMATORRHCEA.
  The despondency of spirits, the  loss of appetite, flatulence, weakness,
pain in the back, etc., under which  many of these patients labor, are
generally removed by adopting  a plain diet, as Aveak coffee, toast, and
bacon, for  breakfast, an  early dinner, consisting  of a chop or two and
bread, strictly excluding all porter, vegetables, cheese, pickles, or pastry;
as little tea as possible ; and in the evening, instead of supper, a  basin of
tapioca, ground barley, or arrow-root, with  a biscuit.
  A persevering use for a few weeks of this treatment will, I think, effect
a cure even in the most inveterate cases.               Part xxv.,p. 241.
  Lupulin (the Alkaloid of Hops) cs an Anaphrodisiac.—M. Debout, of
Paris, editor  of the " Bulletin de  Therapeutique," has found lupulin ex-
tremely useful in chordee, priapism, traumatic orgasm, and spermatorrhoea.
The lupulin should  be used in powder, and triturated with lump  sugar.
The dose is from fifteen to thirty grains.  M. Ricord and M. Puche have
carried the dose from one  to three drachms without any unpleasant effect.
                                                   Part xxviii., p. 320.
  Spermatorrhoea.—According to Mr. Milton, where physical Aveakness is
a prominent symptom, quinine has an undoubted efficacy in  controlling the
•tight discharges of spermatorrhoea.  Spirit of camphor is the best remedy
for relieving the obstinate erections which sometimes remain after  gonor-
rhoea, a teaspoonful for a dose.  Gymnastic exercise is an  excellent  means
of controlling spermatorrhoea.  The best plan is to rise at six in the morn-
ing, sponge Avith cold salt water, use the dumb-bells for half an hour, and
follow this up with a brisk Avalk.  For both the night and day discharges,
opium is a most valuable remedy.   If  the costiveness is obstinate, let the
patient take a pill of gentian with  1-12th of a grain of strychnia, with a
tumbler of unsweetened gin and Avater at night, and one of cold  water in
the morning.   If  the urine scalds, and the patient complains of spasmodic
pain at the neck of the bladder, and the urine be loaded Avith lithates, or
clouded Avith mucus, we may give  the nitro-muriatic acid with laudanum,
in the  decoction  of pareira  brava or chimaphila.  In cases of extreme
uneasy sensation or creeping along the vas deferens or urethra, veratria
ointment, or some mild counter-irritant, are the most useful applications.
The caustic holder is not  to be regarded as the remedy, because,  in truth,
it is not often called  for.  In cases complicated with gleet, Avhere the
cautery has failed, blistering is the best remedy.  A good  instrument for
applying the caustic is a platinum canula  with stilette.   After  introduc-
tion, the stilette is Avithdrawn, and  a bougie passed dowm prepared thus:
the tip being scraped rough, it is rolled in fused caustic, and this again  in
melted tallow, by Avhich means a thin film of caustic is secured.
  The indigestion in this  disease is best relieved by aromatic confection,
with sulphate of soda and mint Avater.  Before resorting  to the  caustic
bougie, the sensitiveness of the urethra must be diminished by occasional
blisters and  injections.   In prostatic gleet,  a blister repeated two  or
three times has cured the patient after all other  treatment  had failed.
The same in night discharges.  Quinine may be given subsequently.
                                                     Part xxix., p. 233.
  Nocturnal Seminal Emissions  treated by Digitaline.—Digitaline,  of
late much extolled and employed Avith success, according  to many practi-
tioners, in case>of nocturnal "seminal losses, has yielded, in the hands  of
Dr.  Laroche, a result which deserves to be mentioned.   A young  man, 
SPINA BIFIDA.
553
a^ed 18, presented himself some months ago to be treated for nocturnal
seminal losses.  The disease had come upon him about tAvo months pre-
viously.   For twenty days, the pollutions had not omitted a single night;
his strength was gone, the appetite had left him, and his sleep Avas troubled
by unpleasant dreams.  M. Laroche prescribed three granules of digitaline
(equal to a grain of the powder of the plant).  The  night folloAving the
administration of the medicine, the  pollutions intermitted  for the first
time.  In three Aveeks he was cured.                 Part  xxxi., p. 167.
  Bromide of Potassium— Use  of  in Spermatorrhoea.— Vide Art.
" Chordee."
                        SPINA BIFIDA.
  Spina Bifida.—Mr. HeAvitt makes the following remarks regarding the
treatment of spina-bifida:   The dissections of the cases of spina bifida
which have been published, and the preparations Avhich are to be found in
our museums, at once point out the rashness of attempting to remove
these tumors either by ligature or by the knife.  I do not consider  this
remark to be in the least invalidated by the success Avhich is said to have
attended the practice of M. Dubourg, who has  published  in the Gazette
Medicale  de Paris, 1841, a paper upon the radical cure of spina bifida.
M. Dubourg operated upon three cases:  in one, a ligature was  applied to
the tumor—the patient died two days after the operation ; in  the other
two, which terminated successfully, the sac Avas removed by the  knife, and
the lips of the Avound Avere brought together by hare-lip  pins and sutures.
The successful termination of these  two cases was, it must be  confessed,
very fortunate;  but this success ought  not, in my opinion, to lead  any
surgeon to adopt so rash a practice ; for, laying aside the question of  thus
opening the theca  vertebralis, there  still remains the  fact that,  iu the
majority of  cases, some nerves are connected with the sac, and that, when
the sac corresponds to the sacrum, the chord itself is generally  connected
with the tumor.  In one of M. Dubourg's cases the tumor was in the loins:
in the other it Avas in the loAver part of the cervical region.   The  sacs
were  examined after  the operation,  but no nerves were connected with
them.
  Several cases in Avhich the plan of treatment adopted by Sir A.  Cooper
has completely succeeded, have been placed  upon record by various authors ;
but in these  cases two points of importance have not, I think, been suffi-
ciently considered, and I Avould, therefore, lay down the folloAving general
rules:
  1st. The tumor ought never to be punctured along the mesial  line,
especially in  the  sacral region; for it  is generally  at this  part that the
chord and its nerves are connected Avith the sac.  The puncture is to be
made at one  side of the sac, and at the lowest part, so as to diminish the
risk of wounding any of the nervous branches.
  2d. The instrument ought to be  a grooved needle, or a small trocar; for
if a lancet is used there will be a greater risk of wounding some important
part contained in the cavity of the tumor.                Part  x.,p. 180.
  Spina Bifida  successfully  treated by Ligature  and  Puncture.—In  a 
554
SPINE.
case where the tumor is pedunculated, OAving to the  defect in the bony
canal being \-ery slight, and the neck of the tumor covered  Avith ordinary
integument, it is possible,  safely  and wdth success, to remove the pro-
jecting  membranous  bag by the application  of ligatures.   The ligature
must be gradually tightened so as not completely to constrict the part for
some days, and if great tension of the tumor  come on, it may be relieA-ed
by puncturing Avith a fine needle.  A case, the text of the abo\Te, is related
by Dr. Wilson, of Glasgow, in which a firm cicatrix, and consequent euro,
resulted.                                          Part xxxviii.,/). 144.
                            SPINE.
  Lateral Curvature of the Spine.— Wry-neck depending on  Contraction
of the Sterno-Mastoid Muscle.—[The object of this  paper of  Mr. Syme's
is to point out the kind of case in wdiich an operation for spinal curvature
may be useful, and to discourage  the  operations which  are  recommended
for all  other kinds  of spinal distortion.  We cannot  always be  sure
Avhether the bones or muscles are the first cause of lateral curvature.  The
muscles may be so weak as to alloAv the spine to bend, and the bones may
at the  same time be  so unhealthy that an  undue pressure may cause a
premature distortion.  All the operations Avhich have been  recommended
for these lateral curvatures are at least very  doubtful in  their efficacy, if
not positively injurious, and there  is  only one kind of  spinal distortion
which  it is proper to attempt to  remedy  by subcutaneous  incisions, and
that is spinal curvature depending upon wry-neck caused by contraction of
the sterno-mastoid, which muscle is liable to contraction both spasmodic
and permanent.  Although spasmodic  contraction does  not generally
affect the shape of the spine, the permanent contraction may  do so  very
materially.]
   Wry-neck,  like  club-foot, is  sometimes  congenital,  but  much more
frequently, like squinting, and the pes equinus, occurs during  childhood, in
connection Avith some inflammatory or feverish state of the  system.  It
depends upon a contracted state  of* the sterno-mastoid muscle,  Avdiich has
usually the feeling and  appearance of a  tense  cord stretching from the
clavicle to the ear.  The  head  is bent toAvard the  side  affected, the faco
being turned to the opposite direction.  Until the  introduction of subcu-
taneous incision, the treatment of this complaint ivas very defective, since
it consisted either in the use of mechanical support, wliich  did little, if
any good,  or in cutting across the  contracted muscle,  together with its
superjacent integuments, Avhich Avas a painful and  bloody operation,
leaving a large sore, sIoav to heal, and apt to renew  the  evil  during cica-
trization.  The  subcutaneous process requires merely  a puncture of the
skin, is not attended Avith pain or  bleeding, needs  no  dressing or  after-
treatment, and at  once affords the relief desired.
   There is still another condition of the complaint, of which I may mention
an instance that came  within my notice last summer, in the case of a boy
who Avas  brought from the  country on  account of lateral curvature.
Observing that his head inclined  to one side, I examined the sterno-mastoid,
and found it, not tense and rigid as I expected,  but  soft and yielding.
I perceived, however,  that AAdien an.attempt Avas made to raise the  head, 
BPINE.
555
the muscle resisted and became tense, and therefore concluded that it was
the seat of the evil.  Under this impression I proceeded to divide  it, and
succeeded in  doing so, though with more difficulty than  usual, from the
want of tension, for which  it was necessary  to  compensate by  stretching
the neck.  A good effect was immediately perceptible, and the folloAving
day the patient's back Avas comparatively straight, Avhich it  has since, I
am informed, become completely.                        m     _
  In concluding these remarks, it may be well to warn against  mistaking
for Avry-neck depending  upon musclar contraction, the distorted position
of  the head  which proceeds from caries between the occiput  and atlas.
The latter disease, like  the  former, usually occurs  in  young persons,
presents to a careless observer similar symptoms, and if confounded Avith
it, leads to treatment not only useless, but extremely injurious.  A young
gentleman had for tAvelve months used friction and  exercise under the
instruction of a  distinguished member of the  profession, wdio  supposed
that he labored under wry-neck from the contraction of the sterno-mastoid.
No  benefit having been  experienced, it  was thought that an  operation
might be serviceable, and with this view I Avas asked  to see  the patient.
He° presented all the characters and Avell marked symptoms of spondy
larthrocace, or caries at  the  occipito-vertebral articulation, in a stage  so
advanced, that there Avas nothing left for me but to explain the nature of the
case and predict the fatal termination, AAdiich soon afterward happened.
                                                     Part vii., j!?. 143.

   Treatment of Lateral Curvature of the Spine.—For many cases of this
affection Mr. Stafford recommends  latercd exercise; and for this purpose
he  has devised a machine, which consists Of a semicircular Avooden frame,
resembling the platform or rocker of a hobby-horse.  This frame  lies  on
its  convex surface, and  the  ends of a  rope, Avhich  passes through tAvo
pulleys  fixed in  the  ceiling,  at a distance from each other equal to the
length of  the rocking frame, are attached respectively to a  bar at each
end of the frame.  "The patient stands  upon this machine,  taking hold
of the rope by each  hand,  and then rocks himself  or herself backAvard
and forward  (from side  to side, rather), by  Avhich both  the  lumbar and
dorsal curve are acted on laterally.''  Mr. Stafford  has " hardly  knoAvn  an
instance Avhen it (lateral exercise) has not been of the greatest service."
But " lateral exercise, however, Avill  not ahvays recover a lateral  curvature.
The spine is sometimes so completely distorted  and the vertebral column
so entirely thrown out of the centre of gravity,  that the muscles have lost
their power.  They are so stretched on the convex, and so contracted  on
the concave side of the curve, that they cannot act.  In such  cases lateral
exercise Avill not alone he sufficient.   More must be done—the spine itself
must be elongated ; and the best  method  of  accomplishing this is  by
gravitation of the body.   " To effect this object I have invented a machine
bv which the patient can be raised up from the ground by the upper part
of the body, Avhile the lower part  hangs suspended.  Hence  the lower
part, by its OAvn gravitation, and by additional Aveights being hung round
the hips, gradually elongates  the spinal column,  until  it becomes nearly if
not quite,  for the time being, straight.  In this manner the muscles on the
concave side  are  lengthened, while those on the convex are  shortened,
and allowed to contract,  Avhereby they are both put into a more fiworable
position to pull back and retain the  vertebra* in their situation.   After  ihe 
556
SPINE.
machine has been used I usually recommend the lateral exercise, as 'the
muscles and ligaments are then in the best state to be strengthened.''
                                                       Part x,2). 161.

  Spinal Irritation.—Dr. Turek, of Vienna, says : " If Ave carefully analyze
the symptoms observed in well-marked  cases of spinal irritation,  Ave shall
find that they can all be elucidated on the supposition, that there  is a cen-
tric change so operating as to exalt the functions of the cerebro-spinal axis.
This change can  scarcely be considered  strictly structural, because  we
knoAV that  structural changes are marked by anassthesia, or paralysis; on
the other hand,  we knoAV that the circulation may be the medium  through
Avhich  the actual change is induced.   Opium  renders frogs tetanic,  as
strychnine acts on man and lower animals; the slightest touch of the sur-
face in poisoning by strychnine is  sufficient to  excite convulsions.  The
poison of the rabid dog so exalts the functions of the incident exciter and
reflex motor nerves of the respiratory and spinal ganglia, that a breath of
air on the face Avill excite  a convulsive gasp and general spasms.   In ' spinal
irritation '  the change is probably in the capillary circulation :  1, of the
cerebro-spinal axis; 2, of the ganglia  of the sympathetic, or ganglia of
the posterior spinal  nerves; and  3, of the fibrils of  the  nerves  them-
selves.   This  purely  functional  derangement  of  the nervous  system
has been  termed neuraemia  by Dr.  Laycock, one of  the recent English
writers on this subject, and the class of diseases to which it gives origin,
neurasmic.
   " If Ave Avere to attempt an  illustration of our remarks as to the diagnosis,
we could not take a more apt instance than that of abdominal tenderness.
Where it depends on spinal irritation, it will be found that the history of
the patient presents instances  of her  having previously suffered from
neuraminic affections.  The affectible  state of the cutaneous nerves of the
abdomen is never observed   to occur alone, the nerves of the abdominal
viscera  suffer  also.    The kidneys,  for example, secrete less  or more
urine than natural: if less, the deficiency amounts occasionally to complete
ischuria; if more, the urine  is pale and diabetic.  And so there is one or
other of the two opposite states of constipation and diarrhoea, but more
usually constipation, with spasm of the colon, giving rise to  colic.  In the
more aggravated cases, the motor nerves of the large intestines,  bladder,
abdominal parietes, and lower extremities are also affected; and tympa-
nites, vesical paralysis, constipation,  and paraplegia ensue.   The tender-
ness experienced is not simply tenderness on pressure, but it is a tender-
ness to the  slightest touch, and when there is soinal tenderness, for it is not
always present in these cases, the  tenderness  is of the same kind.  The
•abdominal  tenderness  of peritoneal  or visceral inflammation differs
altogether  from the preceding, both in its history and concomitant  symp-
toms.  It is rarely seen in neuraemic females, except when the case is quite
manifest, as for example,  when there is  chronic  structural disease of the
peritoneum or abdominal viscera, accompanied by inflammation,  or wdien
it appears in  parturient females  as  a symptom of metritis.  We believe
the neurasmic state is rarely coincident with structural disease wdthin the
abdomen, or terminates in it.
  " The  accompanying phenomena  differ widely ; in the tenderness from
peritoneal inflammation it is impossible not to be struck by the peculiarly
haggard expression  of countenance  of the patient;  in neurasmic tender 
SPINE.
557
ness, the expression is rather that  of peevishness and pain than of mortal
Buffering.  In  the  latter, there is  rarely or never, the grass-green vomit
observed in  peritonitis; the pulse, too, is fuller, rounder, and  larger, nor
are the knees of the  patient drawn up as in  peritoneal inflammation: in
the latter, tenderness on pressure, and not tenderness to the touch, is the
distinguishing characteristic.
  " The diagnosis of all neurasmic  affections, whether their seat lies in the
head, thorax,  or abdomen,  is, mutatis mutandis, precisely similar.  The
previous history of the patient, and the physiological  character  of the
symptoms  themselves,  will  almost  always  enable  the practitioner  to
decide.  Inflammatory diseases of the heart,  lungs, and brain, are pecu-
liarly liable to be confounded with neurasmic affections of those organs.
  '• With respect to the treatment  of cases of  cerebro-spinal irritation, we
would above all observe that it must be  constitutional.  They  principally
occur, idiopathically, in females whose parents  are gouty, and of the nerv-
ous temperament, or at least AAdio have themselves suffered from affections
of the nervous system.  Neurasmia of the cerebral and  spinal  ganglia is
not unfrequently seen in females, one  or  other of whose parents has been
insane.  This Ave believe is extremely usual, and the fact is of importance,
both in the diagnosis and treatment of the affections of all the viscera in
connection with the spinal cord.  While remedies suitable to the constitu-
tional peculiarities of the  case  are administered,  endermic medication, on
the principle of incident  excitor action, will be found of singular benefit;
even the metallic  neurines,  as arsenic, may be thus employed with safety
and efficiency.  We  would conclude this short sketch of the treatment, by
the observation that no plan Avhatever will be successful unless the hygienic
condition of the patient—namely, the condition as  to mental occupation,
sleep, diet, pure air,  sufficient light, and  exercise  be strictly attended to."
                                                        Part xl, p. 13.

  Rheumatic Caries of the Spine.—It is of great importance  in practice
to distinguish between strumous caries of the spine, and the   rheumatic
caries described by Sir B. Brodie, as the tAvo diseases are quite different
in their origin, progress and termination, and the treatment required is
also different in each case.   In the former, pain is frequently, though not
invariably met with; in the latter it is a constant symptom, whilst in para-
plegia  from disease  of the  chord alone, there is  entire absence of pain.
We may also  be assisted in our  diagnosis by the  moral history of our
patient, as Avell as  by the presence of a strumous or rheumatic diathesis.
But  in females Ave meet wdth  the most  anomalous symptoms, Avhich, if
there be no rheumatic diathesis, no increase of pain on pressure, the  pain
shifting from  one  part of the spine to the  other, may pretty safely be
referred to hysteria.
  With respect to  the patholgy of the disease,  Mr. Solly believes that it is
local; the mollities ossium rubra et frag His ; and renders this view pro-
bable by instancing the softening of the  bones of the pelvis occasionally
met with, Avhich is an entirely local disease, and from Avhich recovery not
unfrequently takes  place.  A medical  friend of Mr. Solly's, who had  suf-
fered  under this rheumatic  caries, broaches  the  very pertinent idea that
nervous exhaustion may be a cause  of diminished supply of phosphatic salts
to the bone,  seeing that the phosphorus is an essential constituent of the
brain, and, therefore, that, from the superior  importance of the latter to 
553
SPINE.
the system, the principal portion secreted would be supplied to it in pre-
ference to the bones.   On this supposition, Mr. S. Avould give phosphoric
acid freely, for he says that, even if it does not act specifically, it is a good
tonic, often agreeing  better  than  sulphuric  acid Avith  the system.   The
dose he Avould commence with is ten minims of the dilute acid,   lie men-
tions another important fact wdiich  should be strongly impressed on thj
mind  in the  treatment of all spinal  affections, namely, the necessity for
absolute quiet of the mental  system, on account of the  close connection
existent between the spinal cord and the brain.
  In treating this disease as  inflammatory, it is necessary to be extremely
careful in our antiphlogistic measures, on account of the general depression
of the vital powers attendant upon  inflammation of their structure. It will
scarcely ever bear active treatment, and the blood-letting should be almost
invariably merely local.                                 Part xl, p. 146.

  Alkaline Urine, consequent upon Injuries of the Spine.—Dr. SnoAv says
that the urine is alkaline, because the bladder, being paralyzed, cannot ex-
pel the  Avhole of its contents, and  a  little  is constantly retained.  Wash
thejbladder out with  Avarm Avater every day or  tAvo.      Part xv., p. 144.

   Spine—Lateral Curvature from Relaxed Ligaments.—Sir  B. Brodie
sa}rs that if the patient is 19  or 20, treatment is of no avail; it must  be
begun if possible at 13 or 14, and patiently continued.  Improve the gene-
ral health by country and seaside  residence,.open-air exercise, tonics, etc.
Strengthen the muscles of the back by climbing and other exercises; for
Avhich in delicate girls friction and shampooing for an hour  or tAvo daily
may be substituted.   And let the patient tie  dowm either a part or the
whole of the time that she is not engaged in exercise.
   In inveterate cases, as Avhere one scapula is three times as  far from the
spinous processes as the other, it is necessary to use artificial support. The
patient may  walk on  crutches, so high, that only the toe can be placed on
the ground,  or wear a machine to take the weight of the shoulders off the
spine, and to make pressure  on the projecting ribs.   Some'of the best are
those made by Bigg, of Leicester  Square, Laurie, of BartholomeAV Close,
and that knoAvn as Tavernier's lever belt.
   From Rickets.—The general treatment is  the.same as that for rickets
generally.  Instruments are worse than useless.         Part xv., p. 155.

   Angular Curvature of the Spine.—Dr. Pirrie recommends  the folloAving
as the most judicious plan of treatment to pursue : Any attempt to remove
the curvature would  be most injudicious.  Anchylosis is the only favorable
termination to be hoped for, and therefore the object aimed at in treatment
should  be to place the patient under the circumstances most likely to con-
duce to that result.  With that view it is indispensable, first, to keep the
patient in a recumbent position, so as to remove from the diseased parts
the pressure of the  superimposed Aveight, and to preserve  the parts as
much as possible in a  state of perfect quietude  in that position ;  and, sec-
ondly, to use all means, judicious and available  in the circumstances of the
case, for maintaining the general health. In some cases, local remedies are
highly  beneficial.
   One  particular advantage wdiich results from preserving the parts at
perfect rest in the horizontal position, is  that the removal of the  irritation
 caused by the superincumbent Aveight from the diseased parts, diminishes 
SPINE.
559
the danger of the formation of abscess, Avhich is a most unpromising occur-
rence, and must induce the gloomiest apprehensions as to the  ultimate re-
Bults.   One of the best means for fulfilling the  above indication is to place
the patient in the supine position on Earle's bed, Avhich, beside other ad-
vantages rendering it very convenient for this part  of the treatment, al-
lows the relative position of the trunk and limbs Avith regard to each other
to be slightly changed, without any risk of moving the diseased parts on
mcIi  other.  The slight change  thus  alloAved  lenders the  confinement to
the recumbent position much less irksome than it otherAvise would be.  As
an additional precaution for preserving the diseased parts from any move-
ment, it is in many instances advisable  to apply splints  on each  side of
the spine.  The splints in  such cases must suit the shape of the parts to
Avhich they are applied.
  Best  of the diseased parts, and the recumbent position, whether the
body be prone or supine, are  of the utmost importance from the very com-
mencement of the disease  until  a  cure  is effected by anchylosis.   When
it is believed that anchylosis has taken place, and the patient is alloAved to
resume  the erect attitude, it is a judicious precaution to  employ for some
time an apparatus such as that generally knoAvn by the name  of the spine
supporter, for removing the superincumbent weight.
   [The maintenance of the general health is another important indication,
but,  unfortunately, some of the best means for fulfilling it are incompatible
Avitli the essential points of judicious treatment. Iu individuals of a scrofu-
lous  diathesis, insufficient  clothing and food, or any causes acting perma-
nently or habitually, have doubtless an influence in exciting caseous depo-
sits in bone as Avell as in other textures.  Hence the necessity of a generous
digestible diet, pure air, and exposure to the  light of the  sun.  As to the
tonic remedies, that of iron is the most  useful, but the  class of medicines
more immediately called  for Dr. P. thinks are those which are calculated
to preserve a healthy condition  of the  digestive organs.  In cases Avhere
the disease  depends upon scrofulous  caries of the vertebras, or upon soft-
ening Avith absorption Avithout ulceration or caries, the surgeon should not
deplete, but advise the recumbent position, quietude, and the preservation
of the general health.]
   In scrofulous caries, benefit will often  be found to accrue from the early
and very cautious employment  of counter-irritation along Avith the treat-
ment here alluded to.  If the cuiwe arise from inflammation of the bodies
of the vertebras, of their investing membrane, or of the intervertebral car-
tilages, slight local depletion by leeching or cupping at the commencement
of the  disease, and  afteiwxard counter-irritation, are known  to be  highly
beneficial.   The repeated  application of small pieces of blister to each side
of the vertebral column  at the seat  of the disease  has been found av ell
suited for children, and caustic  issues for  adults.  Of the various  means
lor producing  counter-irritation, Mr. Pott  gave the preference to caustic
issues.   It is improper to produce a great discharge, which would tend to
weaken the patient, and  besides,  the long continuance of a  profuse dis-
charge and irritation might induce  hectic fever.  If abscesses form, the
issues should be discontinued.  Mr. Pott, whose valuable works contain
many cases of disease of the spine, attended Avith paralysis, successfully
treated by the application of  counter-irritants, ivas the  first  who pointed
out  to  the  profession the results of such practice, and many have since
followed it  with equal success.                         Part xv.,p. 161. 
560
SPINE.
  Distortions of the Spine.—Bransby Cooper says that we should endea-
vor to improve the nutrition of the bones, by the use of articles of diet con-
taining a good deal of phosphate of lime, as beef and mutton, giving at the
same time phosphoric acid, to render the salt of lime more soluble.  Bottled
porter will  also do  good, if it  do not relax the boAvels.  Support the
weight of the trunk by the simplest  possible mechanical means, and put
into gentle action  such muscles as  may counteract the unnatural direction
the bones haA'e acquired.  Let such exercise in the open air be taken as
causes the least fatigue, as riding in an open carriage, or sailing on the sea.
                                                     Part xvii., p. 125.

  Spine—Curvature of the.—Dr. Bishop says that when the spine becomes
curved from previous curvature of the  legs in Aveak children,  support
should be given by the use of leg irons, made Avith joints corresponding to
those of the hip, knee, and ankle.  Many object to the use of leg irons,
but their objections are refuted  both  by sound theory and  by the results
of practice.                                           Part xviii., p. 148.

  Functioned Affection  of the  Spine, liable  to be mistaken for Organic
Disease.—The affection alluded to Avas essentially a disease of the young,
being seen most frequently betAveen tAvehe and twenty years of age.  Dr.
Kennedy had, however, met with  it as early as nine years, and as late as
twenty-five.  He  had only seen it  in private practice, and it ivas  more
common amongst  males  than females, in the proportion of at least tAvo to
one.  It consisted in a  pain in the back, combined Avith  weakness, and
this was ahvays referred to the  lumbar region ;  at least he had never seen
it higher up.  This pain commenced gradually, and might or might not be
attended with  the feeling of Aveakness;  afad occasionally only the latter
Avas complained of.   On examining the spine, the patient was nearly always
able to refer the suffering to a particular part; but Dr. Kennedy had seen
cases where the feeling was more  diffused.  It was Avorthy of notice, that
a rough examination of the part might  be made—the spine might he
tivisted, or percussion  strongly used, and yet the patient would not com-
plain.  When  left to their own  feelings,  they invariably preferred the
recumbent  posture.  Walking ivas  much less  irksome than sitting, and
particularly Avhen they had no  support for  the back.   In addition to an
ordinary chair, they Avould use a cushion, so that it might press on the
spine where they complained ; and even when reclining at full length, they
often placed a cushion in the hollow of the  back, so as to cause direct
pressure.  Those  whose  business led  them  to stand or work at a desk,
seemed peculiarly liable to the affection.
   On the subject of treatment, Dr. Kennedy had nothing very definite to
offer.  A considerable variety of means had been used, both  local and
constitutional.  The former included local bleedings, dry cupping, blisters,
frictions, the cold douche,  and galvanism; and the latter, aperients, tonics,
change of air,  and relaxation from business.  Of these tAvo, the  latter had
in  his  experience proved by  much the most useful. He had also seen
benefit follow the application of small and repeated blisters, as also the use
 of a weak stream of galvanism, applied daily, or every second day, accord-
 ing to circumstances.  The patient, too, often got great relief from wear-
 ing a stiff belt.  Still the general measures were the most important.
                                                      Part xxiv., p. 64. 
SPLEEN.
561
  Spinal Exhaustion.—In remarking upon the beneficial effects of strych-
nine in cases of impaired spinal energy, Dr. Marshall Hall says:
  Such cases  occur from causes of nervous exhaustion, such as excessive
study, muscular effort, sexual indulgence, etc.; and in such cases strychnia
has appeared to me the appropriate and useful remedy.
  This agent acts distinctly on the spinal marrow.   In excess it induces
spasmodic affection.  It is therefore contra-indicated in cases of irritation
of this nervous centre of spasm.  Its appropriate use is in spinal exhaustion.
It constitutes one  of our best  tonics, improving the  general health, and
conducing to the recovery of strength and flesh.
  I have given it in minute doses thrice a day, in the  midst of meals, for
many months.  The following is  the formula which  I have adopted:  R
Strychnias acetatis, gr. j.; acidi acetosi,  mxx.; alcoholis, 3ij.; aquas destillatas,
3vj. M.
  Of this, ten  drops,  containing  one-fiftieth  part of  a grain,  may be
given thrice a day; but I have generally begun with five, and gone on to
fifteen.
  In tAvo cases only have I known  it to disagree.   It seemed to affect the
head.  In many the patient has improved in looks, as in general health and
Btrength, Avithout experiencing anything but good from it.
  I am giving the -strychnia a cautious trial in the epilepsy attended by
pallor, thinness, and  nervous  exhaustion; in the paraplegia the result of
sexual excesses, and in  which neither pain nor  spasm has occurred ; and in
the paralysis agitans.                                  Part xxvii., p. 58.
  Spinal. Curvature.—M. Piorry gives one ounce of  fine filings  of  fresh
bones daily, either in milk, or better still, in rice milk, which entirely dis-
guises all disagreeable taste.  At the same time the patient must be freely
exposed to fresh air and sunlight.                      Part xxxv., p. 15.
                           SPLEEN.
   Uses of the Spleen.—Dr. O'Beirne offers an ingenious theory respecting
the uses of the spleen, which is much the same as the one entertained by
Professor Hargrave.
  He arrives at the conclusion that this viscus in the healthy state is con-
tracted and  at rest, that it contains no more blood than is poured into its
cells, after becoming  venous, by its  nutritious  arteries ; and that it per-
forms no function but that of a reservoir for the relief of overloaded states
of the vena cava inferior and the whole portal system.  This is easily seen
to be probable when we remember that the venas cavas hepaticas enter the
vena cava  inferior just as it is passing through the tendinous opening of
the diaphragm, that their mouths are large and always wide open, having
no valves and consequently admitting of reflux, and that the powers which
propel the blood  of the portal system are very feeble compared with those
which propel  that in  the inferior cava, all which circumstances seem to
show that  the venas cavas hepaticas, as well as the rest of the portal system,
instead of offering resistance, are constructed not  only to facilitate but to
provide for determination toward them : the blood of course would easily
find its Avay along the splenic A'ein into  the spleen, and this organ would
thus act as an immense and most important reservoir to  reheve venous
    VOL. n.—36 
562
SPONGE  TEXTS--SPRAINS.
obstructions almost throughout the whole system, either immediately or
collaterally.                                            Part vi., p. 54.

  Engorgement of the Spleen— German Treatment of.—Dr. Schwabe haa
employed the following in engorgement of the liver and spleen:
  R Belladonna root, powdered, a  grain  and a half; muriate of quinine,
four grains ; poAvdered  rhubarb,  fifteen  grains ;  mix.   Divide into  ten
powders.   One to be  taken morning, noon, and night, in any convenient
vehicle.                                               Part viii., jo. 78.
                   SPONGE  TENTS.
  Improved Method of Making.—Mr. Coates says : The plan I adopt is to
select a piece of the  best  cupped sponge, of the required form and size,
and, after beating and washing it Avell to free it from any sand or gritty
particles it may contain, to squeeze it almost  to dryness in a tOAvel. A
piece of tape about ten inches long is then passed through the sponge at
about one-third from its base, making a shallow groove on each side from
the apertures  to  the  base  for the tape to rest  in, both ends of which are
tied together for the withdraAval of the tent  Avhen  necessary.  Having
fixed one end of a piece of whipcord (say two or three yards  long) to
some firm object,  I  commence  Avinding the  other  end on the sponge
gradually, from  apex to base,  as  firmly as possible.  The tent is then
well dried before the fire, or in an  oven, previous  to the  removal of
the  cord.  When it  is thoroughly dry, a small hole about half an inch
deep should be made  in the base, with a joiner's pricker or a heated Avire,
for  the introduction  by the director.  The whole surface of the tent is
then slightly coated  by dipping it into equal parts  of melted lard  and
beesAvax.  The expansion of the tents is gradual, and never requires the
aid  of " tepid water  injections," the  moisture of the surrounding parts
being quite sufficient.
   No possible good can  accrue from steeping  the sponge in a solution of
gum, which  not only renders  the  operation most disagreeable and un-
cleanly, but also prevents the close  contraction by  the retention  of the
glutinous particles in  the interstices of the sponge.     Part xxii., p. 306.
                          SPRAINS.
  Application of Cold to Sprains.—Many different opinions have been
 mtertained  as to  whether recent sprains should be treated by warm or
cold applications.  We find that Mr. Cock, of Guy's Hospital, entertains,
as the result of  his large experience, a very strong preference for cold.
He states that the consequences of a sprain may be Aery much limited,
both in duration and severity, by the early and efficient employment of
cold.  It should  either be done by iced water, or by irrigation.  Mr. Cock
is accustomed to quote  by way  of illustration of the powers  of cold, the
certainty with which the application  of ice will  induce the  absorption of
effused blood in  an  ordinary ecchymosis, a poAver which, by  the way, in
certain cases of " black eye " may be turned to good account.
                                                   Part xxxii., p. 138. 
BQUILL—STAMMERING.
563
                           SQUILL.
  Squill.—According to the "Northern Journal of Medicine," squill obvi-
ates some of the ill effects of opium.  If an aperient be added besides, the
good effects of opium  may often be obtained when it would otherwise be
inadmissible.
  R Pulv. opii; pul. scilke, aa. gr. iij.; aloes; conservas rosae, aa. gr. ix.
Fiat mass, divid. in pil. vj. asquales.   Sign, opiate pills, two at bed-time.
  ^Ve have  remarked Aery beneficial results in cases of chronic  ill health
with tendency to dryness of the skin, from the continued use of such com-
binations as  the following.   Besides its diaphoretic effects,  it should he
regarded as alterative.
  R Besinas  guaiaci; extract, gentiansc, aa. 5j-; pulv. ipecacuanhse, gr. xv.
Ft.  mass,  divid. in pil. xxx. aequales.   Sign,  tonic alterative  pills, two
twice a day.
  Or, if an aperient be required, aloes may be substituted for the gentian,
and then the combination Avill somewhat resemble the pulv. aloes comp. of
the London Pharmacopoeia.                             Part x.,p. 181.
                      STAMMERING.
  M. ColombaPs  Treatment.—M.  Colombat has recommended  a most        i
judicious method of treatment, which if rightly pursued is always sure to        f
effect a cure.  It consists in the adoption of the following three means:
1. Giving the tongue such a position that its apex is directed upward an<{        |
backward.  2. Taking in a deep breath at the commencement of each phrase,        I
and repeating this more or less  frequently.  3. Marking the time in speak-
ing by the  movements of the thumb upon the forefinger.    Part ii., p. 19
   Operative  Treatment.—Various operations have been proposed for the
cure of stuttering, Avhich may be classed as follows :
  1st. Simple transverse  division of the muscular structure of the base of
the tongue, performed by M. Dieffenbach by tAvo separate methods.
  2d. Transverse division,  Avith excision of* a portion of the base of the
tongue, performed by the same  surgeon.
  3d. Mr. Lucas' method, consisting of  excision of a triangular portion of
the bodies  of the genio-glossi muscles.
  4th. A simple incision in the  bodies of the genio-glossi muscles,  common
to MM. Amussat,  Phillips,  and Velpeau, though performed in a  different
manner by each.
  5th. Division of the attachment of the tendons of the genio-glosso mus-
cles (and occasionally of the hyo-glossi muscles also) to the loAver jaAV,
performed, in different Avays, by MM. Baudens and Bonnet.
  6th. Simple division of the mucous and subjacent tissue of the  floor of
the mouth, occasionally found sufficient, by M. Amussat.
  7th. Excision  of a portion of the apex of the  tongue, performed in one
case by M. Velpeau.
  8th. Mr. Yearsley's method cf snipping off a portion of the uvula.
                                                       Part iii., p. 74.
  Auxiliary  Treatment.—Dr. Abercrombie has observed a few facts which 
564
STERILITY.
may lead to a material improvement in the treatment of stammering:
Stammerers never stammer in singing; nor  when  the voice is elevated to
a particular pitch, as during  conversation in a crowd or in a carriage on a
rough road ; on the contrary, they stammer when endeavoring to speak
when the lungs have become emptied of air or nearly so.  Among other
indications of treatment therefore, the patient  should  accustom  himself
never to speak except with a full and continuous current of air proceeding
outward from the lungs.   The affection is  not  perceived to be owing to
any defect in the organs of speech, and if he  would speak in that tone of
voice as if  he were calling to a person at a distance, or in a tone resem-
bling singing or chanting,  he would probably find himself considerably
improved: and for this purpose, Dr. Abercrombie recommends that the
person should read aloud several times a day from an author whose style
is someAvhat declamatory.  " In doing so he should be made to read in a
high-pitched tone, and  to  stop frequently and take a full breath, so as to
have the voice thrown out with a force beyond Avhat is required for ordi-
nary reading or ordinary conversation.  With this view, it is necessary to
make him stop and take a full inspiration much more frequently than would
be  required by any other person.  In particular whenever he feels the
tendency to hesitate at  a word, he is to be taught to stop instantly, take a
full breath, and then try it again."                       Part vii., p. 78.
                        STERILITY.
   Carbonic Acid  Gas, as a  Counter-irritant.—In a discussion in  the
London Medical Society respecting the nature and value of counter-irri-
tation, Dr. James Johnson alluded to carbonic acid gas, applied either as a
local or a general external remedy. In the first mode of its application, the
gas was admitted into the vessel from  beneath, and slowly ascended until
it filled the bath.  The patient's body Avas entirely immersed, his head
being protected by a covering fitting close  to the  upper part of the bath,
admitting the  head only through an aperture in its  centre.  When the gas
was locally applied, it was conducted  in tubes of  various diameters,  and
with such variety of force  as  the case might require.   He had tried the
remedy both locally and generally; it  acted in both cases as a powerful
stimulant.  Its first action Avas the production of a momentary sensation oi
cold which was followed by a feeling of heat,  which when the gas  was
applied locally, was  sometimes so intense  as to  be scarcely  tolerable.
Perspiration succeeded to these phenomena.  The application of carbonic
acid in this manner was  stated to be of great benefit in a variety of chronic
diseases, in  which  there was no  trace of  inflammatory action.  It  was
beneficial  in tic-doloureux, atonic gout, and rheumatism, and similar dis-
eases.  If the reports wrere to  be credited, it also exerted a remarkably
poAverful infl lence upon the reproductive organs.   Females who for years
had sighed in vain for  progeny, became fertile  in a very short space ot
time after this gas had been applied in douches to the uterus, by means of
a pipe introduced into contact Avith that organ into the vagina.  Cases in
which this beneficial result had  followed its use Avere so numerous,  that
the subject merited consideration.
  Dr. Clutterbuck relates a case " of great  irritation and some prolapsus 
STERILITY.
565
of the uterus" in wdiich Dr. Rossi, of Turin, used carbonic acid gas with
the greatest advantage.  There  was " no organic disease of the uterus,
but a preternatural irritation  of the genital organs altogether, and the
general health Avas suffering from sympathy Avith the local disease."  It
was treated by the  repeated  local  application  of  carbonic achl gas to
the uterus,  in the  manner described by Dr. Johnson.  The quantity of
gas applied. Avas thirty cubic  inches on  each occasion.   Nine  hundred
and thirty  cubic  inches were  applied altogether.   The local disease was
removed, both the irritation and the prolapsus altogether ceasing, and
the health became restored.                              Part ii., p. 64.

  Sterility—Proposed Remedy  for.—Dr. Marshall Hall  throws  out  a
suggestion on the treatment of sterility, Avhich may be tried under  some
circumstances.  There is an extraordinary sympathy between the mammas
and the uterus, so that the functional condition  of  the  former influences
that of the latter.   " This  sympathy is partly nervous  in its character,
partly vascular.  As  a reflex action the uterus is made to contract after
parturition,  by applying the newly-born  infant to the mammas.   As a
vascular sympathy, uterine hemorrhage and leucorrhoea occur  from undue
lactation."   Many cases of sterility, of course, arise from organic defect,
but Avhen the cause is of a functional and less permanent nature, it becomes
a question Avhether or not the uterus can be stimulated so as to assume a
healthy functional action in the Avay  suggested by Dr. M. Hall, who says :
My suggestion, then, is, that when the mamma is excited at the return of
the catamenial period, a robust  infant  be repeatedly and perseveringly
applied, in  the hope  that the secretion of milk may be excited, and that
the uterine blood may be diverted from  the uterus  and directed into the
mammary vessels, and that a change in the uterine system and a proneness
to conception may be induced.   I would propose that the  patient should
sleep, for one Aveek  before, and during each  catamenial period, with an
infant on her bosom.                                   Part ix., p. 202.

  Sterility.—Dr.  Oldham  believes  that  the greatest discrimination  is
required in the use of mechanical treatment; both because it is not easy to
distinguish cases in wdiich there is really mechanical obstruction, from per-
fectly natural conditions, and also  because the operations for the relief of
6uch obstructions are  not Avithout danger.  Strictures of the os or cervix
sufficient to preArent impregnation are very rarely met AAdth;  and the at-
tempt at  mechanical  dilatation has been followed by a fatal result.   The
treatment of malposition of the uterus supposed to  be the  cause of
sterility, has also caused death.   Lastly,  obstructions in the fallopian tubes
are probably never, Avhen they do  occur, of a kind which could  be  over-
come by catheterism ; and as this operation Avill be always extremely diffi-
cult, and never Avithout danger, its performance  appears to be altogether
indefensible.                                          Part xx., p. 211.

   Japanese Remedy for Sterility.—Dr. E. Williams  has described a Ja-
panese remedy for sterility. The  tree is one of the order of Ternstromaceas
of Jessieu,  Avith  leaves someAvhat larger than those of the congou tea,
emitting  an odor Avhen bruised  resembling pulegium and sabina.   The
mode of preparation  is to take a  quantity of the leaves, macerate them in
as much rice spirit as will just moisten them, for  six hours ;*then express,
and give  about a teaspoonful every hour, and  two or  three doses will 
566
3T0MACH.
invariably bring on the menstrual secretion, Avhich can be maintained by a
dose or two daily, for any length of time.             Part xxii., p. 320.
  Sterility.—In those cases  Avhich cannot be accounted for by any disease,
but which seem to  depend on defective ovarian action, apply Professor
Recamier's galvanic poultices.                        Part xxiv., p. 348.
  Sterility from Dysmenorrhcea, etc.—When the cervix uteri is very much
contracted, says Dr. I. B. Brown, introduce through  the speculum a lone
stilette into the uterus, then over this  pass  the smallest sized  elastic tube,
and allow it to remain for a short time.  Gradually pass on from this to
larger tubes, until Simpson's dilators can be  introduced.  The best time
for introducing the instrument is immediately after the cessation  of the
catamenia.  Diseases of the  rectum will also produce sterility.  The rectum
and uterus are both supplied by vessels and nerves from the same source,
and  therefore  disease  in the  one organ  must  interfere with the other.
When a female is suffering from bleeding hemorrhoids, during the mens-
trual  period a  diminished  supply of  blood is sent to the uterus,  and its
mucous membrane will not undergo those normal changes necessary for the
reception of the impregnated ovum.  The same observations apply  to pro-
lapsus ani with loss of blood at every defecation :  when  this is  the cause,
apply twro or  three ligatures to the  prolapsed  mucous membrane, and
return them Avithin the sphincter.  Give opiates to keep the boAvels quiet,
and give good diet.  After the usual operation for fissure of the rectum,
you  must give opium regularly and  freely  to relieve  pain and  secure
perfect rest for the bowel.  After a week or ten days they may be  moved
by injections.                                       Part xxxv., p. 251.

                               ---•-•-•—
                          STOMACH.
  Atony of the Stomach.—Dr. Dehreyne believes this disease is not of
unfrequent  occurrence, especially  in  women  affected with leucorrhosa,
chlorosis, anaemia, etc.
  One important  characteristic is, that the  distress of the stomach is
usually increased  by the use of  vegetable  and farinaceous  food,  and
relieved, more or less, by a generous diet of animal meat, Avine, etc.
  Neither opiates nor antiphlogistics  are suited to such a case;  tonics
alone constitute the  most approved  treatment, such as the use of some
mild ferruginous preparation, quinine, or of some other vegetable bitter,
as gentian, calumba,  aloes, etc., in the form either of infusion or wine.
  In a variety of gastro-atony, characterized by frequent returns of vomit-
ing, from 5 to 10 grains of powdered  calumba, recommended 3 or 4 tunes
a day.
  If the epigastric uneasiness should  be troublesome, advised to combine
with the calumba a mild opiate.                            Part i, p. 23.

  Nitrate of Silver in Gastric Affections.—[A good case of this kind is
related by Dr. Dick, in which this remedy Avas useful.]
  A young  gentleman had stomach ailments almost from infancy.  The
most distressing symptom, hoAvever, was eructation of an acid and burning
fluid and gas from  the  stomach,  Avhich often commenced even  during 
STOMACH.
567
meals, and continued for  hours afterward.  Yet his bowels were regular,
urine natural, and the functions of the skin normal, Avith sound sleep—and
no apparent disorder or disease of any other organ in the body.
  The case of this young  gentleman appearing to me to betray a union of
morbid secretions and morbid sensibility, I commenced the treatment with
small doses of blue pill  and ipecacuanha, from which  no immediate benefit
appeared to result.  I  then put him  upon a month's course of nitrate of
silver, with a view to allay the morbid sensibility of the mucous membrane.
The effect in this, as in  almost every other case in Avhtih  I have tried it,
was surprising and gratifying  in the extreme.  This  patient, in common
with many others  who had taken  this medicine, Avannly expressed the
great relief from  irritation,  flatulence, cutaneous  dullness, discomfort,
which it promptly  procured.                             Part v., p. 61.

   Chronic Diseases of the Stomach—Atony of the Stomach.—This kind
of gastric affection, says Dr. Strange, so common among  the  crowded
population of manufacturing toAvns, presents the followdng symptoms and
physical signs :  The tongue is large, flat and flabby, filling the whole width
of the mouth, its surface  almost uniformly pale and without scurf, present-
ing the  appearance  of  boiled veal or  muscular fibre  which has been
macerated  in cold water; the face pale and flaccid, corresponding re-
markably with  the tongue ; the epigastrium distended,  not painful, but
uneasy on  pressure; the abdomen in women often pendulous and flabby,
sometimes  hard and tender;  the pulse  is generally unaffected, or it is
weak and small.
   Patients affected Avith this form of disease  complain that they have no
appetite, or that they crave for things which are to them indigestible.
   There is not  often very acute pain in the region of the stomach or along
any part of the digestive canal; but sometimes to the sense of fullness
succeeds a constriction about  the  loAver  part  of the epigastrium, accom-
panied  by eructations of gas sometimes  mixed Avith acidity.  There is
flatulence, A\dth irregularity of the bowels, a general state of costiveness
being  occasionally interrupted by a  painful diarrhoea.  A feeling of con-
striction, with pain extending through the back, coming on two or three
hours after meals, may be owdng, as is supposed by Dr.  Abercrbmbie, to
irritation created in the duodenum by the passage of insufficiently digested
food into the bowel; and I have remarked that  this pain very frequently
coexists with a relaxed state of the boAvels and painful emotions.   On the
whole, however, a feeling of acute  pain coming on periodically some hours
after a meal is much  more frequently met Avith in another well-marked
form of gastric disorder, viz., where  the tongue exhibits a degree of red-
ness round the edges, Avith furred  centre; and  wdiere there is pain  on
pressing the epigastrium, denoting an irritable state of  the mucous and
muscular coats  of the stomach.
   With the view of reducing the irritation, if any, and of gently stimulat-
ing the stomach, I have for a length of  time  mainly depended upon one
substance, viz.,  the oxide of bismuth, which has also been highly extolled
by Dr. Paris and other authorities.  When cases to which it is applicable
are selected, I believe that not one in ten cases Avill occur in which much
benetit will not be procured from its use.   The manner in which I prescribe
is as follows:
  R Bismuth, trisnitrat., 3j«;  morphias muriat.,  gr.  ss.-j.; acacias mucib, 
568
STOMACH.
|ij.; sirup, zingiber.; tinct. cardam. com., aa. 3tij.'  infus.  cascaiill., fv.
M.—§j. ter die.
  This formula retains its appearance for a length of time;  the mucilage
suspending the bismuth in such a manner as  to give  to  the mixture the
consistence  of cream.  In pyrosis, taken  at the period of attack, and in
that form of gastrodynia previously described, taken half  an hour  after
meals, it immediately assuages the pain and promotes digestion.  In those
cases particularly  wdjere  there  is  considerable  derangement  of the
duodenum, this medicine acts like a charm.
  All kinds of fermented and spirituous liquors, as they  debilitate as ivell
as stimulate, are injurious  in this affection.  Purgatives must not be re-
sorted to  for the relief of the costiveness which so often  accompanies this
form of dyspepsia  as by over-exciting they afterward  debilitate the intes-
tines. Gentle laxatives with tonics, such as small doses of aloes or colocynth
with sulphate of iron, as recommended by Dr. Abercrombie, or with sul-
phate of zinc, are the most beneficial.
  Atonic Morbid Irritability of the Stomach.—I look upon this second
form of dyspepsia as the natural consequence of a long continuance of the
former atonic variety.
  The symptoms  indicating this affection differ considerably from  those
characteristic of mere want of tone.   The tongue is generally slightly red
at the tip or  round the edges ; there is a thin whitish fur all over the
centre which  cannot be scraped off; a sense of heat in the throat, oesoph-
agus, and sometimes in the stomach.  The  sleep  is often disturbed, and
muscular efforts are weakened.  The appetite is always  uncertain in this
affection, folloAving the remissions and exacerbations of the attacks.  There
is a general desire for savory and solid food, although this  almost invari-
ably aggravates the symptoms.  There is pain in the stomach during the
whole time the food remains there, which is sometimes relieved by vomiting
coming on from  half an  hour to  three  or four  hours  after  a  meal.
Substances in small quantities are seldom returned.  In some cases there
is a sense of Aveight only at the stomach until about tAvo hours after taking
food, when a sense of pain and constriction ensues, which lasts frequently
until relieved by a relaxed but unsatisfactory motion.  In these cases  it
has been no doubt  rightly supposed that  the  irritable stomach pushes
onward the partially digested food into the duodenum, whence it is either
forced back by vomiting, or passes out of the boAvels, after  giving pain  in
its  whole  course, in a partially relaxed and often  scalding motion.  This
morbid irritation of the stomach is sometimes accompanied by a degree of
pyrosis, but not by any means in a constant  manner.  The  regurgitations
are more  frequently composed  of the mucus of the  stomach mixed with
acidity, gas, and the aroma of  the food.
  When  the  disorder has not arrived at any very troublesome height a
similar treatment to that recommended for atony of the stomach, will be
found to  answer very well.  In more  exaggerated  cases,  however, and
especially if there be much pain  and heat at the epigastrium, it will he
well to begin  with  moderate counter-irritation, as  a  blister, two  or three
mustard poultices, or the ung. anttin. tart.  All drastic purgatives, particu-
larly mercurial ones, should bo  avoided, as they  increase  the irritation.
The oxide  of bismuth, ivith infusion of rhubarb  and magnesia, will  be
found to answer the  double purpose of maintaining  a steady action upon
the bowels, and of correcting the acidity and heat nf the stomach. 
STOMACH.
569
   The followdng is a good formula:
   R Bismuth trisnitrat,, 3j.; magnes. carb., 3ss.; tinct.  hyoscyami, 3ij.;
    Infus. rhei, §viii. M.
   One ounce of this mixture to be taken three or four times a day.  After
the more acute symptoms have been reduced, the mixture of bismuth Avith
gentle stimulants and tonics, as prescribed for the atonic state, Avill ansAver
well; and, finally, we may have recourse to quinine, iron, zinc,  and other
direct tonics.
   Should there be much acidity with regurgitation some time after taking
food,  accompanied with a costive and unsatisfactory state of the bowels,
the following pill, taken regularly after the principal meal,  will be found
very useful:
    R Aloes in pulv. gr. iss.; ferri  sulph., gr. ij.; sapon. dur., gr. vj. M.—
      Div. in pil. ij. simul sumend.
   The soap is a great addition to the aloes and iron pill in common use, as
it unites chemically with the free acid of the stomach.     Part x., p.  68.

   Vegetable  Acids in Acidity of the Stomach.—Dr. Tracy,  of Ohio,
makes the fodowing remarks on vegetable acids as  correctives of acidity
of the stomach: During the summer of 1841, I AAras myself the  subject of
repeated and severe attacks of catarrhal   inflammation  of the eyelids,
which uniformly yielded to the usual treatment in the course of from three
to six days.   I observed that  they ahvays  succeeded to irregularities of
diet and regimen, or to anxiety of mind, and were accompanied by acidity
of stomach.  This I attempted  to correct by the  early and free use of
soda, but in vain ; it had but a very slight and temporary effect.  As these
attacks became more  and  more frequent, I observed that they Avere pre-
ceded by a  sense of fullness  and oppression in the prascordia.   I had  for
months abstained from the use of acids, under the impression  that they
were  not suited  to my state of health; but having received no benefit
from  soda, I was induced to take a glass of lemonade, at the  first com-
mencement of the attack, and almost instantly I experienced very copious
eructations of gas, together wdth  much alleviation of  my feelings of dis-
tress.   The remedy was again and repeated, and the threatened ophthalmic
attack effectually prevented.  I have since resorted to my bottle of lemon
sirup, Avhenever threatened Avith a recurrence of the complaint, and uni-
formly with  complete  success; all the  symptoms being removed ill the
course of a short time.  I have from the time above mentioned to the pre-
sent (June, 1843), made a free use of acids, and  have not experienced a
single recurrence of ophthalmia, and very few, indeed, of pyrosis.
   I have found vegetable acids uniformly and entirely successful in remov-
ing the disposition to attacks of acidity of stomach, in persons who, dur-
ing the intervals of such attacks, were free  from all such symptoms; and
my impression is, that  in all such cases they can be relied upon Avith more
confidence than any other remedy.  In cases of acidity, arising from preg-
nancy, I have found the sub-acid fruits of great service, Avhile those that
were tart could not be  borne, and  mineral acids Avere decidedly injurious,
and where alkalies or absorbents were of little or no avail.
                                                       Part x., p.  13.
   Use of Acids in some Affections  of the  Stomuch.—It seems to be a
contradiction to cure acidity of the stomach by the administration of vege-
table acids;  but such seems to be the case in some peculiar  and obstinate 
570
STOMACH.
affections  of this organ.  Dr.  Chapman, of  Philadelphia, refers to the
same thing in his late work on the diseases of  the thoracic  and abdominal
viscera,  lie has found  occasionally the most  discrepant sorts of nourish-
ment agreeing with dyspeptics.  One patient  Avas cured of his dyspepsia
by drinking sour beer, another by living exclusively on raw turnips; other
cases  are related in  Avhich sour pie-cherries and vinegar were used.  Dr.
Tracy states that the vegetable acids will be successful when  the  alkalies
have failed, and for general use he recommends lemonade or lemon-juice.
                                                        Part xl,p. 61.
  Digestion of the Mucous Membrane by the  Gastric Juice following
simple Ulcer of the Stomach.—In that gastric disorder which often occurs
in the advanced stages  of phthisis, says Professor Budd, and is attended
with increased secretion of the gastric juice,  such  as may  produce ulcera-
tion, give liq. potassa?, fifteen  drops, or bicarb, potassa?, a scruple, thrice
a day, or giAe infusion of logwood, fj. thrice a day, which will also arrest
diarrhoea.                                            Part xxi, p. 149.
  Simple  Ulceration of the Stomach  going on  to  Perforation.—[The
symptoms of this disease, in its early stage, are not yet defined.   Dr.  Sey-
mour has found, that before the fatal seizure,  the patient has long felt pain
after  eating, unaccompanied av ith symptoms  of acidity;  and aggravated
sometimes by one kind of food,,and sometimes by  another, but most com-
monly by solid meat.  As to  treatment, Dr. S. observes]:
  In  the treatment  of such cases, when there is real reason to suspect  so
serious a  disease, soothing remedies seem to be indicated.   The bowels
should be carefully kept open by enemata, so as to prevent any acrid medi-
cine coming in contact with the ulcer ; and  occasional blisters to the epi-
gastrium may be expected to be useful.  Where the  existence of the com-
plaint is more clear, from the preceding pain and the  subsequent vomiting
of blood, a case Avhich  I have frequently seen, I know of no remedy  so
uniformly successful as the oil of turpentine taken internally.
                                                      Part xvi., p. 150.
   Observations on Disorder of the Stomach.—Dr. Seymour observes, that
pain dependent on excess of acid in the stomach, often becomes attended
Avith  great irritability of the heart and pulsation in  the epigastrium, so
that the  patient is led to believe that he is  suffering from disease of the
heart, or aneurism of the aorta.   These alarming symptoms are cured  by
the regular administration of antacid medicines wdth  sedatives, or alkalies
with rhubarb and calumba root.   His formula is rhubarb, six grains;  bi-
carbonate of soda, fifteen grains ; calumba poAvder, three grains; compound
cinnamon powder, two  grains; to be taken in a glass of water, before din-
ner or at bed-time, and continued regularly during  at least a fortnight.
Pain  without heartburn or vomiting, is most likely to be the result of ir-
regular contraction of the stomach, in which case he relies on  bismuth
with magnesia, in the following  formula—trisnitrate  of bismuth, calcined
magnesia, compound tragacanth poAvder, of each a scruple: rub together,
and add Avater an ounce and a half; sirup half a drachm :  this draught  to
be taken every four hours.  He says  bismuth is highly useful in all painful
spasm arising from disorder in the intestinal canal, and states from his owrn
knowledge that it was used Avith much effect at Moscow in the  spasms of
the Asiatic cholera in 1831.
   When the pain of the stomach resists this treatment, he  trusts to a grain 
STOMACH.
571
of opium administered thrice  daily; the bowels  being in the meantime
kept open  by injections.   In  simple pyrosis  he employs the compound
powder of  kino (Ph. Lond.)—namely, kino and  opium Avith cinnamon, in
doses of five grains a day, the bowels being kept free by aloes, rhubarb, or
enemata.  A blister over  the  epigastrium is sometimes  useful at first.
When  under the idea that the liver is diseased, " calomel and  purgatives
are prescribed, such cases become greatly aggravated, both as to time and
severity."  Pyrosis is often, however, the forerunner of an incurable dis-
ease—namely, the fungoid disease of the stomach.       Part xxi, p. 150.
  Sarcina  Ventriculi.—In a case of this  disease under the care of Mr.
Amyot, attended by frequent and most violent acid vomiting, after alkalies,
hydrocyanic acid, creasote, nitrate of silver, and opium,  had been tried,
without permanent  effect, §ss. of the concentrated essence of calumba, to
the 5viij. of water, and given every two or three  hours during the attack,
gave the most decided relief.                           Part xxvi, p. 87.
  Sarcina  Ventriculi.—One indication  necessary to  be  fulfilled  in the
treatment of this disease is to destroy the fungus by a regular and  syste- %
matic exhibition of alkalies, thereby removing the acidity so essential to its
formation and development, and then to employ some remedy capable of
destroying its groAvth.  This  may be  done, says Dr. Hassall, by giving
bicarbonate of potash and infusion of quassia, and afterward the  sulphite
of soda. The operation of this salt seems  to be that the sulphite being
decomposed in the stomach by the acids therein  generated, sulphurous
acid gas is  liberated, the destructive  effects of Avhich upon parasitic forma-
tions like the sarcina is  Avell known.                   Part xxvii., p. 83.

  Sarcina}  Ventricular.—In a case  of this disease, of many years' stand-
ing, under  the care of  Dr. Neale, University Col. Hospital, the following
was the successful  treatment:  At first  the diet was  the  same as  that
ordered commonly  in diabetes mellitus.   Three grains of sesquicarbonate
of ammonia Avere  given three times a  day in one ounce of infusion of
quassia, ivith one to two drachms of sulph. sublim.,  to open the bowels.
Afterward  the same diet Avas  continued,  but   the medicine was  sodas
hyposulph., 3vj.; infus. quassiae, gxij.-gss.  ter die.   The only variation
made Avas,  that precipitated sulphur  Avas preferred to sublimed sulphur;
and one ounce of cod-liver oil was given three times a day.
                                                   Part xxviii., p. 109.
  Sarcinai  Ventricular.—This  diseasT  is  easily  recognized,  says  Prof.
Budd, by the vomited matter fermenting, both the foam on its surface and
the sediment thrown down containing abundance of sarcinas  and torulas.
The fermentative process may be checked by giving half a minim of crea-
sote in a pill at each meal.   Common salt has the same effect.  Bisulphite
of soda from the  liberation of sulphurous acid,  has the same power.  It
may be given in  doses of 3ss. to  3j. in water, two  or three times  a
day.
  In chronic cases of the disorder, the drain from the coats of the stomach,
and the frequent throAving up of part of its contents,  causes constipation;
and it is requisite to obviate this condition, since  any undue accumulation
in the  boAvels^ aggravates  the stomach-disorder.   The best aperients are
probably aloetic or  colocynth pills.
  When the disorder is severe, and the  patient reduced in flesh, opiates, 
572
STOMACH.
timely administered, are of much service in lessening the uneasiness at the
stomach, and promoting sleep.
  It now and then happens, that the disorder coexists w ith  chronic ulcer
of the stomach, and that eating solid  food  causes pain in the stomach,
Avhich is  different from the uneasiness that results from  distention of the
stomach, and pain  also  in  the corresponding part of the back.  In such
cases, as  in ordinary cases of simple ulcer, the diet should be of the least
irritating kind.
  By the various means  enumerated, the disorder  may  be greatly miti-
gated, the strength of the patient kept up, and his life  prolonged ; which
Is  as much as can be promised for any disorder wdiich originates, as this
usually does, in irremovable organic changes.          Part xxix., p. 108.
  Epigastric  Neuralgia.—[On the slightest  pressure in the  epigastric
region great pain is felt in these cases—not occupying a space above  the
size of a five-shilling piece.  The following illustrates  this kind  of case,
which might  easily be  mistaken by the young practitioner.   Dr. Lees
proceeds:]
  He says that he never experiences pain in  the stomach, but that, after
eating, he has been  often  obliged  to  lift his  shirt  from  contact with the
epigastrium, as the tenderness caused by even its apposition Avas intoler-
able, although  it Avas not aggravated  by increasing the pressure.   The
state of his general health and appetite is good ; functions natural; tongue
clean ; boA\rels regular ; no thirst, nausea, or vomiting.  He does not suffer
from flatulence, has no  headache, but is very  Ioav spirited.  The  circula-
tion is languid, pulse 56 ;  heart's action feeble, but regular, and without any
murmur; the abdominal muscles are in a state of constant  tension, hard
and  rigid; there is no evidence of any tumor,  nor abnormal pulsation in
the epigastric region ; neither pain nor tenderness in the back, nor in  the
course of the intercostal nerves.  His easiest  posture is on his left side,
with the right  leg drawn  up.  When he lies on his back Avith the right
leg extended, the  spine is  arched,  so that the hand can be passed freely
under it, but it becomes quite flat and in contact with the bed, on the leg
being flexed.  The urine is of natural  appearance, sp. gr., and reaction;
no  visible  sediment, but  on  microscopic examination  there  are  seen
numerous very minute  crystals  of oxalate  of lime aggregated in  long
masses.
  He could not assign any cause for his complaint, except that he has been
constantly employed in  a  very dusty meal-room, but  he  has neither
suffered from cough, nor from any difficulty of respiration.
  Tincture of aconite was applied over  the tender  part, but wdthout any
relief.  Ordered:
  R  Infusi valerianas, infusi cinchonas, aa. |iij.
  Sumat |j. ter in die;  a small blister  over  the part, and to be dressed
with acetate of morphia ointment, gr. j. ad §j.
  He ivas allowed meat  every day, and advised to walk about and amuse
himself.  Under this treatment he was cured.           Part xxx., p. 51.
  Remedies for Stomach Disorders.—Prof. Budd remarks : Quinine, and
the bitters generally, are especially .grateful to persons avIio have injured
their stomachs by hard  drinking.  With such persons they improve the
appetite  and strengthen  digestion, and have a bracing effect upon the sys-
tem  at large. 
STOMACH.
573
  In  persons exhausted  by over-work,  or  wherever  weakness  of the
stomach is the result of general debility from other causes, they often do
much good in the same way—by improving the appetite and strengthen-
ing the digestion.
  They do harm in the organic diseases of the stomach ;  in plethoric states
of the" system;  and generally where there is a furred tongue, or Avhere
the urine throws down a sediment of lithic acid, or of lithate of ammonia.
Their most striking effect is to improve the appetite, Avhen this has  been
impaired from hard drinking or from over-work, or from nervous  exhaus-
tion from other causes; and the best time for giving them is from half
an hour before meals.
  The different  bitters have not precisely the same effect.  Calumba has
a sedative influence not possessed by the others, and probably on this ac-
count has  had a wdder reputation as a remedy for mere indigestion.   Gen-
tian and chiretta (Avhich is of the gentian tribe, and is much employed by
practitioners  in  India) tend to increase the secretion of  the liver, or, at
any rate,  do not impede the secretion of the liver, which  quinine and
quassia seem often to do.   They are, therefore, better suited  to  bilious
persons, and to those cases  of indigestion where the secretions of the liver
are defective.
  The different preparations of steel are especially useful in the indigestion
that occurs in chlorosis, and generally Avhere  weakness of the stomach
results from anemia.
  They do harm in plethoric  states of  the system, and generally where
there is a furred tongue, or where the urine throws down a sediment of
lithate of ammonia or of lithic acid.
  The citrate, or ammonio-citrate is  the most agreeable preparation to the
taste, and generally the  most grateful to the stomach.  If there  be any
disposition to sickness or nausea, or any tendency to furring on the tongue,
it may be given  in conjunction wdth the bicarbonate of soda or  potash.
This makes a mixture having much the same effect as Griffith's mixture—
the mistura ferri composita—and far more agreeable.
  The m'uriated  tincture of iron is more astringent than the other prepa-
rations, and may be given in conjunction Avith dilute muriatic acid, in the
forms  of  indigestion suited to  this  latter medicine, when these  exist in
states of anaemia.
  The sulphate  of iron, like  other metallic sulphates, has a tendency to
cause  sickness, and should not be given in cases where a disposition to sick-
ness exists.
  Steel medicines do  good by improving  the quality of the blood rather
than by their immediate action on the coats of  the  stomach, and are best
given  at meal-times.   They then are mixed with the food, and gradually
absorbed with the products of  digestion, and are less apt to offend the
stomach and to cause  headache than  at other times.
  Whenever steel medicines are given, it is essential that a regular action
of the bowels be kept up.  These medicines tend to confine the bowels and
to  cause evolution of  sulphureted hydrogen in them : and unless this ten-
dency be counteracted, they are apt  to fur the tongue and  cause headache.
  The choice of purgatives is a very important matter in stomach dis-
orders.   The different purgatives  exert their chief action on different
portions of the  intestinal  canal: some  excite the secretion  or the peri-
staltic movement of one  part, some  of another.  In disorders of the sto- 
574
STOMACH.
mach and- bowels, where a purgative is required, care should, therefore,
be taken to  select those Avhich are least prone to irritate the injured or dis-
ordered part.
  Castor oil, for example, offends the stomach, but acts very mildly on the
large intestine.  It should  not be  used in stomach disorders, or Avhere,
from any cause, a tendency to  vomiting exists; but is better than  any
other purgative in dysentery, or during convalescence from typhoid fever,
when the intestines are ulcerated, and in various other  conditions where
a speedy and sure purgative, and one not apt to irritate  the  large intes-
tine, is required.
  Senna  acts chiefly  on the  small intestine,  and,  besides exciting its
peristaltic action, increases  the  secretion from its  mucous  membrane.
It acts, also, on the liver, increasing the secretion of bile.   In conjunction
with a few grains of calomel or blue-pill, it is, as every one knoAvs, one of
the best purgatives in bilious states of the system, or Avhere an evacuant
is required ;  but in mere disorders of the stomach it is often objectionable,
from the tendency it has to cause sickness.
  The best  purgatives in stomach disorders are aloes and colocynth, Avhich
exert their chief action  on the large intestine.   These medicines may do
much harm Avhen the large intestine is ulcerated or inflamed; but in simple
ulcer of the stomach, and in the most severe functional  disorders of the
stomach, they may generally be given  without  causing  either pain of the
stomach or sickness.   In some kinds of functional disorder of the stomach,
aloes  seem  indeed,  tike other bitters, to  improve  the appetite  and
strengthen  digestion.
  Aloes appear to act more exclusively  on the large intestine, and irritate
the  stomach much less  than colocynth, and  hence, in  stomach disorders
are  generally preferable to it.
   Where, from the existence of piles, or from pregnancy, or some other
condition, these medicines are objectionable, the best substitutes for them
in stomach  disorders are the  saline purgatives, which exert their chief
action on the small intestine, and have little tendency to cause pain in the
stomach, or sickness.                                   Part xxx., p. 58.
   Stomach—Dilatation  of, with Obstructions at the Pylorus.—A good
diagnostic symptom of disease of the pylorus, says Dr. R. B. Todd, is the
vomiting of sarcinas  with  a peculiar  yeast-like   substance.   Give  half
a drachm of sulphite of soda in an ounce and a half of water every four
hours.  If necessary increase the dose to a drachm.   The sulphite of soda
will destroy the sarcinas, but it will not act upon a diseased pylorus.
Where the disease, therefore, is simply from sarcinas, give the  sulphite, but
otherwise, it is not to be depended upon.               Part xxx., p. 59.

   SarcincB  Ventriculi.—Chloride of calcium, says Dr. A. Beared, is per-
haps a better remedy to  restrain the vomiting than hyposulphite of  soda.
Give the folloAving draught: R Liquoris calcii chloridi,  3j.;  aquae  3vij.J
sumat haustum taleni ter quotidie.                     Part  xxxi, p. 92.
   Gastric Affections.— Vide Selections from Favorite Prescriptions, Art
"Medicines."
   Gastric Ulcer.—Dr. Handheld Jones thinks there are many who cannot
dissever  in  their minds the idea of inflammation from that of ulceration,
but he bebeves that  the perforating gastric  ulcer is essentially the result 
STOMACH.
575
 of a local failure of nutrition, and not in any degree necessarily connected
 wdth inflammation.  Our chief obusct in treatment must be to improve the
 general condition  of the system, by good  nutritious diet, alloAving five or
 six hours' rest between the meals; we must attend to the general mucous
 surface, and  invigorate the organ as much as possible.  For this purpose,
 counter-irritation,  Avith  sedatives and astringents, may be  necessary at
 first; and, as soon as they can be borne, tonics, as acids, bitters, quinine,
 iron, and cod-liver oil.   If there be  much vomiting and pain, Avhich the
 ordinary remedies tail to  relieve, order  strychnine, one-sixteenth  of  a
 grain ; muriatic acid, one minim ; Avater, one ounce;  three times a day.
                                                  Part xxxiii., p. 111.

   Affections of the Stomach—Excessive Secretion of Mucus and Gastric
 Juice.—Prof. Budd  gives the following: Bismuth, combined  with aro-
 matics or  alkalies, may be administered  before meals  Avith advantage.
 When there are fetid  eructations, you may give creasote pills (containing
 from a quarter to half a minim) or a feAv grains of bisulphite of soda; or
 some finely powdered Avood charcoal.  To alleviate pain, and allay general
 nervous  irritabiltiy, the best medicines probably  are conium and  bella-
 donna, which do not confine the  boAvels or check the  secretions as opium
 does.
   Deficient Secretion  of  the Gastric Juice.—Take care that the  albu-
 minoid food be as liquid  as possible; let the quantity requisite for the
 day's consumption be taken at frequent short intervals; and if likely to
 turn sour,  guard it Avith alkalies.  We often find a draught of cold Avater,
 an hour or tAvo after meals, w ill remove the discomfort arising from difficult
 solution of meat meals ; in part by replacing the gastric juice, and also by
 favoring the absorption of the delayed nutrimentary mass.   In the way of
 medicines, a  pill containing a grain of ipecacuanha, or capsicum, Avith three
 grains of rhubarb,  may be taken before dinner.   For slo\Arness of digestion,
 ipecacuanha  is more  effectual than  any of the other  stimulants.  When
 digestion  is  habitually sIoav and feeble, much  lasting benefit will be de-
 rived from nitro-muriatic  acid, taken half an  hour before the principal
 meals.
   Sympathetic Vomiting.—The most effectual  remedies for this are, seda-
 tives, to lessen the irritation from which it springs ;  alkalies, to neutralize
 the acids Avhich the stomach contains; astringents,  to restrain the undue
 and untimely secretion.  The insoluble antacids, magnesia and chalk, are
 very suitable ; bismuth has a remarkable effect  in restraining undue secre-
 tion, especially when combined with  magnesia or chalk.  If there are any
 symptoms  indicating  inflammatory action, apply a  blister  to  the epigas-
 trium, and attend carefully to the diet, which should consist chiefly of milk
 and farinaceous food.
  Pyrosis.—The classes of remedies  Avhich have been found  most useful
 are astringents and sedatives.  We  might advantageously combine five
 grains of bismuth  with a tAvelfth of the grain of the muriate of morphia;
 or five grains of the compound  kino powder,  or logwood, catechu, kra-
 meria, w ith opium, given tAvo or three times daily before meals.
  Indigestion of  Drunkards.—The  most efficient remedies  are bitters,
opium, and solid food.   Gentian,  quassia, and calumba, may  be taken
singly or combined, in  the  form  of tincture, an hour before the principal
meals; Avith  these, small  doses of  opium or  morphia may be advan- 
576
STOMACH.
tageously combined, to tranquillize the  nervous system, but in  all these
cases it is essential  that the patient should eat as soon as possible some
solid, nourishing food.
  Employment of Vegetable and Mineral Tonics.—Quinine and the bitters
generally do much good in persons exhausted by ovenvork, hard drinking,
or other  causes; they improve the appetite and  strengthen digestion.
  The best time for  giving them is  about half an hour or an hour before
meals.  The different bitters have not precisely the same effect;  calumba
has  a sedative influence not  possessed  by others;  gentian  and chiretta
tend to increase the secretion of the liver; quinine and quassia seem to
impede secretion.  Tonics  do harm in organic diseases of the stomach, in
plethoric  states of  the  system, and generally Avhere  there is  a furred
tongue, or Avhen  the urine throws down  a sediment  of the lithates.
When there is any disposition to sickness or nausea, the amonio-citrate of
iron, in conjunction wdth the bicarbonate of soda or potash, is the most
pleasant preparation, and will have  the  same effect as Griffith's  mixture.
the sulphate of iron, like other metallic sulphates, has a tendency to cause
sickness.   Steel medicines act generally instead of locally, and are there-
fore, best given at meal-times, so as to be absorbed wdth the food.
                                                    Part  xxxiv., p. 71.
   Ulcer of the Stomach.—If there be a  constant gnawing pain at the epi-
gastrium, says  Dr. Brinton, apply some  counter-irritant, as a blister, mus-
tard poultice, etc.;  if the  powers  are exhausted, dry cupping is the best
means of mitigating it.   A still more valuable remedy, in some cases of
obstinate vomiting  and severe pain, may be found  in frequently swallow-
ing  small bits of pure ice.  In cases of severe hemorrhage its use is almost
indispensable.  When-severe pain is accompanied by very frequent vomiting,
a very small opium pill is retained better than any other sedative.  If diar-
rhoea be present, the compound kino poAvder, combined with the trisnitrate
of bismuth, is an excellent remedy.  Ten or tAventy grains of the trisnitrate
of bismuth, wdth five  to ten grains of the compound  kino powder, has a
very remarkable effect in relieving pain,  vomiting, and diarrhoea.   If flatu-
lence be very troublesome the alkaline carbonates Avith bitter infusion are
the  best  remedies.   We  can  recommend  the following combination:
potass,  iodic!., gr. j.; potass, bicarb., gr.  xv.; tinct. aurant., 3ss.; inf.
calumb., 3viiss.  To  be taken an hour after food.      Part xxxiv., p. 76.

  Syncope Senilis, arising from Gastric Irritation.—This complaint, ac-
cording to Dr. Higginbottoin, is common to all ages, but more particularly
to infancy and old age.  It is generally  observed in persons above sixty,
and  takes place Avithout any organic disease, although both the vascular
and  nervous system must be inactive and in an impaired condition.
  Gastric irritation from the food remaining undigested  in  the  stomach,
appears to be the sole cause of the attack; this gives rise to syncope and
convulsions which may be fatal.  Vomiting at an  early period is the most
effectual remedy.  Half a drachm of the powder of ipecacuanha, with ten
or fifteen grains  of bicarbonate of potash to neutralize  any acidity, will
produce  full vomiting  and raise the system to its normal condition.  The
nausea and ineffectual natural attempts at vomiting produce debility and
exhaustion.  If the first half drachm of ipecacuanha  does not operate, a
second dose may be  given Avith perfect safety.  In advanced age the body
does not require the  same amount of solid food.   It has been erroneouslj 
STOMACH.
577
  said that « wine is the milk of old age;" the truth is that milk is the wine
  of old aije ; second childhood should be treated as directed by the late Dr.
  James Hamilton, of Edinburgh, "Plenty of milk, plenty of flannel, and
  plenty of rest."                                      Part xxxiv., p. 99.

    Treatment of Ulcer of the Stomach.—When hemorrhage from a chronic
  ulcer amounts to a considerably quantity,  says  Dr. Brinton, although it be
  only a symptom of the disease, yet we must direct special attention  to it,
  and we may remark that the astringents we introduce are much more effi-
  cacious than in the case of bleeding into  the lungs.   If there is reason to
  believe that the bleeding is from a large \-essel, the stomach must be kept in
  the state of perfect rest, the supine position must be rigidly observed, and
  the minimum of food that will support life, taken lest the clot wdiich alone
  intervenes between life and  death be disturbed.
    In many cases of hematemesis, if there be no great tendency to vomiting,
  turpentine, or the sesquichloride  of iron act admirably; but what is pre-
  ferable, because it is not so apt to excite vomiting, is ten grains of gallic
  acid, dissolved in an ounce  of distilled water by the aid of about ten min-
  ims of the dilute sulphuric acid.  Among tonics, the preparations of iron
  claim the  foremost rank.   When vomiting and pain have ceased, begin
  with the very mildest preparations,  such as  the ammonio-citrate, which
  should always  be given immediately after food.   The  insoluble oxide
  should generally  be avoided.  As  a combination  of the vegetable and
  mineral tonics, none is so elegant and so generally useful as a mixture of
  sulphate of quina and iron, kept in solution by a few drops of sulphuric or
  hydrochloric acid.
    It is impossible to cure ulcers of the stomach by any remedies in the ab-
  sence of proper regimen ; drugs, although invaluable as aids to a strict diet,
  are powerless as substitutes for it.  Milk  diet, given in small quantities at
  frequent intervals, is the best that can be given under such circumstances;
/ if the stomach be excessively irritable, it may be diluted wdth lime Avater.
  During convalescence the diet must  be kept up as  much as prudence will
  alloAv; ground rice Avith milk forms an excellent food, wheaten flour is best
  given as bread steeped in boiling Avater, and  pressed  through a muslin sieve
  while still hot (bread jelly) and boiled ivith milk.   With respect to alco-
  holic stimulants Ave may say that it is  advisable they should  be  studiously
  avoided : in cases of extreme exhaustion,  Avhere alcohol seems necessary, it
  must be  given as  an enema.  But we may ask, are  there no  stimulants
  wdiich may afford us the advantages of alcohol Avithout its disadvantages ?
  In such cases  the peculiar  stimulant effects of opium make it by far the
  most valuable of them all.                             Part xxxv., p. 55.

    Cardialgia.—Dr. Tilt says, that if this does not depend upon foul secre-
  tions, requiring purgatives,  give a sedative mixture before meals ; an alkali
  after meals ; three grains of blue-pill and two of extract of hyocyamus every,
  or every other, night; a  mustard or  hot linseed poultice, sprinkled with
  coarsely-powdered camphor, every other  night.  If the  pains continue,,
  prescribe a pitch, belladonna, or opium plaster:  the two last may be alter-
  nated every fourth day.  Often much benefit  is derived from the  applica-
  tion to the pit of the stomach of a piece  of lint steeped in chloroform and
  covered  with  oil-silk.  In  some of the  Avorst  cases, in which the pain is
  rgonizing, relief will sometimes he. obtained by about thirty to sixty drops
    VOL. II.—37 
578
BTOMACn.
of aromatic spirit of ammonia, in the smallest possible quantity of water, or
by the same quantity of chloroform, on a lump of white sugar.
  The following liniment, recommended by Dr. Oldham, may be tried with
advantage:  Extract of belladonna, half a drachm; tincture  of aconite
(Fleming's), four drachms ;  for an ounce and a half of soap liniment.   Dr.
Shearman gives nitrate of silver and opium, wdth quinine and potash water,
in one drachm doses; Mr. J. Frank recommends oxide of bismuth;  and
Hufeland  Avrites  favorably  of nitrate  of bismuth, in ten or  twenty-grain
doses.                                               Part xx\x.,p. 58.
  Liquor Pepsinoe in Dyspepsia from Ulceration of the Stomach.—Prof.
Nelson gives the following case:
  Miss S. J., aged 18 or 20, was brought by her mother to me from Chel-
tenham, laboring under pain and fullness of the epigastrium and right side,
vomiting of blood, and sometimes of purulent matter.  She was excessively
anasmic, her skin being nearly Avhite, and the legs cedematous.  There had
been  no catamenia for a considerable time, and her father, as reported, had
died  of cancer of the  stomach.  She became worse after the journey.  I
saw her in bed, and detected a rounded SAvelling to  the right of the epigas-
trium, Avhich I  inferred  might  be  a  hepatic abscess, complicated  Avith
stomach ulceration.   At this time she  lay faint and  helpless, vomiting
everything  she  ate, sometimes intermixed with blood, and occasionally
being composed entirely of muco-purulent matter combined Avith bile.   She
was afraid to speak above a whisper, her tongue and mouth were parched,
and her legs pitted  deeply under pressure; the  pulse Avas small, frequent,
and thready, about 140 per minute.  Soothing poultices Avere applied over
the sAvelling, large masses of hard round fecal matter were removed by
injections, nitrate of silver was administered before food, and the alkalized
liquor pepsinas, with hydrocyanic acid, Avas given  after food, at intervals
of one hour.  At the same time the food Avas  entirely pultaceous or liquid,
and  consisted  of the  smallest quantities at a time, seldom more than one
teaspoonful.   After  several fluctuations, and  occasional severe attacks of
purulent  vomiting, she gradually began to amend.   So soon as the above
symptoms abated, she went through  a course of quinine and steel;  and,
after a tedious treatment of about ten months, she recovered plumpness,
color, and strength,  contrary to the expectations of all her friends and ac-
quaintances.  The  remedy could haire little  poAver over hepatic abscess;
but I can scarcely  see hoAv, in  her  utterly reduced condition, she  could
have gone  through the treatment Avithout the  support  derived from the
solvent action of the pepsine upon the food—oysters, arrowroot, and milk
and wine, having all been previously rejected.        Part xxxv... p. 294.
   Heartburn.—In anaemic feeble  persons, Dr. T. R. Chambers believes this
arises generally from  over-sensibility of the  nerves to the natural acidity
of the stomach.   This is relieved by alkalies, but alkalies prevent perfect
-digestion by neutralizing the acidity necessary to a proper performance of
the digestive function.  The treatment must therefore  be directed to alle-
viate the over-sensibility of the  nerves, temporarily, by hydrocyanic acid
and bismuth; permanently, by strengthening  the general nervous system
by quinine and iron, combined with seabathing, or the shower-bath.  In
other cases heartburn depends on too large an amount of acid being pre-
sent  in the stomach, resulting from chemical decomposition of the sugar in
the chyme, OAvdng  to  decreased vital power.  The treatment here is to 
STR ANGUR Y--STRICTURE.
579
increase the power and vigor of the stomach.  The activity of the pepsine
may be  much  augmented by neutralizing the  saliva collected in the
stomach  and  oesophagus  just  before the meal, by a little hydrochloric or
lactic acid; for the saliva arrests the solvent action of the gastric juice in a
close proportion to its amount.  The quantity of gastric juice may be further
increased by supplying one of its most important constituents, water, which
is best taken as cold as possible about half an hour after the meal. _
                                                   Part xxxvi., p. 65.
  Eructation and Vomiting.—When from simple relaxation of the oesopha-
gus, Dr. Chambers gives astringents, as gallic acid combined Avith a little
rhubarb.  When from excess of air, swallowed from irregular nervous ac-
tion, as in hysteria and chorea, valerian, either in infusion  of the herb or
combined Avith ammonia.  When  these fail, strychnine or creasote.   The
shower-bath is a very powerful remedy.   When  from the formation of
foreign gases  from chemical decomposition, no agent is so useful as sulphu-
rous acid, Avhich may be given as hyposulphite of soda; if this chance to
disagree, charcoal will scarcely fail to arrest gastric fermentation. When
chronic vomiting is sympathetic,  i. e., from some disease or condition else-
where, as in peritonitis, pregnancy, etc., give hydrocyanic acid. When
from gastric mucous flux, Avith copious formation of acid, give carbonate
of magnesia.   When the vomiting is accompanied by much local pain, as
from gastric ulcer, malignant  tumor, peritonitis, hernia, perforation of the
gut, opium is the remedy of most value.  When at the commencement of
fevers and in cholera,  apply chloroform on cloth to the epigastrium.   Milk
and lime-water, as a sole  diet, will often alone stop chronic vomiting;  com-
plete rest and absence from excitement must  accompany  it.   Chloroform
does not arrest the nausea of sea-sickness, but it controls the violence of
the straining.                                        Part xxxvi., p. 10.
                        STRANGURY.
  From  Administration of  Canthtrides.—Dr.  Seymour relies  chiefly
upon starch injections containing twenty or thirty drops of tinct. of opium.
Cantharides should not be given to patients Avith stricture of urethra.
  Dr. S. believes that cantharides should not be given to women, from its
peculiar effects upon the uterine system.  Camphor is  recommended in
some books, but is very slow in its operation.  Hyoscyamus, however, in-
creases its efficacy—especially in chronic irritation of the neck of the blad-
der.                                                   Part viii., jo. 68.

                              -—•-•-•—


                        STRICTURE.

              RECTUM—CESOPHAGUS—URETHRA.
     Of Rectum:—Dr. O'Beirne considers that it is our  duty, if possible,
to avoid making an  opening into any part of the colon, and that in cases
of stricture it might be avoided. The failure in the  use of the instruments
in cases of spasmodic stricture, he attributes to want of sufficient boldness 
580
STRICTURE.
in their use, and mentions a few facts to embolden practitioners, and to
show the impunity with Avhich the most obstinate constriction of the bowel
in question might be overcome.
  The facts were as follows : Of all the diseases in which constipation is most
obstinate, tetanus is certainly the one.  In some cases of this disease which
had terminated fatally, he succeeded in passing the instrument to a consi-
derable height, but only by means of long-continued, gradually increasing,
and  determined pressure against the  point of  resistance ;  Avhen first he
used this force, he remembered  the instrument  passed rapidly upward, as
if through a narroAv ring, giving to his hand a sensation as if he had per-
forated the walls of the intestine; accordingly he withdrew the tube, and
was much pleased to see its extremity coated with fieces, and bearing no
marks of blood.   This circumstance had  occurred to  him not once, but
twenty times in the treatment of those fatal cases to which he alluded. In
those cases it was found, after death, that the Avhole of the colon Avas so
enormously distended as to conceal the other intestines, and to equal in
size the thighs of a very large man, while the uppermost part of the rectum
was  contracted to the diameter of the  barrel of a quill, but  felt much
firmer.   On  cutting into the  intestine at this point, neither  the serous nor
the mucous coat was found in the least thickened, neither did the muscular
coat exhibit any signs of thickening other than  that caused by the  power-
fill contraction of its fibres upon themselves. It ivas quite evident in these
cases that even this firm structure was forced at each introduction of the
instrument, so as to enable  the bowels to  be freed.   Why, then, should
we be deterred from employing a sufficient degree of force in another case
when the degree of resistance is  infinitely less ?   When the difficulty of
introducing the tube is great, the application of a blister over the sacrum,
extending up  a little  on the spinous processes of the lumbar vertebras,
would  be found a  considerable assistance ; and in order to effect this
rapidly, if the case  be very urgent, a sponge should be impacted into  a
tumbler,  boiling wrater poured upon this, throAving it off repeatedly  in
order to produce the necessary degree of heat, and then the tumbler could
be inverted over the part to be blistered.   Having thus disposed of spas-
modic stricture, he would now say that, in cases of the organic kind, every
success might be obtained  by the same means,  wdth this difference—
namely, the  use of small tubes gradually increased in size.  With  respect
to malignant stricture of the rectum, he Avas of opinion that this might be
a legitimate case for the lumbar operation.
   [Dr, Williams says that the great difficulty in the formation of an artifi-
cial  anus  in the lumbar colon consists in the  difficulty of distinguishing the
colon from  the small intestine; for the signs mentioned by M. Amussat,
whether taken separately or  collectively, are not diagnostic, consequently
there is always a risk of opening the  peritoneum,  and  thus sacrificing the
entire principle and chief advantage of the operation.  M. Amussat has,
however, discovered  a  sign which  bids fair  to do much toward removing
the difficulty in question].
   The sign rested on the fact that the small intestines sustained a motion
of alternate  ascent and descent corresponding to expiration and  inspira-
tion, in wdiich the  lumbar  colon  did not participate ; if, therefore, the
exposed intestine presented this oscillation, it was small intestine—if it did
not, it  might be  presumed  to  be the colon.  As M. Amussat made no
mention wThateyer of this distinctive sign  in  any of his  publications on the 
STRICTURE.
581
subject, it was verv satisfactory that it  had now been made known and
recorded.                                             Part xl., p. 110.
  Stricture of the Rectum and Oesophagus.—If non»malignant, these may
be treated effectually with instruments, invented by Mr. Wakleyj consist-
ing of a flexible  guide  and four dilating  tubes  about ten inches in length
for  the rectum, and tAventy for the oesophagus ; the guide being also longer
for  the latter tube.  The guide is first introduced, and over this, the direc-
tors, which fit accurately, and  must be used of progressively larger size.
Mr. Wakley  also uses  instruments for the dilatation of the os uteri, con-
structed on similar principles, but  the dilators are shorter, and have an
inverted cup-shaped rim to fit the os uteri.           Part xxxv., p. 130.
  Dilatation of the Urethra in Stricture.—Dr. Arnott makes use of " a tube
of oiled silk lined Avith the thin gut of some  small animal, as the cat, to
make it air-tight, and  attached to the  extremity of a small canula, by
wdiich it is  distended Avith the air or water from a bag or syringe at  the
outer end Avith a stopcock or  valve to keep the  air in when received."
The canula may be of elastic  gum, or of the flexible metal used to make
the metallic bougies, or of silver.   The instrument is easily passed, and as
soon as the bag is sufficiently Avithin the stricture as much air is to be injected
as the patient can easily bear.                            Part iii., p. 94.
  Aphorisms of Practical Surgery.—Few diseases  are more difficult to
cure radically than a  very tight  (tres grand) stricture  of the urethra.
For, after the canal has been Avidened by the prolonged use of bougies,
there is always a  great tendency to a relapse of the disease.  It is then
that cauterization becomes useful* because we thus  obtain a cicatrix molded
upon  the bougie.
  There are cases of stricture,  etc., in Avhich the keeping of an instrument
in the urethra, instead of being a  means  of cure, becomes actually an ob-
stacle to it:  Dupuytren used to cite several  instances of urinary fistulas
cured by the mere withdrawal of the sound.             Part iii., p. 115.
   Use of Alum  in the Treatment of Stricture of the Urethra.—M. Jobert
regards alum as possessing many advantages in the treatment of this dis-
ease.   He uses it as follows :
  A bougie is selected, the finer at the extremity the narrower  the stric-
ture.   By placing its extremity for a moment  in a candle, it is so far soft-
ened,  that on immersing the instrument in pulverized alum, it adheres to
the entire heated surface ; the point  is then rounded off between the fingers,
so as to communicate to it a suitable shape. The bougie, AAThen thus armed,
is passed into the stricture and left there for twenty minutes  or an hour,
according to the period of the  treatment, the sensibility of the patient, etc.
After a few minutes a slight smarting is felt, hut no other apparent effect
is perceived.   On withdraAving the bougie, a few drops  of whitish mucus
escape, which M. Jobert considers as tending to liberate the canal of  the
urethra.   Not unfrequently, on the day following the application, bougies
of a considerable size can be passed  into the bladder.
  M. Jobert also uses large bougies armed with alum, in the treatment of
stricture of the urethra.       .                         Part v., p. 145.
  Stricture of the Male  Urethra— Urinary Abscess.—Sir B. Brodie thus
describes the ordinary course of the affection.   The patient, he says, com-
plains of more than usual difficulty in voiding his urine; but the difficulty 
582
BTRICTUR1C.
does not amount, at least  in  the  first instance, to an absolute retention.
Perhaps he has a  shivering.  There is a sense of fullness  in the perineum,
and some degree  of deep-seated induration is perceptible in one part. This
gradually increases, ^and a tumor presents itself under the skin of the peri-
neum, surrounded Avith more or less of oedematous effusion, especially into
the scrotum.   The skin  becomes inflamed, and  the fluctuation  of fluid is
perceptible underneath.   An abscess bursts or is opened wdth a lancet, and
a considerable quantity of putrid pus  is discharged.  Here the oedema of
the neighboring part subsides.   Pus continues to flow through  the orifice
of the abscess, and after some time it is observed that urine flows through
it also.  The discharge  of pus diminishes, but the urine  flows in larger
quantity; and whenever the patient makes Avater, part escapes through the
natural channel and part by the neAV opening.   The abscess has evidently
a communication  wdth the urethra, behind the stricture.   If you  have an
opportunity of dissecting the diseased parts while the abscess is recent, you
find it  to open into the urethra by a ragged, irregular  orifice.   If you ex-
amine  them  at a later  period, the  orifice in the urethra is found to bo
smooth, regular, and rounded  at the  margin; the external  orifice in the
perineum is reduced to a narrow diameter, and  is  seen in the  centre of a
button-like projection of the skin ; and the abscess itself is contracted, per-
haps reduced to a narrow passage, with a smooth  surface, which presents
somewhat of the appearance of its being lined by a mucous membrane.  We
now say that the case is one of fistula in perinceo.  The whole of these
phenomena are easily explained.  The urethra, constantly teased by the
pressure of the urine against it, ulcerates  behind the stricture.  If the stric-
ture had been  completely closed, as in fhe case of retention of urine, an
extensive extravasation  of urine would have immediately taken place ; but
under the existing circumstances, this does not happen, and only a mode-
rate quantity, perhaps not more than a few drops, dribbles into the cellular
membrane, sufficient to  induce inflammation and  suppuration  and no fur-
ther local mischief.   A fistula  in ano is formed in the same manner, by ul-
ceration of the rectum allowing the  escape of a minute quantity of feculent
matter into the neighboring textures.
   Sir Benjamin goes on to  remark, that sometimes the  abscess of the peri-
neum is accompanied by typhoid symptoms.   If the abscess is  opened, the
matter that issues is putrid and urinous—if the opening  is deferred the
patient may die.
   " I have described," continues our author, " the simplest form of the uri-
nary abscess.  But it is  often more complicated.  It is  not always confined
to the perineum;  sometimes it makes its Avay forward  through the upper
part of the scrotum, and presents itself on the loAver part  of the penis, be-
tween the scrotum and the glans. At other times it burrows in the opposite
direction, forming a large collection of matter in the nates, or it may burst
in the groin,  or in the scrotum.  In one  case, in which I  had an  opportu-
nity of examining the body  after death, I found a large abscess in front of
the pubes, extending half-way  toward the navel; another among the adduc-
tor museles of the left thigh ; and a third among the  muscles at the upper
part of the right thigh, as far outward as the foramen ovale of the ischium;
the periosteum having been destroyed, and the bone itself rendered carious
to a considerable extent: and all these abscesses  could  be traced into an
abscess in the perineum, communicating with the urethra behind a stricture
by a small orifice.   In  another case which I attended with Mr. Samuel 
STRICTURE.
583
Cooper, there Avas a fistula inperinmo, communicating w ith a large abscess
of the pelvis on one side of the bladder.
  " I have seen a few cases in which an abscess of this kind had made its way
into the  rectum,  forming a fistulous communication betAveen it and the
urethra.  If such communication be of a large size  it is a source  of great
distress, as feculent matter occasionally passes through it from the rectum
into the urethra.  If it be small, however, the absolute inconvenience is but
trifling, and the patient is rendered sensible of its existence only in  conse-
quence of a small quantity of air escaping occasionally by the urethra;  and
this may  continue,  without any further symptoms  supervening, for  many
years."
  Bougie.—" The best kind of bougie," he observes, " is that  in common
use, made of plaster spread on linen, and rolled up.  It should be smooth
on the surface and neatly rounded at the extremity.   The plaster bougie
should be rubbed until it becomes Avarm, so that it may be  molded  by the
hand, and bent into the form of the urethra.   Thus bent, it is much tobe
preferred to the elastic bougie, which is made of elastic gum on the outside
and of catgut within.  The latter may, it is  true, be bent into any  form;
but it is elastic, and however you may bend it, it always regains its straight
figure ; and hence it is not Avell constructed for being passed along  the
curved canal of the urethra.   The bougie  Avhich  is used  for  the purpose
of examining the urethra should be of full size, that is, large enough to fill
the urethra  without stretching it.  A small bougie may deceive you  in two
Avays : it may pass through  a  stricture, and thus lead you to  believe  that
there is no stricture, when there really is one; or it may have its point en-
tangled  in the orifice of one of the mucous follicles of the urethra, or in
some accidental irregularity of the canal,  and  lead you into the opposite
mistake  of supposing that there is a stricture Avhere none exists.   If you
use a bougie of the size of the urethra, you are not at all liable to the first
error, and you are much less liable to the  second than you would be other-
Avise.  The bougie should be cylindrical.   There is no advantage  in any
bougie,  except a  very small one, being  conical.  A  conical  bougie,
becoming larger toward the point Avhich  is held  in the hand, is likely to
extend forcibly the orifice of the urethra,  and to excite inflammation in it."
   Retention from Spasmodic Stricture.—Sir  Benjamin  recommends the
immediate and direct recourse to mechanical means.
   " Begin," he says, " by taking one of the smallest gum  catheters, which
has been kept for a considerable time on a curved iron wire, and which re-
tains the curved form after the Avire is withdrawn.  Introduce it wdthout
the wire ; and as it approaches the stricture, turn the  concavity  of  the ca-
theter toward the pubes, elongating the penis at  the same time by drawing
it out  as much as  possible.  It is  not very improbable that it will  pass
through  the stricture, and enter the bladder.  The urine will  then  flow
through  it in a fine stream, and the  patient Avill obtain immediate and  com-
plete relief.
   " If you fail Avith the small  gum  catheter, try, not a plaster, but  a small
catgut bougie.   Let this  be well made; that is firmly tAvisted, nicely
rounded at the extremity,  and everywhere well  polished.   Observe the
same rule of elongating the urethra, and it Avill probably enter the stricture.
It is not necessary that  the catgut bougie should pass on  to the bladder; it
is sufficient  if the stricture grasps or holds it.  Let it  remain in  the  stric-
ture until there is a violent impulse to  make water.   Then withdraw the 
584
STRICTURE.
bougie, and the urine will follow it in a small stream. If the patient empties
the bladder, the object is attained; but, otherAvise, re-introduce the catgut
bougie, or rather introduce another of the same size (for a  catgut  bougie
wdiich  has been once used is not  fit to be employed a  second time) ;  and
let the patient retain this second bougie as long as he can.  If the straight
catgut bougie cannot be passed, you will often  succeed in  effecting its in-
troduction by bending the point of it.  This contrivance enables you to
keep the point sliding against the upper surface of the  urethra, avoiding
the loAver part, in which the obstruction is always most perceptible, and
in Avhich the bougie is most likely to become, as it were, entangled.
  " Even Avhere you have failed to relieve the patient by means of the catgut
bougie, you will often succeed in introducing a silver catheter, or an elas-
tic gum catheter mounted on a firm iron  stilet,  into the bladder.  The ca-
theter  employed on this occasion, if the  stricture be of recent  formation,
should be nearly of the full size of the urethra; but if the stricture has been
of long duration, it should be considerably  smaller.  The  common silver
catheter  is not so well adapted for the purpose as that  Avhich I now show
you.   You will observe that it is shorter and less curved than  usual, and
that it is fixed  in  a Avooden handle, which  renders the instrument more
manageable than it would be otherwise.   If you use an elastic gum cathe-
ter, the iron stilet should have a flattened handle, resembling that of a com-
mon sound.  You should pass it as  far as the obstruction,  and having as-
certained where it is situated, Avithdraw the catheter a little, a quarter of
an inch for example, and then,  as you pass it on again toward the bladder,
keep the point sliding against the upper part of the urethra, which is toward
the pubes, avoiding the lower  part, Avhich  is,  of  course, toward the peri-
neum.   Be careful to employ no violence.   If you lacerate  the urethra, so
as to cause hemorrhage, you Avill be  defeated in  your  object.  Press the
catheter firmly, but gently and steadily,  against the stricture, keeping in
your mind the anatomical position of the parts, and being  careful to give
the point of the instrument a right direction. When the pressure has been
thus carefully continued for some time, the stricture Avill  begin to relax.
It will alloAv the point of the catheter  to enter, and, at last, to pass com-
pletely through it into the bladder.  In some instances this will be accom-
plished in the space of one or  two minutes; while in others it may he ne-
cessary to persevere for a quarter of an hour.  As  soon as the catheter has
reached the bladder, the patient's sufferings are at an end,  as the bladder
becomes completely emptied.   If you have used the elastic gum catheter,
it may be prudent to allow it to remain in the urethra and bladder for one
or two days, or even for a longer period ;  and  this w ill  go  far  toward ac-
complishing the cure of the stricture.,'
   Use of  Opium.—" The remedy on which you are most to rely, where
these mechanical means fail, is opium.  From half a drachm to a  drachm
of laudanum  may be given as a clyster  in two  or three  ounces  of thin
starch.   If this should not succeed, give  opium by the mouth, and repeat
the dose, if necessary, every  hour until the patient can make water.
According to my experience, the cases  in  which the  stricture does not
become relaxed under the use of opium, if administered freely, are  very
rare.   The first effect of the opium, is to diminish the distress which the
patient experiences from the distention of the bladder.   Then the impulse
to make  water becomes less urgent; the paroxysms of straining  are less
severe and less frequent; and after the patient has been in this state of 
STRICTURE.
585
comparative ease for a short time,  he begins to void his urine, at first in
small, but afterward in larger quantities."
   Warm Bath.—"• It is customary in these cases to employ the warm bath.
It is, indeed, sometimes useful,  but you  can place no dependence on it as
compared Avith opium.  It is not sufficient that your patient  should sit in a
hip-bath:  the  bath,  to  be at all  efficient, must  be complete ;  his whole
person ought,  therefore, to  be immersed, and  he should remain  in it for
half an hour,  or an  hour, or longer, unless he previously becomes faint.
Bleedino from the arm is seldom required in cases of retention of urine
from stricture; but in some instances, even where other means have failed,
taking blood from the perineum by cupping gives immediate relief."
   Purgatives,  when induced by Spirituous Liquors.—" Purgatives require
some time to produce their effect, and in  most cases, at the period of your
being called in, the symptoms  are  too urgent  to admit  of this delay*
Where, hoAvever, a stricture is chiefly spasmodic, and the retention follows
the too great use of fermented liquor or spirits, I would advise you, if you
are sent for  on the commencement of the attack, to prescribe a draught of
infusion of senna  Avith the tartrate \>f potass and tincture  of jalap.  As
soon as this  has fully operated, and the bowels are emptied,  give thirty or
forty drops of tincture of opium by the  mouth, or order an opiate clyster
to be administered, and, in all probability, the attack will subside."
   " After all, there is no absolute rule as to the treatment of retention of
urine from stricture.  One person is relieved in one Avay, another in another;
and you will do Avell in each case to bear in  mind the particular mode of
treatment which has proved of service, in order that  you may  at  once
resort to it,  if you are called a second time to the same patient,  under the
same circumstances.   In  one instance,  you  will be able to  pass a catgut
bougie, and  not a catheter; in another you will be able to pass a catheter,
and not a catgut bougie.  One individual is relieved by opium, another by
the warm bath.   A gentleman of my acquaintance, who Avas subject  to
attacks of this description for a considerable time, almost always began to
make water  after a pint of warm water had been thrown up as a clyster."
   Sir  B. Brodie relates a case of old stricture of the urethra, in  Avhich the
attack of retention of urine came on periodically, and was cured like other
intermittent diseases, by  prescribing sulphate of quinine.
   When an  operation becomes indispensable, which  Sir Benjamin thinks it
must rarely be, he is of opinion  that puncturing  the  bladder from the
rectum is applicable to the greatest  number of cases.  But those who
operate frequently must often operate unnecessarily.
   Stricture in the Anterior Part of the 'Urethra.—Sir Benjamin observes
that a stricture at the orifice of the urethra may be dilated by means of  a
common bougie, or a short metallic instrument; the size of the bougie
being gradually increased, and the introduction being repeated daily or on
alternate  days, according to circumstances.   The process  of  dilatation
is, however,  in many instances, attended  Avith much inconvenience to the
patient.  In those cases, especially, in  Avhich the contraction  began  in
early life, every introduction  of the  bougie causes considerable pain;  at
the same time  that the disposition to  contract  is so great that the opera-
tion requires to be repeated almost daily.  The  consequence is that the
part is kept  in a constant state of inflammation, and, between the disease
and the remedy, is a source of incessant  annoyance to the  patient.   In a
case of this  sort,  Avhich ivas  extremely  troublesome, Sir Benjamin deter- 
586                           STRICTURE.
mined at once to divide the contracted part of the urethra.   This was
easily accomplished by means of a pair  of knife-edged scissors, one blade
with a  blunt  point being introduced into  the urethra, and the division
being made in the situation of the frasnum.   No hemorrhage folloAved the
operation.   A  piece of lint  was kept betAveen the cut surfaces to prevent
their reunion, and in  about ten days  they Avere cicatrized, being covered
by what had already assumed a good  deal of the appearance of a mucous
membrane.
  Strictures hi the anterior part of the urethra, but behind the orifice,
require to  be  mechanically dilated,  by the introduction  of bougies  or
metallic instruments.   Sometimes the patient obtains relief on  very easy
terms, the dilatation being readily accomplished, and the use of the bougie
once in three or four days being sufficient to prevent a recurrence of the
contraction.  At other times, hoAvever,  the disposition to contract is  so
great, that  it  becomes necessary to introduce the  bougie once  or tAvice
daily; and, indeed, Sir Benjamin  has knoAvn cases in Avhich the  patient
was seldom able to  expel his urine  until the  bougie  had  been em-
ployed.
   Caustic Bougie.—Sir  Benjamin  conceives that the caustic bougie is
applicable to the folloAving cases :  1st. Those of spasmodic stricture, where
two or three applications of the caustic  may be sufficient to relieve all the
urgent symptoms. 2dly.  Some cases of old stricture,  in wdiich there is
still a considerable disposition  to spasm.  In these last cases  apply the
caustic tAvo or three times, and no  oftener.   It Avill probably relieve the
contraction as  far as it is spasmodic,  and thus enable you to proceed more
adArantageously, AAdth the use of the bougie or metallic sound.  3rdly. The
caustic may be used  very properly in some cases  of stricture Avhich are
endowed with peculiar irritability, in which  every  application of the com-
mon bougie induces severe pain, or brings on spasm, preventing it entering
the stricture.   Two or three applications of the caustic may be sufficient
to deprive the  stricture of that unnatural sensibility which otherwise Avould
have foiled  your efforts to effect a cure.  Yet our author  seldom employs
caustic for these reasons:  1st. Although the caustic often relieves spasm,
it also very often induces it.  It is true, that in many instances it enables
a patient to make Avater wdth more facility;  but in  many instances also, it
brings on retention of urine.  2dly. Hemorrhage is a more frequent conse-
quence of the use of the caustic than of the common bougie, and it some-
times  takes place to a very great  and to  an almost dangerous extent.
Ddly. Where there is a disposition to rigors, the application of caustic is
almost certain to produce them; and frequently the application of caustic
induces rigors where there had  been no manifest disposition to them pre-
viously.  4thly. Unless used Avith caution, the application of caustic may
induce inflammation of the parts situated behind the stricture, terminating
in the formation of abscess.                              Part vi., p. 92.

  Stafford's Treatment  of  Stricture—  The Lancetecl Stilette.—Mr. W.
Coulson arranges those cases of stricture in Avhich  the ordinary plans  of
treatment fail  to relieve or cure under three or more classes :  the  first,
in which there is simple  stricture of the urethra,  so complete, however,
as sometimes to cause retention of urine ; the second, in which two, three,
or more inches of the urethra, are thickened and contracted, and  often
complicated with fistulous openings in the perineum ; the third, in which
> 
STRICTURE.
587
  one or more bad strictures exist in an extremely irritable urethra, which
  is frequently combined w ith an irritable state of the whole system.
   Three cases are produced to elucidate the above varieties, and to  show
  that, after every other method had fiiled,  Mr. Stafford's mode of dividing
  the part with  his  instrument was  successful.  After Avhich  Mr. Coulson
  goes on to say :
   My object in publishing these case? is to assist in removing the feeling
  which too generally prevails against Mr. Stafford's  treatment  in cases of
  impermeable stricture : for nearly all who  have written on the  complaint
  more or less condemn the use of  his instrument.   In alluding  to it,  Sir
  Benjamin Brodie says :  " Mr. Stafford has invented an ingenious machine,
  which is intended  to divide a stricture by means of a cutting  instrument.
  If any cases occur in which this method may be useful, they are undoubtedly
  very fe v in number;  and great caution must be  required to avoid making
  false passages, which might be followed by effusion of urine and purulent
  deposits."  These were the  fears wdiich unfortunately  influenced me in
  rejecting for years  this most valuable instrument.   I  say unfortunately,
 for I now recall to my recollection numerous cases in Avhich I failed to
  afford relief for A\rant of this or a similar instrument.  I believe that there
 is much less danger of making a false passage wdth the lanceted stilette,
 carefully directed against an impermeable stricture, than in the use of the
 common catheter  or  sound.  As to the  effusion of urine and purulent
 deposits, how rarely do  they occur, in cases Avhere great violence has
 been used, and  lesion of structure  has taken place in the  attempts  to
 introduce instruments into the  bladder.   In the  use of  Mr.  Stafford's
 instrument, admitting that the division is not made in the direction of the
 canal, it is certain to be made anterior to the obstruction, and consequently
 not  likely to be attended Avith infiltration  of urine.   In lieu  of  Mr.  Staf-
 ford's operation, Sir. Benjamin Brodie proposes the following modification,
 which he adopted in the patient,  viz.:   "I then make an  incision in the
 perineum, dilating the fistulous sinus,  and laying open the membranous
 part of the urethra as far  fonvard as the stricture, the exact situation  of
 which was marked by the bougie.  The bougie  was then withdrawn ;  an
 instrument Avas then introduced in its place, consisting of a straight silver
 tube, closed at  its extremity, except a narrow slit, through wdiich a small
 lancet could be made to project, by pressing on a stilt which projected on
 the handle of the instrument; the round extremity of the tube being pressed
 against the anterior part of the left hand,  introduced through the wound
 in the perineum and urethra to its posterior surface.   The pressure of the
 instrument being distinctly communicated  to the finger through the sub-
 stance of the stricture, the  lancet ivas protruded, and the  stricture  was
 divided.  A silver catheter Avas then easily introduced through the urethra
 and divided stricture into the bladder, and  allowred to remain there.  The
 urine, of course, llowed through the catheter.  At  the end of two days
 the silver catheter  was removed, and  replaced  by  one of elastic gum.
 The Avound in the perineum gradually healed, and the patient ultimately
 recovered, making  Avater in a full  stream, and  being able to  introduce
 a sound of a full size into the bladder, so  as  to  prevent a recurrence of
 the contraction."
  Now the follow ing is Mr. Stafford's plan.  The single lanceted stilette,
or urethral perforator,  is passed down to the stricture, the exact distance
of which from the  extremity of the urethra is first  ascertained.  When 
b88
STRICTURE.
the point of the instrument is arrived at, and  rests upon the contraction
(Avhich is knoAvn by means of its graduation), and is in an exact line with
the natural course of the canal, the instrument is held  and  maintained in
that position by the left hand, the fore-finger of Avhich being passed through
the ring on the under part of its  handle, the thumb of the  right  hand is
passed through the ring on the handle of the stilette.   The stilette is then
pressed gently and gradually forward, Avhen the lancet is protruded  out
at its  point, and is thus made to incise the  stricture.  The lancet must be
immediately drawn  back, or alloAved to  retire into  the sheath, by  the
action of the spring.
   In the operation\vhich  is proposed by Sir Benjamin Brodie, as a modifi-
cation of Mr.  Stafford's, and as a substitute for it, an  external Avound is
made in  the perineum for the purpose of preventing  infiltration of urine,
and next for the purpose of guiding the lancet.
   I have already alluded  to the  little chance of infiltration of urine, and
I know of  no case in which it has occurred.  As to guiding the lancet, I
really think the instrument may be as safely guided  when passed doAvn
the urethra,  and  held properly  against the  stricture, as by the finger
introduced through the Avound  in the perinasum.  The principle of  the
operation is Mr. Stafford's ; the modification is the opening in the perineum,
which complicates the operation, inflicts additional  pain, and  prevents  the
patient, for a time at least, from following his usual avocations.
   I am not wishing to urge this plan of treatment  in cases where there is
any passage,  however small,  through the stricture ;  but in  every  case
where the  contraction is so great as not to admit  of the introduction of
an instrument, Mr. Stafford's plan, in my opinion, offers a safe, speedy, and
effectual mode of  cure.                                Part vi., p.  115.

   Stricture of the Urethra.-r Dr.  Leroy d'Etiolles,  advises  when  the
stricture produces complete retention of urine, to endeavor to pass bougies
in  conjunction with bleeding,  baths,  etc.; try the application ot  tobacco
smoke';  should these fail, press a small catheter against the obstacle lor an
hour.  Cut down  upon the urethra posterior to the obstacle, but should a
calculus be  there detained, cut through the rectum.  If necessary to
puncture the bladder, do it through the rectum.  M. Lallemand cuts down
on the strictured part itself.                           Part xnb, p. 286.

   Opium in Stricture of the Urethra.—There is a  case related in  the
reports of  the  Ipswich Medical  Society,  of an old man with obstinate
stricture, and Avho had passed no urine from the Saturday to the Tuesday,
when it was determined to puncture the bladder.  But having taken two
grains of opium, and repeated the dose in  an hour, the spasms relaxed and
the operation Avas not required.                        Part xx., p. 229.

   Instrument for Dividing Strictures.—  M. Civiale  has invented a new
instrument for the division of indurated  strictures of the urethra.  The
principle of the improvement consists iu the division of the strictures from
behind forward, instead of cutting in the reverse directions, as hitherto
practised by surgeons.   The  new  instrument, according to  M. Civiale,
has the.  advantage over  the old  method  in the fact, that  the extent of
the incision can be precisely ascertained,  and  controlled by the operator,
and a division of all the tissues can be performed Avith safety.
                                                      Part xix., p. 184 
STRICTURE.
589
  Stricture of the Urethra.—There is a form of stricture, marked by the
" tightness of the contraction,  the resilient disposition  displayed after
dilatation, and the great degree of irritation induced by attempts to effect
this," in which Mr. Syme has advised the free division  of the  contracted
part upon the director.
  The best plan is to introduce a grooved director into the tight portion,
to cut  down upon it, and  freely  divide the stricture, and introduce a
catheter into the urethra.  This plan must not be confounded with that of
introducing a catheter as far as the stricture, cutting doAvn upon its point,
and then Avith the knife cutting a way for the catheter to the bladder.
                                                     Part xix., p. 181.

  B. Cooper's Treatment of.—[Mr. Cooper would substitute the name of
" irritable" for that of " spasmodic,''''  as  applied to stricture, since the
latter term involves the idea of  the disease being caused by muscular
action :  Avhile this is not really the case, except in the membraneous and
bulbous portions of the urethra.]
  Irritable or Spasmodic.—Give a dose of opium Avith tartarized antimony,
a hot bath, and warm  purgative enema.  These measures should ahvays
precede the employment  of the  catheter,  and Avill  generally be found
sufficient to afford relief without resorting to its use.   In obstinate cases
of mixed stricture, cup in the perineum, give two grains of calomel and a
grain of opium at night, and, during the day, small doses of the tincture
of muriate of iron.  At the same time employ the bougie very gently.  If
it produces pain and bleeding, apply caustic to the stricture to diminish its
irritability and introduce into the rectum, at bedtime, a suppository con-
taining a grain and a half of opium, and five grains of  extract of henbane,
mixed with soap.
  Permanent.—In the first place, explore the urethra. Making  the patient
lie down on a sofa, introduce a bougie or silver catheter (No. 6), and press
it gently, for a minute or  more, against the stricture.  If it should pass
the stricture, do not seek to introduce  it further.  After the  use  of the
bougie,  let the patient keep  quiet and on low diet for the rest of the day,
and take a draught containing  liq.  potass., gtts. xx.; tinct. opii, gtts. x.;
mjst. camph. §iss., at bedtime, and an aperient in the morning.  In about
forty-eight hours, introduce the bougie again, and  this time  it may be
passed  into the bladder,  and allowed   to  remain for ten  minutes or a
quarter  of an hour.  If No. 6 cannot be  introduced, carefully try a smaller
one. If no instrument can be passed, be guided as  to  the treatment, by
the urgency of the symptoms.  When there is retention of urine, and the
pain complained  of is very  severe, put the patient in a hot bath, give a
grain and  a half  or  two grains of opium, and a purgative enema; and
when the bowels are opened, introduce into the rectum a suppository, con-
taining opium, and a quarter of a grain of belladonna.  These  means will
generally relieve  the urgent symptoms.  Then proceed with  the treat-
ment, introducing a bougie gently every  other day ; and Avhile  this is
being done, insist  on the  patient living very  carefully, and  give such
medicines as blue pill with tartarized antimony, followed by aperients.  K
the stricture becomes irritable,  give sedatives,  and  apply the caustic
bougie carefully.  If the attempts at dilatation by the bougie fail, try the
repeated injections of tepid water into the urethra.  If by all these means
relief is  not  obtained, and  the  patient  is suffering  from retention, or is 
590
STRICTURE.
threatened with ulceration of the urethra behind the stricture, the bladder
must  be punctured.  Under very urgent  circumstances Ave may puncture
by the rectum  (provided that  the  prostate is not enlarged);  but as a
general rule it is much better to cut doAvn upon the urethra, and divide the
stricture in the perineum.
  The operation of dividing the stricture in perineo is performed with the
patient in  the  same  position as in lithotomy : an instrument is passed
down to the stricture, the grooATed staff being perhaps the most appropriate
to the purpose.  An incision is  next made  in the perineum, commencing
at the point where the end  of the instrument can be felt  resting on the
stricture ; the groove is  then to be cut into, and the knife carried down-
ward Avith great caution, cutting the way  for the point of the staff, which
should be made to follow it as it gradually divides the stricture, and the
staff,  being pushed  on, passes into the bladder.  The staff should then  be
withdrawm, and an elastic gum catheter put in its place, and retained there
for several days.
  In cases of fistulous opening in the perineum being concomitant wdth the
stricture, Mr. Cooper adopts another plan for performing this operation.
He says :
  Having  made the  incision into the perineum,  instead of opening the
urethra at the groove of the staff as before described, I have first opened
the membranous parts of the urethra behind the stricture, and then passed
a female catheter into the bladder, and drawn off the urine ; thus relieving
the patient of the retention, but having still to divide the stricture ; this
is effected by feeling  within the wound for the point of the grooved staff
above the stricture;  and,  proceeding to  cut  through the  obstruction,
carrying forward the staff as before described  (first, however, having
withdrawn the female catheter), the staff enters the bladder through tho
opening originally made for that instrument.   The staff should then  bo
withdrawn, and an elastic gum catheter inserted in its stead ; this should be
left in for a week, Avhen  it must be removed, and substituted by a neAV one.
At first, some urine will escape by the Avound through the perineum, as in the
operation for lithotomy; but generally in the course of a week or ten days
it passes entirely through the  catheter.  About a fortnight  after it has
entirely ceased to flow from the perineum, the catheter should be removed,
but still for some time the patient should  regularly have the Avater drawn
off, and this, if performed with gentleness, produces much less irritation than
would be excited by the constant presence of an instrument in the bladder.
  When a permanent stricture occurs in the urethra anterior to the  bulb,
and especially in  that part of the canal covered  by scrotum,  it is not
advisable to cut  down  upon  the  stricture from Avithout, owdng to the
liability to infiltration of urine if the incision be made through the scrotum,
and of the difficulty of healing the Avound when the  opening is  made
anterior to it.  The cure of such stricture must, therefore, be assiduously
attempted by  the  use of bougies or caustic, or  should  they resist this
treatment, perhaps the  instrument,  furnished with  a cutting  stilette,
employed by M. Stafford, may  be used; as this part of the urethra may be
rendered straight, the instrument may be directed wdth much more certainty
than Avhen the stricture is seated in the curved portion of the canal.   I
should myself, however, prefer opening the urethra behind the stricture, if
reteution demand it, rather than to puncture the stricture itself.
                                                     Part xix., p. 189 
STRICTURE.
591
  Use of the Bougie in Stricture.—Mr. Solly,  of St. Thomas' Hospital,
Bays:
  "When the catgut bougie is used, the great secret is  to  handle  it Avith
the utmost  delicacy, and twirl it gently betAveen the thumb and finger
when  it  meets  Avith  obstruction.  When  it  is introduced it  should  be
allowed to remain  for an hour.                         Part xix., p. 194.
  Case of Stricture attended by Profuse Discharge.—[In  this  case there
Avas such profuse discharge, that gonorrhoea Avas suspected.  The  patient
had previously had stricture, and as he completely negatived the idea that
it was gonorrhoea, Mr. Smith suspected  that he  might  have stricture
remaining.   He says:]
  I requested permission to examine the urethra, and, on doing so,T dis-
covered two irritable strictures.  I told him that tins Avas the cause of the
discharge persisting, and that it was necessary for him to come to London
every week to have the bougie passed.   I,  at the same time, desired him
to refrain as much as  possible from sexual  connection, and from all other
species of excitement.
  I need not enumerate the  particulars of this  case,  Avhich Avas trouble-
some to treat—for  the urethra Avas so excessively irritable that about three
weeks after this, I could only introduce, Avith some trouble, a No. 4  bougie.
In a short time, hoAvever, a good-sized instrument could be introduced, the
discharge diminished,  and, at the end  of  two months,  I  passed  No. 12
bougie ; all discharge  had ceased.  He  had latterly used a weak solution
of acetate of zinc,  in order to diminish the irritability of the urethra, and
hasten the cure.  I advised him to return to me in another month, in order
that I might ascertain if the cure Avas satisfactory.  He visited  me last
Week. " The urethra admitted No. 12 bougie, and  the discharge had never
returned.                                             Part xx., p. 159.

  Strictures—Mr.  Guthrie''s Conclusions Respecting.—1. That a hard and
elastic, or an intractable stricture is never permanently cured by dilatation,
or by the application of caustic, although it may be materially relieved by
the regular periodical use of a dilating instrument.
  2. That the division of an old, hardened, or elastic stricture through the
perineum is not usually followed by a permanent cure, although  it is always
attended by immediate relief.  The disease being apt to return unless a
solid sound or catheter is occasionally passed to  prevent it.
  3. That the operation of dividing the perineum and urethra  in such
cases  is sometimes attended by severe hemorrhages,   by fever,  and is
occasionally folloAved  by fistulous openings, giving rise to much incon-
venience.
  4. That such division does, in some instances,  effect a  permanent cure.
  5. That the division of the urethra through the external  parts  should
never be attempted in any portion of it anterior to the  bulb, such opera-
tion not being necessary; for the narrowest stricture  of the pendulous or
movable part may  ahvays be divided internally with much less comparative
danger than by  the external incision, inasmuch  as the instrument  can be
guided through this part by the finger  and  thumb of the left hand of the
Burgeon wdth a certainty almost unerring.
  6.  That the stricture considered by all surgeons as the most important
and difficult of cure—viz., at the termination of the bulbous portion of the
urethra—may always be divided, when impassable, by a straight instru- 
592
STRICTURE.
ment, and in general more easily than by a curved one;  the use of which
is  founded on  the erroneous belief that the stricture is situated  in the
membranous part of the urethra, instead of being, as it is, anterior to it.
   1. That the division of a stricture should, if possible, be effected  by an
instrument passed through it, and  cutting from behind forward,  rather
than from before backward, although a combination of both methods wdll
frequently be necessary to insure success.
   8. That the division of a stricture by these means will not ahvays  insure
a permanent  cure if more than the mucous membrane is implicated,  unless
such parts be divided also.
   9. That in cases of intractable stricture, the mucous membrane, the inner
layer of involuntary muscle, and the elastic tissue external to it, should be
divided when the  operation is done from within, but not the outer layer
of muscular  fibres, Avhich should remain as a barrier betAveen the stream
of urine and  the common integuments of the  external parts— an accuracy
of division not ahvays to be  attained;  Avhence, perhaps, the difficulty of
effecting a permanent cure.
   10. That Avhen  a permanent cure  is effected in these cases, the divided
elastic wall of the  urethra is not re-united by a structure exactly similar to
itself, but by common areolar tissue, rendering the part  more  dilatable
under the pressure of the stream of urine; the formation of which  dilata-
tion can be aided during the progress of the  cure  by pressing on the
divided part Avith the point of a solid instrument passed daily for the pur-
pose of preventing, if possible, that contraction wdiich ahvays takes place
during the process of cicatrization ;  a proceeding Avhich cannot be  advan-
tageously adopted Avhen the parts are divided through the perineum, lest
it should encourage the formation of a fistulous opening, to Avhich there is
always a tendency.
   11. That in cases of intractable stricture accompanied by one or more
fistulous openings in  the perineum, in young persons, or  of middle age,
the operation through   the  external parts,  or  along  the urethra, may
be resorted  to at the pleasure of the  surgeon with  an equal chance of
success, provided  the portion of the obstruction or bank preventing the
free passage of the urine be  effectually divided, the sine  qud non of the
operation.
   12. That the operation within the urethra should always be preferred in
elderly  persons, particularly  if somewhat stout  or fat, as less likely to
create severe constitutional disturbance, and if this operation should fail
from any cause, it by no means interferes with the due performance of
the other through the   perineum, which in serious  cases then becomes
imperative, as the last resource capable  of giving relief.
                                                    Part xxiv.,  p. 221.

   Pr f. Syme's Operation for Urethral Stricture.—The  patient  having
been placed under the influence of chloroform, is " brought to the edge of
his bed,  and his limbs are supported  by two assistants, one on each side.
A grooved director,  slightly curved, and small enough  to pass  readily
through the stricture, is next introduced, and confided  to  one of  the  as-
sistants.  The surgeon  sitting, or  kneeling on one knee, now makes an
incision  in the middle line of the perineum or penis, wherever the stricture
is seated.  It should be an inch Or an inch and a half in length, and extend
through the integuments, together with the subjacent textures exterior to 
STRICTURE.                           593
the urethra.  The operator then taking the handle of the director  in his
left hand, and  a  small  straight bistoury in his right, feels, Avith his fore-
finger guarding the blade, for the director, and pushes the point into the
groove behind,  or on the bladder side of the stricture, runs the knife for-
ward, so as to divide the wdiole of the thickened texture at the contracted
part  of the canal, and Avithdraws the director."  A silver catheter is noAV
alloAved to remain in the bladder for forty-eight hours, after which it is to
be withdrawn.  After eight or ten days a moderate-sized bougie should be
passed,  and its introduction repeated once every Aveek or fortnight for
two  months.  Mr. Syme makes it an indispensable condition of his  opera-
tion, that the stricture should be permeable; in  other Avords, should  admit
the passage of an extremely small  director at least; and in  order  appa-
rently not to limit the usefulness  of  his operation, he asserts that there i»
no truly impermeable stricture.   He also condemns, in measured terms,
the old operation  of cutting into the  perineum in search of the obstructed
canal without any further guide than the point of a catheter, introduced,
not through, but merely down to the contracted point.   An  imperfect di-
vision of the contracted part—want  of care to pass instruments while the
urethra is healing, as all injuries of the canal are apt to occasion strictures
when this precaution is neglected—and subsequent exposure to a repetition
of the causes which give rise to the  disease—may prevent the advantage
gained from lasting so long as could  be  desired.  The first  of these cir-
cumstances  tending  to  cause relapse did not originally occur to me, but
was  suggested by facts  falling under  my observation, Avhich led to the per-
suasion that as a stricture  gives the canal a sand-glass form at the part
affected, it is not  sufficient to cut merely the narroAvest portion—the coni-
cal-shaped contraction on each  side of it  also requiring division;  so that,
instead of being  limited to a quarter or half, the incision should extend a
Avhole inch through the  coats of the urethra.  In regard to the after-treat-
ment, as wounds and bruises  of the urethra are apt to induce  strictures,
unless  a full-sized  bougie be passed occasionally  until  the  part  affected
recover from the injury  which it has  sustained, there can be no doubt that
if this precaution  is neglected after the operation for stricture, there must
be a risk of relapse.  And it is no less obvious, that hoAvever perfectly the
patient may be  relieved  from an existing  stricture, he cannot reasonably
claim exemption from the production of another, if he exposes himself to
the exciting  causes.  It Avill, therefore, be prudent to enjoin sach a mode
of life  as may, as far  as possible, afford protection from the influence of
circumstances calculated to  act  in  this way.   With due attention to all
these points, it is  reasonable to  expect that the obstinate forms of stricture
in question may be effectually remedied by an operation of the utmost sim-
plicity and most perfect safety; and  that the relief will  generally,  if not
always, prove permanent.                              Part xxvi, p. 199.

   Traumatic Stricture  of the Urethra.—Mr. Coulson asks  the question,
where great damage has been done to the urethra from injury, whether it
would not be better to contrive some artificial  outlet for the renal  secre-
tion, than to  make repeated  attempts  to rectify the  state of the natural
canal when they are not likely to be attended by success.   He thinks  rather
than risk repeated attacks of  retention, the best plan wrould be to make
an opening into the bladder aboAre the pubes, or through  the  rectum, and
by allowing the urethra perfect rest  for a few days, favor  its leturn to a
     vol. n.—38 
594
STRICTURE.
 normal state, and then, if after several weeks' rest, the urethra is found so
 mutilated as not to be amenable to the treatment by dilatation, to make
 such temporary opening permanent.                   Part xxvi, p. 213.
   New form of Director for  the remedy of Stricture by External Inci-
 sions.—In  his operation by external  incision, Mr. Syme  has  frequently
 found the inconvenience of not being able by ordinary instruments to tho-
 roughly divide the contracted portion of the urethra.  To this fact, Mr.
 Syme believes, are OAving the relapses said sometimes to take place.  He
 has had a solid director recently made, but with  a long slender  portion
 which is grooved, and this latter part being much  smaller than that usually
 employed,  passes Avith more readiness completely through the stricture.
 The operator noAV cuts through the integuments above the stricture into
 the groove, runs the knife down until the contraction is completely divided,
 as  is readily seen by  the thicker portion  of the  director passing easily
 through the whole length of the canal.               Part xxviii., p, 215.
   Stricture of the Urethra.—Dr. Dick operated  in a case  of stricture  as
 folloAvs:  Making a very small  opening above the stricture  through  the
 integuments into the urethra, he introduced a curved tenotome and divided
 the stricture from before backward.  The ready  passage of  the  sound
 proved that the stricture Avas completely divided.     Part xxviii.,/). 215.

   Stricture  of the  Urethra.—If we wish to know whether the bougie is
 pressing against  the Avails of the  urethra, or has entered the stricture, we
 must draw it gently back; if the latter, we shall meet with some degree of
 resistance, as if  it had been grasped  by some contracted  orifice.  If the
 stricture  be long and  callous, the bougie may cease to advance, and in this
 case it should be withdrawn and a larger  one introduced.  Catgut bougies
 are going out of use; the  common plaster ones  are not very convenient,
 but they must be employed wdiere the contracted parts are tortuous and
 of  small  calibre.  Mr. Listen, however, rejected  them altogether, and  if
 the stricture was moderate, used a plated metal bougie, and if very tight,
 a small silver catheter.  Mr. LaAvrence is another higb authority in favor
 of  metallic sounds.   Having been passed, the instrument should remain in
 the urethra a short  time, and then be withdrawn, introducing it again on
 the third day, and if it is Avell borne, introducing it daily, and allowing it
 to  remain a  longer  time, so  as  gradually to dilate the strictured part.
 This is a good but a tedious plan, and some surgeons prefer introducing a
 small  instrument first, and then immediately passing  in rapid  succession
 two or three of  a larger  size, until the patient complains of weariness or
 pain.  Permanent dilatation is effected by passing  an instrument and allow-
 ing it to remain forty eight-hours or longer, according to the case, then this
 is withdraAvn and a gum-elastic catheter substituted.   This  maybe left for
 from two to six days ; it is then withdraAvn and a larger instrument passed,
 and so on until the dilatation is complete.    For this purpose Mr. Wakley's
 instruments are very useful, consisting of silver and flexible tubes of gradu-
 ated sizes.                                           Part xxix., p. 226.
  Stricture  of the Urethra.—Prof. Syme says :  Stricture never occurs in
the membranous  portion  of the urethra.   If you divide the urethra into
three portions, the prostatic,  membranous, and the remaining part which
is OA'ered by the  corpus spongiosum, it is in the last portion that all stric-
tures exist.  It is never  necessary, therefore,  to cut beyond the bulbous 
STRICTURE.
595
 part of the urethra, as no strictures are beyond the bulb.   If you bear these
 facts in mind, you need not dilate sinuses, which  are  sure  to close  when
 the stricture is removed.   A catheter should  be introduced into the blad-
 der after the operation, and retained  for 48 hours—not less, on account of
 the risk of extravasation of urine, and not longer, because it is unnecessary
 and apt to do harm.
   Mr.  Syme's set of bougies are exceedingly small in size.   No. 1 is per-
 haps smaller than those made anywhere else.  The tightest and worst stric-
 tures are  anterior to the scrotum.  A stricture in this place is felt like a
 small pea, somewhat elongated.  This is the kind most unmanageable by
 dilatation, and most successfully and easily treated by division. T'ass a very
 small director (Avhich is here comparatively easily done, but Avould be very
 difficult at the bulb).   Introduce the  point of  the  knife into the groove of
 the director anterior  to  the stricture, and push it backward through it,
 while the  end of the penis is held firmly.   Cut backward in stricture ante-
 rior to the scrotum, and forward when  the stricture is at the bulb.  Yon
 will never meet with a tight stricture behind the scrotum along with an
 extreme contraction in front of it.                     Part xxxl,p. 159.
   Stricture of the  Urethra.—As a rule, Mr. Syme, in common with sur-
 geons generally in this country, treats  stricture by simple dilatation, es-
 chewing the use of caustics and internal incisions.  So firmly persuaded is he
 of the  efficiency of the catheter, that he believes there is no  stricture, how-
 ever narrow, Avhich will not admit an  instrument, provided it be sufficiently
 small,  and be employed with  care and  patience.   He therefore beheves
 that it is wholly unnecessary to  resort  to  the operation of dissecting
 through what have been termed impermeable  strictures, preferring to
 insinuate a catheter rather than to employ a knife in these  circumstances.
 Hence  he disapproves of that operation  usually termed  "the perineal
 section," which has been frequently resorted to in this country for the last
 thirty-six years.  Having proceede 1 to employ dilatation, if he finds that the
 stricture rapidly reappears in spite of it, or that the process involves much
 constitutional disturbance, he  prefers to divide freely the  stricture from
 the perineum, upon a grooved director, performing the incisions in the
 median line, tying  in  a catheter for forty-eight  hours, and subsequently
 passing it  a few times  at about  Aveekly  intervals.  This  proceeding, to
 which  he  gives the name of "  external division," is stated  by him, on the
 ground of an extensive experience, to be devoid of danger, and generally
 to be attended with a successful result, a conclusion Avith wdiich our own
 experience of it leads us, wdthout any hesitation, to coincide.
                                                    Part xxxii., p. 169.
   Stricture of the  Urethra.—Mr. Lawrence, surgeon to Northern Dispen-
 sary, says :  The following method of applying caustic in these cases is free
 from the  ordinary objections  to the practice.  Coat the end of a catgut
 bougie very evenly wdth a fine layer of caustic, by immersing it in  fused
 nitrate of silver, to which a little water has been added.  Pass a full-sized
 straight catheter w till one terminal aperture completely down to the stric-
 ture, then  pass the armed bougie through the catheter into the stricture,
 and by gently rotating the bougie, the  Avhole tract of the stricture  may
 be freely and equally cauterized.                     Part xxxii., p. 115.
  Stricture  of the  Urethra.—In the employment of dilatation, says the
" Lancet,"  the golden rule which must guide  us, both in  regard to the 
596
STRICTURE.
extent it  may be  carried at the time, and the length of interval which is
to elapse between each repetition of it, is to exercise just so much pressure
and  dilating poAver as can be exerted without producing pain or uneasi-
ness, or more than slight irritation, and not to repeat the process until any
excitement produced by the previous catheterism has completely subsided.
The fulfillment of these indications will conduce in the long run the most
quickly and safely to a successful result.               Part xxxiii., p. 194.
  Maisonneuve's  Method.—The  method which M. Maisonneuve  adopts
for their radical and instantaneous cure is that by internal division.  When
very contracted, he commences by passing a very fine thread-like bougie
into the bladder—this will require great tact  and  perseverance :  another
larger bougie is then  articulated  to  the end of this, and pushed forward,
so  that the first  bougie becomes coiled up in the bladder; when this is
thoroughly in the stricture it  must be AvithdraAvn, and another filiform
bougie passed, to  Avhich is attached the cutting instrument of Frere Come.
When this is fairly in the stricture, you must unsheathe the bistoury and
withdraw  the instrument,  cutting through  all resistance.  The patient
generally gets  Avell in fourteen  days.  As to the possibility of relapses,
nothing at present can be affirmed—it is a question to be  judged of here-
after.   This method of treatment has been the subject of much discussion
before the Surgical Society of Paris  ; the result of this  shows that dilata-
tion is still the best and safest plan, and that the cases are very few requir-
ing incision.  If a patient can bear  with tolerable ease  a  moderate stric-
ture, he had better do so  than  be operated on, for experience  shows it is
not free from danger, hoAvever  practised.             Part xxxiii, p. 206.
   Stricture of the Urethra.—Mr. Solly, of St. Thomas' Hospital, believes
that the  knife ought never to be  employed  in  any case Avhen  you can
introduce the thread catgut bougie, that  is, in  any stricture Avhich is
pervious.  When  you can once introduce a bougie  into  the bladder you
can cure that  stricture  without  cutting.  There is not  one case in two
hundred, of even  bad strictures, ivhere the knife  need be used at all.
Mechanical means must be combined with medical treatment; if you can-
not pass  a bougie, give one grain of the iodide of mercury three times a
day to promote absorption, and the buchu mixture  to relieve irritation.
To  pass the  bougie as far as the stricture, and allow it to remain half an
hour with gentle pressure, wdll  excite the  absorbents.  If you can pass a
fine catgut bougie, pass over  it  a  No. 5 elastic tube, and Avithdraw the
bougie.  As a general rule, the bougie  should be passed every other day
for the first Aveek or fortnight, afterward the periods to be lengthened to
once a Aveek, then once a fortnight, but the use of the  instrument must
never be  abandoned altogether.                      Part xxxiv., p. 167.
   Stricture of the Urethra.—In Syme's operation for stricture, one element
essential to its success has by many  been entirely overlooked, and that is,
the necessity of passing a full-sized bougie at intervals, gradually increas-
ing, and for a considerable time after the cicatrization of the opening made
in the urethra.  In the treatment of stricture of the  urethra great advan-
tage wdll be gained  by passing  a  No. 8 catheter as far as possible, and
keeping its point pressing Avith moderate firmness against the obstruction
for  t\velve or twenty-four hours : systematic attempts should then be made
to overcome the impediment, first, with the No. 8, and then, if necessary,
 others of smaller calibre.  This is  a powerful idjunct to the ordinary mode 
STRICTURE.                          597
of treatment Avith the bougie, and should be employed in certain cases,
which may be  classified as folloAvs:   1.  Those in AA'hich the contracted
portion  is longer than  usual.  2. Those A\dtich afford but little  time for
treatment.  3. Those which are likely to  resist the passage of an instru-
ment for a considerable time.  4. Those which would yield if the patient
would rest, but Avhen he cannot.                     Part xxxiv., p.  169.
  Syme's  Operation for.—Prof. Syme states that there can hardly be any
serious hemorrhage  in urethrotomy by external incision unless the artery
of the bulb has  been  wrounded,  which  may certainly be avoided by cutting
in the middle line upon a grooved director.^   Extravasation of urine  may
take place if the stricture be not freely divided, or, still Avorse, if the stric-
ture be undivided and the  urethra  be opened behind it.  The urethra
should be freely exposed before opening it, so  that the incision  of its coats
may not  be  subcellular, Avhich Avould expose the  patient to the same
dangers Avhich  attend internal  incision.  There can  be no safety unless a
free drain be provided for the urine through a full-sized catheter;  this
will require very careful management: the external  extremity should be
curved doAvnward, so that the urine may fall into a vessel Avithout wetting
the bedclothes; stopcocks  are  productive of much danger, the person in
charge gets confounded, so as not to know whether the catheter is open
or shut, and if the patient makes  any  expulsive efforts he may do himself
much injury.  It will be much better to keep the catheter constantly open,
so that the urine may not pass along its outer  surface.  The patient should
remain  quiet on his  back, with a pilloAV under his knees, for forty-eight
hours, no  change of  position  being alloAved.   It is not desirable that the
wound should heal by the first intention;  if there be any tendency to  this,
the finger must be occasionally introduced so  as to feel the instrument, or
the patient Avill be exposed to  a relapse of the disease.  Strictures do not
occur behind the bulb, except in cases of extreme rarity, so that incisions
into the membraneous portion of the canal are  unwarrantable.  The danger
of extravasation will be especially serious when the deep facia of the  peri-
neum has  been  divided ; in such cases the introduction of a straight tube,
as after lithotomy, will effectually prevent the  risk of serious consequences.
                                                   Part xxxiv., p. 181.
  Retention of Urine from  Stricture—Syme's Operation.—When there
is repeated retention of- urine, says Mr. Lane, it will be necessary to open
the membranous portion of the urethra behind the stricture.  To do this
it is necessary to hit  off, wdth microscopic  accuracy, the delicate line of the
raphe, for, if we cut  sideAvise  through the muscles, the wound will  be
found to gape, there  will be hemorrhage and extravasation of urine.   This
operation  is much more easy  and  successful than puncturing  the bladder
through the rectum, for, while the recent Avound is healing the previous
stricture Avill be found to give Avay very much, so that an instrument may
readily be passed.                                   Part xxxiv., p. 183.
  Remedy of  Stricture by  External Incision.—Prof.  Syme says,  with
regard to  the use  of  external incision  in the treatment of stricture, that it
is not true that wounds of  the  urethra, like those of the skin, must  heal
either by adhesion or granulation, and so the old contraction  be restored
with greater firmness than  before.  It has been repeatedly shoivn that the
most tightly contracted urethra may remain perfectly patent after division
of the stricture, and in the bodies of some persons Avho  have died several 
598                           STRICTURE.
years after  the  operation, the canal has  been found actually lvider than
natural, and the surface of the previously deranged mucous membrane not
distinguishable from the neighboring portion.        Part xxxvi., p. 113.
  Source of Danger in Division of Stricture.—Out of the great number
of cases operated upon by Mr. Syme, he has met Avith two in Avhich during
the act of micturition, acute pain in the  perineum was followed by quick
pulse, delirium, and death.  In neither were there any signs of local mis-
chief, but in one  the  kidneys were gorged with blood  to  an extreme
degree ;  besides these  two  cases, slighter symptoms of disturbance oc-
curred in many others.  It was  noticed that these symptoms were always
connected wdth micturition  after wdthdrawal  of  the catheter, therefore
probably proceeding from  the action of the urine upon a raAv surface, pro-
duced by tearing  of the  imperfectly  united wround in the  urethra, and
being of the nature of a sudden shock to  the nervous system.   To obviate
this he introduces  a short  catheter by the wound  in the perineum, about
nine inches in  length, and slightly curved in  opposite  directions  at the
extremities.   By  thus keeping  the wound open a little longer perfect
security is obtained.                               Part xxxviii. p. 154.
  Stricture of the Urethra.— Urethrotomy.—Prof. Syme's practice is to
cut from behind forward, and not  backAvard, as is the London practice.
The risk of cutting the deep perineal fascia is much lessened.
                                                  Part xxxviii., p. 157.
   Sensitive and Contractile Stricture.—In cases of stricture so exquisitely
sensitive that the passage  of a catheter is followed by severe constitutional
and local disturbance;  also in cases  in which immediately upon omission
of  treatment  contraction  begins  to  return,  the operation  of external
division is  most valuable.  The above  opinion of Mr. Bryant upon this
subject  is  valuable, from  the large amount of experience necessarily ob-
tained at so large  a hospital as Guy's.               Part xxxviii, p. 158.
   Stricture of the  Urethra.—Syme's Operation.—Mr. Lee, surgeon to
Lock Hospital, observes : It is singular that the success Avhich has attended
Mr. Syme's operation should have varied  so considerably in different hands.
This can be accounted for in a great measure by the kind  of stricture for
which  the  operation  had  been undertaken hy different  surgeons.   An
incision  through the bulb is a safe proceeding, but an incision through the
membranous part, involving, as  it necessarily does, a division of the deep
perineal fascia, is a very unsafe proceeding, and not to be undertaken
except in cases of perineal fistulas, where the parts are often so condensed
by  adhesive inflammation, that incisions  may be made with instruments:
otherwise the operation is  adapted only to  cases of stricture confined to
the bulb of the urethra.                              Part xxxix., p. 207.
  Internal  Urethrotomy.—Mr. Thompson, of University College Hospital,
considers the  best instrument for ordinary use to be that designed some
fifteen years ago, by Civiale, of Paris.  The shaft is almost equal in size
to an ordinary  No. 3, the  bulb to No. 5.   By means of the bulb the extent
of the narrowing can be accurately told.   When  the instrument is used,
the bulb having been passed about half an inch beyond  the obstruction,
the cutting side must be  directed downward, and directly in the middle
line ; the blade is  made to project to the required extent, by means of an
apparatus  in the  handle, which  accurately controls it, and the instrument 
STYPTIC--SUPPOSITORIES.
599
is firmly pressed on the floor of the urethra, and slowly and steadily drawn
outward, about  an inch  or an inch and  a  half, so as fairly to divide the
obstructing  portion.  For smaller strictures than Civiale's instrument is
applicable to, Mr. T.  has  invented a smaller  instrument on essentially the
same plan.                                            Part x\.,p. 130/
                           STYPTIC.
  Aid of Turpentine as a Styptic.— Vide Art. " Turpentine."
  Styptic (M. Pagliari's).—This  styptic hquor,  which seems to have
abundant testimony in its favor, is  composed as follows: Eight ounces of
tincture  of  benzoin, one  pound of alum,  and ten pounds of water, are
boiled together for  six  hours in  a glazed earthen vessel, the vaporized
water being constantly replaced by  hot water, so as not to interrupt the
ebullition.  The resinous mass is to be kept  stirred round.
                                                    Part xxvi., p. 349.
  Styptic.—Solid Perchloride of Iron.—The perchloride of iron is manu-
factured  in a solid form in which state it is particularly manageable as a
styptic.  Another, and perhaps  superior way of using  it is to apply, by
means of a spun-glass brush, a small quantity of the thick brown fluid, into
which the solid perchloride kept in  a bottle always deliquesces.  It is par-
ticularly  useful, according to  Mr. Lawrence, in such cases  as  excision of
the tonsils, bleeding from the deeper-seated gums, etc.   No inflammatory
action follows the use of this drug.                      Part xl., p. 298.

                              ---»•«

                    SUPPOSITORIES.
  Dr. Simpson's Morphia Suppositories.—Mr.  Spencer WeU$ has intro-
duced into use at the Samaritan Hospital, a form of morphia suppository,
used with great advantage by Dr. Simpson of  Edinburgh.  Mr. Wells has
found  it  a most  convenient  form of suppository after  operations on the
vagina, rectum, uterus or perineum  of women, both in hospital and private
practice,  and  especially so after operations made  on the  genito-urinary
organs, as lithotrity, in cases of retention of urine, irritable stricture, xetc,
and after division of fistula in ano, or the removal of piles or  prolapsed
mucous membrane of the rectum by the ecraseur.  They act much more
efficiently than the soap and opium in common pill use as a suppository,
and are seldom or never expelled from the rectum after  then: introduction
above the sphincter.  The following is for the half grain suppository: Take
of acetate of morphia, 6 grains;  sugar of milk, 1  drachm;  simple cerate,
half a drachm, or as much as may be sufficient to make a proper consistence,
and divide the mass into tAvelve suppositories.   Then dip each suppository
into the following mixture, to form a coating: Take of white wax one part,
lard plaster tAvo parts; melt  together.   The best way is to insert a needle
into the apex of the  suppository, dip it into the melted  wax and lard, and
immediately afterward into cold water to harden it before it loses its shape.
The shape is conical, like a pastille.   It  is easily introduced by the finger,
or more  neatly by the ordinary ivory suppository syi/^.  Mr. Coulson 
*X)
SUTURES—SYNOVITIS.
has also used these suppositories  lately in several  lithotrity cases, and has
found them of the greatest benefit  in allaying the irritation Avhich often
attends the passage of the fragments of calculi through the urethra.
                                                    Part xxxv., p. 255.

                              -—♦■-•-•-----

                         * SUTURES.
  Employment of Threads of Caoutchouc for Sutures.—Mr. Nunnely,
of Leeds, recommends the use of caoutchouc sutures.
  " There are many cases where  the unelastic ligature in  common use  is
even prejudicial, and Avhere a more elastic thread might be advantageously
substituted.  It produces less  irritation, and holds the divided  parts to-
gether ivith much less stretching than  the common  ligature, and at the
same time it keeps up an equal degree of tension, 'for if the parts swell,
the ligature gives  way in  proportion to the pressure;  on the contrary, do
they contract, so also does the ligature, and an equable approximation  is
maintained.'  In hare-lip this kind of ligature might supersede the use of
pins."                                                  Part iii., p. 78.
  Bead Suture.—Vide Art. " Palate."
  Suture—New form, of.—This  form of suture was used by its inventor,
Mr. Spencer Wells, in an operation for  the cure  of vesico-vaginal fistula.
It is applicable in  most cases in which the quilled  suture is employed, and
is more easily applied.  Pass a pin, armed  with a shot  and  perforated bar,
through one edge, and then through the opposite  edge of the Avound, then
pass a second bar  over the point of the  pin, and  then a shot, which must
be pressed by  forceps  on  to the pin, so as to fix this bar in its  place, then
cut the pin off close to the shot.                      Part xxxv., p. 111.
  Lead- Wire  Suture.—In cases where it is desirable  to place a suture to
any part not easily reached, take a curved  needle, and a piece of lead-wire
which is very soft and flexible—the  end of the needle must be  so made
that the we may be screwed into it.  Pass the needle through the edges
of the wound,  cut off the needle, and with a pair of forceps twist the two
ends of the wire together, and double up the ends to prevent scratching.
                                                    Part xxxvi., p. 273.
  Aluminium  Sutures.—When  union by the first intention is required,
few will deny that silver sutures  possess great advantages over  ordinary
thread or silk ones.  Their great  drawback is their great cost.  Dr. Frod-
sham, surgeon to Cumberland Infirmary,  says that aluminium possesses all
the pliability and  other properties  of silver, and is  only hah0 the price.
Sutures may with great  advantage be  made of  this  metal, and will be
found to answer quite as well as silver.              Part xxxviii.,/*. 163.
                         SYNOVITIS.
  Gonorrhoeal  Synovitis.—Mr. B.  Cooper says: Patients suffering from
gonorrhoea are subject to the attacks of a  peculiar form of synovitis,
which so closely resembles the rheumatic affection, that it is sometimes ex-
tremely difficult to distinguish between them; and, indeed, it is only from 
SYPHILIS.
601
a history of the case that a just diagnosis can be  formed.  It usually
happens in such cases that the gonorrhoeal discharge ceases simultaneously
w ith the accession of the disease to the joint; and it is of the highest im-
portance that the  former should be reestablished  as quickly as  possible,
the best means being the application of Avarin fomentations over the organs
of generation.  I have never knoAvn  an attack of the above kind to occur
unless  the  patient has  taken copaiva, and am inclined to think that this
medicine acts specifically on the synovial membranes; for I have invariably
found  the symptoms of inflammation  greatly aggravated by its adminis-
tration.  Bark and alkahes, combined AAdth opium, seem to be the most
appropriate remedies, as colchicum does not afford  relief.  In these cases
the latter circumstance constitutes a further  distinction between gonor-
rhoeal and rheumatic affections.                        Part xvii., p. 130.

                              ----*♦-•----


                          SYPHILIS.
  Inoculation as a Test—M. Ricord's Process.—In all doubtful cases, the
patient is inoculated  from his OAvn sore, and if a  syphilitic ulcer is  pro-
duced, similar to the one from w hich the matter is  taken, it is considered
to be genuine syphilis, and treated accordingly.  But instead of alloAving
this second  sore to  proceed, M. Ricord destroys the  part  inoculated, on
the third or fourth day, before it has  proceeded far enough to produce
bad effects.   By long experience, M. Ricord knoAvs, even on the second or
third day, what would be the effects  of his inoculation, and  thus destroys
the part in time, as  unpleasant effects  might take  place Avere the second
sore to become intractable, as has occasionally happened.  Part l, p. 123.

  Employment of Platinum—Therapeutic Action.—The perchloride is to
be  regarded as  an efficacious  remedy in syphilis,  especially of a chronic
form.  The  chloride  of platinum and sodium is  more  applicable to the
recent  forms of the disease.   It is equally efficacious in rheumatic affections.
Platinum must be ranked amongst the alteratives along with gold, arsenic, and
iodine.  It differs from mercury in producing  previous excitement of the
system; and it does not cause the same serious accidents which often follow
the use of that drug.                                     Part iii., p. 61.
  Treatment of  Chancre—Vide Preparations of Antimony  and Mer-
cury, Art. "Antimony."
  Aphorism  of Practical Surgery.—Syphilitic  exostoses do not ahvays
disappear, although their primary cause has  been entirely removed.
                                                       Part 'ii\.,p. 116.
  Gangrenous Syphilitic  Ulcers.—Nitrous  acid saturated with nitrate of
silver,  recommended topically to arrest gangrenous inflammation and pha-
gedenic ulceration, resulting from syphilis.                Part v., p. 115,
  Inoculation as a  Test of Syphilis.—[Several objections  have been re-
peatedly urged against the process  of inoculating a patient to ascertain
with certahity Avhether or not the chancre is really syphilitic.  It has been
urged,  that by producing another sore, Ave increase  the chance of affecting
the  constitution ; but most  surgeons now believe  that  one sore Avill pro-
duce as much  mischief  as tAvo.   It  has  been also asserted,  that matter 
602
SYPHILIS.
from  any angry  sore, introduced below the skin, is likely to cause the
point to fester.   This, hoAvever, is denied by Mr. Mayo.  He makes the
following remarks on the way in which the inoculation is to be performed :]
  Before  arming the lancet, the suspected sore  should not have  been
wiped,  or dressed with  any chemical application, for two or three hours
at least.  The most convenient part for inoculation is the back of the lore-
arm immediately above the wrist.
  The point inoculated should be covered with a patch of sticking plaster,
and not disturbed for three days.
  At the expiration of that period, on examining it, either the punctured
point is found to be scarcely distinguishable, having healed, and having no
redness about it; or it has ulcerated, and  the skin  around it is inflamed,
and, if the epidermis is  not broken in raising the sticking plaster, there is
seen a small flat vesicle containing lymph 01  pus, surrounded by an inflam-
matory zone.   Occasionally, but very rarely, the inoculated point does not
become inflamed during the first three days, but on the fourth or fifth a
pustule suddenly forms.
   When  the  inoculation has  taken to this extent, the evidence required is
obtained.   The  suspected sore is certainly of syphilitic origin.  And, if
circumstances  are not present to contra-indicate the use of mercury, a
mercurial course should be immediately commenced.
   In  order to get rid of the artificial sore, we must freely apply the nitrate
of silver, so that the texture may be destroyed to the depth of half a line,
which  will almost certainly destroy it, and cause the sore to heal.
                                                        Part v., p. 145.

   Chronic Venereal Ulcers— Creasote.—In  chronic venereal ulcers, Dr. R.
Cormack of Edinburgh  has repeatedly  used creasote wdth advantage.   It
ansAvers very well to apply it pure once, when there is great deficiency of
action, and  subsequently to  employ an ointment of from four drops to
thirty, to the ounce  of lard.   The lotion is also a very  excellent form of
application.   In phagedenic ulcers, ulcerated chilblains, and sores yielding
a sanious discharge, Dr. C. has often used creasote with great benefit.
   In the application of creasote to ulcers and other solutions of continuity,
there are several facts wdiich  the practitioner should  bear in mind.   It is
important to remember that water only dissolves one-eightieth part.   If an
excess  of creasote be present, it  wdll float on the surface in small globules,
and can therefore very easily be removed;  but if this is not done, when
the lint is dipped in the lotion, these globules will adhere, and in this way
a very  different  wash from what was intended, is  placed upon the sore.
In very few cases, Avhere the  raAv surface is  extensive, pure creasote ought
to be applied to the whole of it, as severe irritation is generally the result.
                                                        Part vl, p.  14.
   Syphilitic Sore Throat—Iodine Gargle.—Dr. James J. Ross says :
   Another case in which the local use of the tincture of  iodine is of signal
efficacy, is that of ulcers of the tonsils and fauces—specific or non-specific.
I have seen the ugliest sores  in  this situation put on quite a healthy  ap-
pearance  in  a few days under  its use.  It is  highly recommended  by
Ricord, and certainly I do not  know anything equal to  it in such cases.
It is best in the form of gargle; thus :
   E Tinct. iodin., 3j-ij-; tinct. opii, 3j.; aquas,  §aj.  M.  Fiat. garg.  ter
quaterve in die utenda. 
SYPHILIS.
603
   It may be made Aveakcr or stronger, with »r Avithout the laudanum.  It
 requires to be well shaken when used.
   The first case in which I  used it, avus one of irregular phagedenic ulce-
 ration near the base of the uvula, Avith patches of a white exudation on the
 back  of the  pharynx ;  the voice, respiration,  and  deglutition being all
 affected. The general aspect of the patient was cachectic, but he denied ever
 having had syphilis.   The above gargle was ordered.   An improvement
 was observable on the third day of its use, which Avent on steadily and rapidly
 to a perfect cure.   In another bad case of syphilis, wdth sloughing, irregu-
 lar uicers on the velum and fauces, the local use of the same gargle (made
 first with 3j. to §vj. and afterward increased to 3iss), arrested the phage-
 denic  ulceration, and reduced it to a heating sore, which soon  cicatrized.
 Patients do not complain of the gargle being disagreeable.
                                                      Part vl, p. 118.
   Chronic Indolent Bubo and  Ulcers.—Dr. James J. Ross recommends
 the iodide of mercury as follows :
   1. An ointment of iodid. hydrarg., 9j. to §iss of lard,  is  extremely ser-
 viceable in various syphilitic ulcers, particularly those  indolent greyish
 regular sores, which are seen on the arms and legs  of venereal patients,
 and those which are left on  the separation of  the concreted scurvy cuta-
 neous tubercles, Avhich are met with on the face in bad cases,   The above
 ointment is one of the most effectual applications for such sores that I have
 seen used.   It is applied in the usual manner—spread on lint.
   2. An ointment of this substance may be used  like other preparations
 of iodine,  with the  view of causing the absorption of various tumors.
 Ricord uses it in this way for chronic indolent bubo.     Part vl, p. 123.

   Treatment  of Syphilis  by Tartarized Antimony.—Mr. Smee recom-
 mends the  use of tartarized antimony for the cure of syphilis.   Mr. Smee
 says that by giving very small doses  of this medicine frequently repeated,
 we charge the system with it; thus irritating the capillary system, and in-
 citing it to action throughout the whole body, causing it to throw off the
 antimony and Avith it the syphilitic poison.
   He goes on to say:
   As  a  general rule, most patients  laboring under  syphilis, except, in-
 deed, if it  be a sloughing  phagedena, \dolent inflammation, or some such
 analogous case, no matter  what form or  duration, primary or secondary,
 provided the  party be otherwise robust, or at any  rate, not in very  ill
 health, Avill  be benefited by the antimonial treatment.  The medical man
 begins, if necessary, by ordering an aperient of colocynth, jalap, black
 draught, or similar purgative, and then  directs the patient to take from 20
 to 60 drops (30 medium) of antimonial wdne, or the solution of antimony,
 every two or three hours regulady, and  in every case ivhere pus  or a puri-
 form discharge exists, use  at th ■ same  time a lotion of chloride of soda,
 the strength of Avhicn should be regulated to the sensitiveness and delicacy
 of the part  of the body affected.
   Simple Sores.—In simple sores, either of the prepuce or glands, the
 treatment is  extremely efficacious,  and here had  better be  conjoined
 Avith a  solution of chloride of soda, containing about an ounce of the latter
to a pint of  water, which should  be applied two or three times the first
day.    In many cases, in twenty-four hours the character of the sore be-
comes changed ; the surface is no longer covered Avith white pus, a heal- 
604.
SYPHILIS.
ing edge begins to shoAv itself, and the sores, perhaps three, four or more,
are speedily healed.  As soon as the character of the sore is changed, the
part had better  only be dabbed once or tAvice a day Avith the lotion, and
at other times simply covered with a piece of dry lint; for Ave may be sure
that here, as in all other cases, too much disturbance of a healing part only
interferes wdth  the  natural  healing process.  Superficial sores will fre-
quently, although of three weeks' or a month's standing, be healed in four
or five days; but it  is prudent to continue the antimony till not only the
surface of the skin is not in the  slightest degree raised, but even till the
part affected assumes its natural color.
   Indurated Sores.—The  treatment of indurated  sores  is similar  in all
respects to that of superficial sores, and indeed that slight puffiness ahvays
to be seen round the most superficial sore is perhaps to be considered as a
slight induration, and the dense cartilaginous hardness which occasionally
presents itself is nothing but the same thing differing  in degree rather
than in kind, and we have the authority of some most eminent surgeons,
in confirmation of universal  experience, that  either produce indifferently
secondary symptoms.  The  rapidity with which  the cure is  effected in
these cases is proportionate  to the degree of  hardness.  If the induration
is moderate, the sore may heal, but the induration Avill remain ; in which
case the  person is  by no means  to be considered as cured, for  the  anti-
mony must be continued not only till the sore is cured but till the indura-
tion is removed.   If the  induration  is very intense and hard, the sore,
although healthy, will not heal till that is absorbed.   In all these cases
the antimony  should  be given  very frequently  at  the commencement,
and with  the  utmost regularity: for  the remedy always  produces the
greatest effect on its first  administration, and seems rather  to lose its
power after many days, for which reason it should be gradually increased
in quantity.
   Phagedenic Sores.—Phagedenic sores generally occur in poor, Aveakly
constitutions, and require  peculiar treatment  on that  account.   The
employment of antimony in  these cases acts decidedly as a mild tonic;
but still, as its excreting  effects seem to exceed its tonic powers, Ave find
it advisable in these cases to conjoin the  use  of the remedy with that of
other  more potent tonics. If, indeed, the skin  is  cold  and clammy, Ave
should use such remedies as experience has taught us determine the blood
to the surface, for a feAv days previous to the employment of the antimony.
A grain of  sulphate of quinine may be given twice  or thrice a day. A
grain of proto-sulphate of iron, or a grain of sulphate of zinc, may be used
with great  advantage for the same purpose; and the antimonial  drops
exhibited as before.  If the patient is but  slightly feeble we may begin at
once wdth the followdng mixture :—
  R Zinci sulphatis, gr. v.; aquas dest., §ss.; vin. ant. pot. tart., |ss.; quaque
3ss. vel 3j- pi'o dose 2da vel tertia hora sumenda.
  Proto-sulphate of  iron  may be substituted for the zinc with similar suc-
cess.   If the patient is restless or sleepless,  or the nervous system much
affected, the addition of about tAventy or thirty minims of sirup of poppies,
or a few drops of laudanum to each dose, is of much service.  A little
Dover's powder may be given at bed-time.  Whenever iron is employed it
appears to be essential that the metal  should be in the state of the pro-
toxide ; for  probably the persalts have but  very little action on the system,
and even that little action maybe dependent upon a portion of the salt giving 
SYPHILIS.                            605
up one equivalent of oxygen.  The nature of the salt of iron, provided it
be a protosalt, does not seem to influence the result.
  In all cases where the patient is feeble, he should be desired, immediately
on leaving  his bed in  the morning, to rub his entire body  wdth a coarse
towel till the skin is red, Avhich Avill further help to promote a proper flow
of blood to that important organ.
  Buboes.—Bnhoes give way to antimony perhaps more rapidly than they
do to mercury, and a more fiworable prognosis  may be given if  this treat-
ment  be  adopted.  It  Avould, hoAvever, be vain to  attempt the removal
of an inflamed bubo containing a large  quantity of pus,  by any general
means.
  Eruptions of  the Skin.—Various eruptions of the skin, the sequelas of
syphilis, as a general rule,  yield favorably  and rapidly to antimony.
   Ulcerations of the Throat.—Ulcerations of the pharynx,  uvula, and roof
of the mouth, yield rapidly to this line of treatment.  It is a good plan to
use a gargle containing from 3j. to §j. of  chloride of soda to the pint of
water, as that much facilitates the favorable termination  of the disease.
The ulceration, in these  cases, rapidly loses its white layer of pus, fre-
quently mistaken for lymph or sloughs ; and as  soon  as a perfectly healthy
surface is established the ulcer heals as rapidly as a common sore.
   Ulcerations of the Mouth, etc.—Ulcerations of the corners of the mouth
and tongue,  and a peculiar  growth  of  the papitias of that organ, yield
rapidly to this line of treatment.
   Syphilitic affections of the testicle, rhagides digitorum, etc., yield rapidly
to this plan.
   Of the value  of antimony in syphilitic iritis and nodes I do not happen
to have had any experience.                             Part vl, p. 125.

   Syphilitic Ulcerations of  the Throat.—The  inhalation of ammonia gas
recommended.   Vide Art. " Hoarseness."

   Buboes.—The ferruginated pill  of mercury recommended as a superior
resolvent, especially ivith respect to buboes.   Vide Art. " Pills."

   Treatment of Chancre.—Mr. Langston Parser, of Btimingham, recom-
mends the folloAving mode  of treating a chancre:  A chancre when first
presented to the notice of the surgeon, is  generally in one  of two states—
either in that of a small  pustule  with its contents yet undischarged, or a
minute ulcer. In Avhatever state it may  be, our first duty is to endeavor,
by the use of escharotics, to convert  the specific sore into a simple one.
For this  purpose you will find most authors recommending either a strong
solution of the nitrate of silver, or the  application  of this caustic in sub-
stance.  When  the nitrate of silver  is used, if the disease be pustular, it
will be necessary to open the pustule with the point of a lancet, to discharge
its contents, and rub the Avhole surface  and edges  of the ulcer thus pro-
duced Avith the  nitrate  of stiver, previously cut to a  sharp point; if the
disease be an open ulcer, it is to be treated in the same Avay. The nitrate
of silver thus applied Avill sometimes have the effect  of producing a simple
sore, but it Avill  more  commonly give rise  to  considerable  irritation and
inflammation, Avhile the specific character of the sore is not destroyed.
   The great evil in the use of the nitrate of silver in these cases is, that it
is powerful enough to irritate, but not  sufficiently powerful 'to destroy.
We waut a remedy that Avill at once disorganize the tissue to a depth co- 
606
SYPHILIS.
equal with that of the chancre.   For this purpose I now employ several
remedies:  highly concentrated nitric acid, the acid nitrate of mercury,
tbe acid nitrate of silver, or the potassa cum calce of the London Pharma-
copoeia.  The second of these remedies is made by dissolving a drachm of
the subnitrate of mercury in an  ounce of nitric acid; the third by dis-
solving the same quantity of the nitrate of silver in the like  quantity
of acid.
  When it is determined  to destroy a primary venereal ulcer wdth any of
the three first caustics, a camel's-hair pencil must be dipped in them, and
the surface and edges of the  sore pencilled thickly over;  if the acid be
sufficiently concentrated, the whole surfaces touched are at once destroyed,
and converted into  a yellow eschar, which, on separating, generally leaves
a clean simple sore underneath.  When the potassa cum calce is employed,
which is the most certain  of all the remedies I have mentioned, it must be
made into  a  paste  of moderate consistency, with  spirits of wine, at the
time it is wanted for use, and the  sore  and its edges covered Avith it.
When it has been  on a  few  seconds, a smart burning pain is felt, which
continues to increase as long as the caustic is suffered to remain on, Avhich
it should be from half a minute to a minute, or even longer, according to
the effects produced. After this the caustic must be all removed by means
of a fine  bone spatula, and the black eschar left may be covered w ith a
poultice, a cold saturnine  lotion, or fine, soft, dry lint.  The pain soon sub-
sides after the caustic has been removed.   The parts touched by it are at
once destroyed, and on the separation of the eschar, we have a clear granu-
lating sore left, which commonly heals wdth great  rapidity, particularly if
the  ulcer  be a recent one.  A poultice is the most convenient and best
application during the time the eschar is separating, if the patient can rest,
which should always be  urged upon him as an essential point, if it can
possibly be managed.  The moment the eschar begins to be detached, and
a secreting surface  is exposed, the poultice must be done away with, and
other remedies employed.  Of these, weak lotions are the best.  I employ
weak solutions of the nitrate of silver, acetate or sulphate of copper,  alum,
or zinc, or tannin in port  wine, in  the proportion of about two drachms of
the former to six ounces of the latter.
  There are certain conditions of  primary venereal ulcer, which contra-
indicate the use of the caustic in the first instance.   R"an ulcer of this kind
produce violent inflammation of the penis, this must be reduced by a pro-
per general treatment before wre have recourse to these remedies, which
may be used after the inflammation has been subdued, if the sore be foul,
and stationary, and show  no disposition to heal.
  Preliminary  Cautions.—Whenever  a  patient consults you with a pri-
mary venereal ulcer, particularly if it is the first from which he has ever
suffered, point out  to him in  as strong terms  as you can the necessity of
his adhering rigidly to a very abstemious diet till the ulcer assumes a
granulating condition ;  it  is well, also, at this period,  to administer  re-
peatedly, for some  few days, aperient medicine, and  to  insist on a total
abstinence from malt liquor,  wine, or spirits.   If your patient, from cir-
cumstances, cannot lie by and rest altogether,  press upon him the advan-
tage of retiring early to bed, rest in bed being  a most important auxiliary
in the treatment of all forms of primary syphilis.
  Mercurial Courses.—Whether it be your intention to submit your pa-
tient ultimately to mercurial treatment or not, these preliminary cautions 
SYPHILIS.
607
should never be omitted. Many of the evils attendant on mercurial courses
are to be attributed to not preparing the patient by diet, rest, and  appe*
rients, for the administration of this medicine.
  If you administer mercury for  the cure of a primary venereal ulcer, do
not have recourse to it till your patient has been prepared to receive it by
adopting, for some days, the regimen laid down, and till all inflammation
produced by the action of the escharotics has subsided ; you may then use
it with every hope of realizing its most beneficial effects.
  Mr. Parker's method of treating a bubo is equally judicious.  When, as
a consequence  of a primary venereal ulcer not yet  healed, or just healed,
we perceive enlargement with tenderness in the groin producing stiffness
when the patient walks, we may be  sure that a bubo is about to form.  I
would not recommend you at this period to follow the old-fashioned prac-
tice of applying leeches; it is a practice generally very unsatisfactory, ren-
dering your cure long, uncertain, and tedious ; you must insist upon a strict
regimen on the part of your patient, and absolute rest, if possible.  You
may smear the part thickly over  Avith mercurial ointment, over  this a lin-
eeed or a bread poultice, cold, and a piece  of oiled  silk to keep it moist,
confining all by a bandage.   Pressure may also  be made by the emp. am-
moniaci c. hydrarg. spread on thick wash leather, the plaster to be placed
lengthwise  parallel to the thigh, and not at right angles with it; this pre-
vents the plaster  getting displaced Avhen  the  patient  walks.  The best
means of all, however, is to paint over the enlarged gland night and morn-
ing with a  strong solution of iodine  in hydriodate of potass.  (Iodide, one
scruple ; hydriodate of potass, two scruples; water, one ounce.)  The effect
of this is almost magical.   In the intervals of the dressings pressure should
be made by a pad and bandage.  If the patient  has  not used mercury for
the treatment of the primary sore, the dispersion of the bubo will be has-
tened by noAV administering  it  so as gently to affect  the system—always
presupposing that the patient is in a condition to bear mercury.   Should
these means not succeed (which in a majority of instances they will), and
suppuration appears inevitable, hasten it by all means in your power by
warm poultices and fomentations. When matter is ready to be discharged
a question of very great importance suggests itself—viz., how should this
be done?   Many surgeons open  the abscess freely Avith the  bistoury or
lancet, whilst some prefer the potassa fusa for this purpose.  I Avould not,
under ordinary circumstances, recommend either of these methods.
  When  a  bubo  is ready to puncture, I would  not advise you to open it
by a free incision; for, almost under every circumstance where this is prac-
tised, there is a quantity of integument in the edges, which Avill  not unite
Avith the granulating surface of  the sore thus produced.  By opening an
abscess in  this way the ivhole anterior Avail of  it is  destroyed, and your
cure must be performed by the cicatrization of a granulating surface which
springs from the floor or posterior wall of the abscess.  Your great object
is to evacuate the matter first, then  to diminish the disposition to its refor-
mation, and lastly, to procure union  of the two  sides of the cavity.  This
may generally  be  done in the  way I have  adopted  in  the treatment of
chronic abscesses in the Queen's Hospital.
  When a bubo is ready to be opened, you should not  suffer the skin to
become too thin ;  Avhen you practise this method, with a fine lancet make
several very small punctures  over the thinnest part, perhaps, six, eight, or
ten; through these the matter will ooze out till the cavity of the abscess is
empty.  Through one of the punctures the point  of a very small  glass 
608
BYPH1LI8.
syringe may be introduced, and a very weak solution  of the sulphate of
zinc injected, in the proportions of two or three  grains to the half jfint of
water.  When the abscess is quite empty, place over it a large compress of
lint, and use moderately tight pressure by means of a roller.  In many in.
stances, if you can keep your patient quiet  for twenty-four hours, you will
get either partial or total adhesion of the sides of the  bubo, and a speedy
cure ivill be the result; in other instances this may not be the case, but by
the daily use of the injection through one of the punctures, which should
be kept open for that purpose, you ivill  succeed in a  few days, in almost
every case, in effecting a cure.
  I generally employ for an injection in  these  cases the weak solution of
sulphate of zinc.  I have used also a weak solution of iodine in hydriodate
of potass.
  Iodine, four grains;  hydriodate  of potass, eight grains;  water,  eight
ounces.  An injection.
  The injections must be varied in strength to suit the feelings of the pa-
tient, or a gentle warmth and slight irritation  should be experienced, but
violent pain on no account produced.  Solutions of the sulphate, or acetate
of copper, alum, port Avine, wine with tannin, may all be used;  and if one
does not succeed quickly, have recourse to another.  This is the best Avay of
treating a suppurating bubo with which I am acquainted. Part vii., p. 140.
  Local Treatment of Chancres.—Dr. Strohl assures  us that his local
treatment of chancre is one of the most  successful  yet practised.  It con-
sists in cauterizing  the sore if it is not much inflamed nor extensive.   If it
is so, he employs sulphate of copper  instead, and dresses the part five or
six  times a-day with charpie soaked in a solution of about a grain and a
half of sulphate of copper to  an ounce of Avater.  The  sores Avill generally
heal in about tAvelve days.  At other times he uses an ointment composed
of two grains of cyanuret of mercury to an  ounce of axunge. This ointment
is spread upon a piece of linen  corresponding to the size of the sore.  When
this is too painful, it must be taken  off for a time and replaced in a weaker
form.  When  it has been on from four to ten hours,  it is dressed with
mercurial ointment, or opium cerate.                    Part  vii., p. 167.
  Syphilitic Affections of Throat—Mercurial Cigars.—M. Paul Barnard
proposed to the Acad, de la Medecine, the  use of cigars impregnated with
a weak solution of bichloride of mercury for  persons  affected with syphi-
litic affections of the throat and palate, as a mode of conveying mercurial
fumigation.   It has been proposed first to  deprive the tobacco of its nar-
.jotine by frequent washings.                            Part viii., p. 80.
  Success of Arsenic in Syphilis.—Dr. Sicherer, of Heilbrunn, cites the
following case :  A lady having become affected through her  husband with
the virus of syphilis, had at length passed  through  the various stages of
that disease until about to sink under final marasmus. * The palate and the
organs of deglutition were destroyed to such an extent that scarcely any
liquid could be SAvallowed, and then only in a recumbent position. As a forlorn
hope (for other remedies had been unsuccessfully employed), Sicherer had
recourse to arsenic, ordering Fowler's solution to be taken, at first in doses
of two drops, but gradually increased to thirty drops, three times a day.
The remedy Avas continued until about two ounces of the arsenical solution
had been taken, by Avhich time a considerable portion of the impaired struc-
tures had been restored, and the facidty of deglutition regained; and after a
period of ten years no relapse had been experienced.    Part viii., p. 164» 
SYPHILIS.
609
  Proto-ioduret of Mercury.—MM. Cullerier, Biett, Ricord  and others
employ this  remedy in many forms of constitutional syphilis, especially
where secondary and tertiary symptoms  are  combined, and  in  primary
sores in strumous habits.  Cullerier says that it is chiefly in constitutional
syphilis that the proto-ioduret of mercury is administered  with success.
Its effects are principally evident  in secondary ulcerations of the mucous
membrane, cutaneous  tubercles,  exostoses, and chronic  affections of the
joints, where the other preparations of mercury havre had little effect.  It
should ahvays be guarded by opium, and given in half grain doses tAvice or
thrice a day.  The deuto-ioduret is more stimulating, and consequently its
dose is smaller.   Either of these may be employed in friction upon tumors
and indolent buboes, after the removal of all acute inflammatory symptoms.
                                                       Part ix.,p. 21.

  Use of Mercury—Inunction preferred.—It is, perhaps, easier  to know
when  Ave ought to administer mercury, than when Ave ought not.  In per-
sons of a scrofulous disposition, for example, who are disposed to  phthisis,
it requires  the  greatest  discrimination: in such a case, however, we may
be obliged to give it, knowing hoAv frequently tubercles  are developed
in the lungs after  any morbid  poison has been circulating.  This result
may consequently  follow an attack  of syphilis  as  Avell  as an attack  of
measles, scarlatina, or small pox.    Sir B. Brodie prefers  mercurializing a
patient by inunction, to any other way, Avhen the case is seArere, and Avhen
the process is not inconvenient to the patient.   It gripes and  purges  less
than any other  form, and is said  to cure the disease a  great deal better.
Sir  Benjamin even expresses his opinion of this method  as folloAvs :   " It
does not damage the constitution half so  much as  mercury taken by the
mouth; nay, I will go so far as to say that, except in very slight cases, you
really cannot depend upon any mercurial treatment effecting a certain cure,
or even giving a  good chance of it, by any other  means than inunction.
You may very often patch  up the  disease by giving mercury internally,
but it Avill return again and again and you may cure it at last by a good
course of mercurial ointment."   In such a case, he  recommends  that the
ointment be rubbed in at first before the fire, for three-quarters of an hour
at a time, and afterward for a shorter time; the patient taking great care
not to expose himself to cold.  Sir Benjamin further states, that Ave ought
not to leave off the mercury as soon as the sore has healed, but to persevere
in it till  the hard  cicatrix has disappeared.  In short, he recommends us
rather to  recur to the old  practice of using mercury in abundance, and
Avarns us against using it too slightly, according to some modern notions.
He says: " You must  not suppose that Ave  have made an advance in all de-
partments of surgery; on the contrary, I am sure  that  in some we have
gone back.  I am satisfied that the mercurial treatment of syphilis, as em-
ployed by  the  late Mr. Pearson, during a great part  of his  life, was as
nearly perfect as possible, and it was much more successful  than the less
careful treatment  of modern practitioners."   Sir Benjamin's method of
using mercury in children, is, in our opinion, very judicious,  as it  prevents
most of the griping and purging which follow the internal use.
  " Children, when born, sometimes  labor under  syphilis, the  father or
mother having been affected Avith it—perhaps the father and not the mother.
The child at birth looks thin, and is of small size, and instead of thriving
it becomes still  thinner.  At the end of three weeks it is covered by a nasty,
    VOL. n.—39 
GiO
8YPHILI3.
scaly eruption; there is a  sort of aphthas in the mouth, and chaps aliout
the lips and anus.  I have tried different ways of treating such cases.  I
have given the  child grey powder internally, and given mercury to the wet
nurse.   But mercury exhibited to a child by the mouth generally gripes
and purges, seldom doing any good; and given to the wet nurse it does
not answer very well, and  certainly is a very cruel practice.  The mode in
which  I have treated such  cases for some years past has been this—I have
spread mercurial ointment, made in the proportion of a drachm to an ounce,
over a flannel roller, and  bound it round the child once a day.   The child
kicks about, and the cuticle being thin the  mercury is absorbed.   It does
not either gripe or purge, nor does it make the gums sore, but cures the
disease. I have adopted this practice in a great many cases Avith the most
signal  success.  Very few children recover in Avhom mercury is given in-
ternally, but I  haATe not seen a case where this  method of treatment has
failed.
   " Mercurial inunction maybe used in certain cases in Avhich Avere mercury
taken  internally it would do absolute harm.   For example, a gentleman
had a nasty phagedenic sore upon the penis; it could not be said  that he
was hi ill health before, and therefore there was  some reason to  believe
that the disease Avas spreading from  the intensity of the venereal  poison.
He had taken calomel and opium until the gums Avere sore, and he was
decidedly  worse  under it.  The disease  destroyed a great part of the
glans,   and  evinced no  disposition whatever to  stop.  It resisted all
modes of treatment until he Avas put on a course of mercurial inunc-
tion ;  its progress was then arrested  directly, and the sore  healed with
great  rapidity. I have seen several instances of the same character."
                                                       Part ix.,p. 111.
   Prevention of the Contagion  of Syphilis.—The problem of the means
of extinguishing  syphilitic contagion, appears to have been sohed at the
hospitals at St. Petersburg.  In principle, it appears  simple  enough, the
point to be effected being merely to  prevent the absorption of muco-puru-
lent matter, either by means of washings, Avhich remove  it directly, or by
liquids, such as the chloride of lime, which have the property either of de-
composing it, or of preventing otherwise its inoculation.  In  practice,
however, it proves a matter of great difficulty, especially in the female.  In
St. Petersburg, the most  satisfactory results are said to have followed the
use of the prophylactic soap of Dr. Pfeffer.  The active ingredients of this
soap appear to be—in 500 grains of the substance, six grains of bichloride
of mercury, four of tannin, and forty-five of chloride of lime, incorporated
into a soap with soda.                                   Part ix.,p. 180.

   Treatment for  Buboes.—In commenting on the process adopted by M.
Regnaud of treating buboes, by first blistering, then  applying a corrodve
stimulant, etc., Dr. Johnson states that the plan is needlessly complicated,
and that the application  of the  caustic potash so as to form an eschar of
sufficient depth is sufficient.  He further says :
   Unquestionably the best method, as a general rule  at  least, of opening
buboes is with caustic—in preference to the use of the knife—and we are
therefore glad to find that Mr. Regnaud is in the habit of adopting it; the
 only objection Ave make to his practice is as to the mode of effecting this
 purpose.  When the abscess is once fairly open, and its surfiice and edges
 are in an  unhealthy condition, feAv applications are so good .as the tinct, 
BYPBTLIS.
611
benzoini comp. (Friar's Balsam), applied  with lint; it is an admirable de-
tergent to foul ulcers in general.  Besides its  stimulating and antiseptic
properties, the balsam  seems to act beneficially by totally excluding the
admission of the air to the sore, in consequence of the varnished coating
which it forms.  When the ulcer is tolerably clean, but very tardy in heal-
ing, we have seen excellent  effects  from  covering it daily wdth a layer of
powdered rhubarb.   As a matter  of course,  bark and other tonics are
generally required to  be administered internally at the same time.
                                                        Part x.,p. 161.
   Treatment of Secondary and Tertiary Syphilis.—M. Devergie, one of
the physicians of the St. Louis Hospital, Avhich receives a much larger
number of syphilitic patients than any of the other hospitals in Paris—has
met Avith great success in the treatment of the secondary and tertiary affec-
tions by adopting the following remedies.  The patient is to drink every
day about a quart of a sudorific ptisan, in wdiich from five to twenty grains
of the ioduret of potash have been dissolved, and also to take every morn-
hw, fasting, a pill composed of guiac, opium and a minute  quantity of the
corrosive  sublimate.  In the  course  of a Aveek or so, a second pill is to be
taken at night also.  These medicines are to be persevered with for tivo or
even three months, Avithout intermission.   A tepid bath is to betaken once
a week.  No  Avine is  allowed;  but milk is  given  freely instead.  If the
patient's constitution  has been  much damaged by irregularity or Avant,
M. Devergie  recommends  the use  of some ferruginous preparation,  or
of bark, or  of both together; at the same time diminishing the dose of
the sublimate, if the state of the symptoms should still require  its continu-
ance.
  When, after six or seven weeks' use of these remedies, the local symptoms
still exhibit an unhealthy character, the application of the crystallized acid
nitrate of mercury—dissolved in water, to Avhich a feAv drops of nitric acid
have been added—will be found most convenient.  The ointment  of the
proto-ioduret of mercury is also a valuable application, to promote the heal-
ing of certain ulcers.                                    Part x.,p. 172.

   Treatment.—[With regard to the use  of mercury, Mr.  Carmichael
says:]
  Primary  Ulcer.—1st.  I do not think it necessary in the treatment of the
simple primary ulcer Avithout induration, nor for the papular eruption, and
other   constitutional  symptoms  it  produces; but  should the  eruption
linger into the fourth or fifth week after it has desquamated into scaly
spots  or blotches, mercury  in  alterative  doses, either in the  form  of
Plummer's pill or  the  proto-ioduret of mercury, will be of service in clear-
ing the skin of the eruption, and in removing the  pains of the  joints,
Avhich are constantly present  in this form of venereal.  But I protest most
strongly against the use of mercury at the period when the eruption  first
appears in its papular  form, at a  time  that it is usually preceded and
accompanied by considerable fever, like all  the other exanthemata, to
Avhich class of Cullen it obviously belongs.  If we should exhibit mercury
prematurely during the eruptive stages of this as well as the other forms of
disease, the scaly  excepted, Ave may possibly clear the skin of the eruption,
but in all probability it will return again to the great disappointment of the
patient and perplexity of the medical attendant.
  Iritis.—2d. For  iritis I Avould give  mercury, so as to excite  its full 
612
SYPHILIS.
effect upon the system, and at the same  time not neglect the usual anti-
phlogistic measures to remove this dangerous inflammation.
  Nodes.—3d. For nodes I  would  exhibit mercury, and I think  the
iodide of that mineral for their removal is superior to any other prepara-
tion.
  Phagedemic Ulceration.—4th. For phagedenic  primary ulcers I have
ahvays found mercury most injurious.
   Use of Nitric Acid.—They are most successfully treated by the applica-
tion of strong nitric acid, immediately followed by a douche of cold water.
The same application is also the most efficient for phagedenic ulceration cf
the throat, which if not checked will soon extend over the velum, uvula, and
back  of  the pharynx, from Avhence it will spread upAvard into the nares,
and downward into the larynx.  In either of which situations I need not
state the difficulty and danger of the case.  Instead of the douche of cold
water, in  this situation  inadmissible, I  employ a probang, the sponge
moistened in  a solution  of soda or potash ivill neutralize any superabun-
dant  acid applied to the ulcers.
  Scaly Eruption.—During  the eruption of pustules or tubercles which
cause those crusts termed rupia, I have found mercury injurious, although
its exhibition may at first flatter both patient and surgeon that the disease
is yielding to this remedy.  But the natural tendency of this eruption is
also to become scaly after it  has existed several Aveeks or months.  This
scaliness is a sign that the  disease-is on the  decline, and indicates that
mercury in alterative  doses  may then be employed ivith safety and
advantage. Should  any of the  constitutional ulcers  on the skin  spread
after the rupia crusts fall off, their progress may also be effectually checked
by the application  of nitric acid to  their phagedenic margins.  They of
themselves first show signs of healthy reparation in their  centres, which
need not therefore be meddled with.  Mercury in this stage of the disease
should not be exhibited.   Hydriodate of potash, sarsaparilla, country air,
and the  tranquillizing effects of opium, should the  patient be harassed by
extensive ulceration, are the constitutional means most to be relied upon.
  Hunterian  Chancre. — 5th.  For  the true  Hunteiian  chancre with
hardened edge and base, and for  the scaly eruptions which  attend it, as
well as the deep excavated ulcer of the tonsil, nodes, and other symptoms
belonging to this form of disease, mercury may be  esteemed a certain and
expeditious remedy.                                    Part xl, p. 174.

  Infantile Syphilis.—[In the treatment of congenital syphilis, marked by
copper-colored  blotches  over various parts of  the body, Dr. Bird has
found that two grains of hyd. cu. creta, continued for a fortnight or so. by
Avhich time the eruption has usually faded very much, and then the admin-
istration of pot.  iodid. gr. j. in 3ij.  sir. sarzas, ter  die,  will soon effect a
cure.   Dr. Bird remarks that syphilitic eruptions are exceedingly frequent
among the infants of the lower classes, and that the  simple treatment just
mentioned is very effective in their  cure.   There are few affections among
children, the treatment of wdiich is  more  satisfactory than that of syphilitic
eruptions; indeed they seem to fatten upon their medicine.  If the mercury
cause diarrhoea, it is sufficient to suspend its use for a time. The diagnosis
of this disease is frequently mistaken, though of great importance, as while
it readily yields to proper treatment, it is extremely obstinate Avhen mis-
managed.] 
SYPHILIS.
613
  There is seldom any real difficulty in the diagnosis of these cases Avhen
once the  practitioner has learnt to recognize them.   The characteristic
snuffing will often enable him to recognize the existence of disease, even
before he has confirmed his opinion by visual examination.  The puckered
mouth, the position of the very characteristic eruption  round  the lips  and
anus, in addition to the peculiar varnished and fissured appearance of the
purts from wdiich the scales have faded, will seldom if ever fail to convert a
suspicion of the true nature of the disease into positive certainty.  Condy-
lomatous excrescences from the margin of the anus have neiTer, in any of
the cases, accompanied the earliest development of the syphilitic affection,
but were always secondary, being observed in those children only whose
primary affection was  neglected or incompletely eradicated.   When the
eruption occurring on the nates and face in the first few Aveeks of life had
been promptly treated, no condylomata appeared on the anal margin, at
least so long as the children Avere kept  in sight.  But on the contrary,
when the eruptions Avere neglected, condylomata wrere the almost certain
results.  I have not treated any  case by the iodide of potassium alone,
although this drug appeared to be of peculiar service after the  mercury had
produced a decided effect on the disease.                 Part xl, p. 175.

  Mr. Acton employs the subjoined treatment:
  Syphilitic  Alopcecia.—Cut the hair close, and use warm baths; and
then apply the following liniment: Equal parts of rectified spirit, eau de
cologne, and castor  oil; or  equal  parts of  honey-water and.  tinct. can-
tharides.  Should little red spots or blisters be produced, cease the appli-
cation for a short tnne.
  Lichen, Lepra,  Psoriasis, Impetigo, etc.—Frequent warm baths, taking
care to soak the head Avell ; and cover  the  spots  night and morning with
olive oil, §ss. ; citrine  oint., 3j.;  M.  Make a liniment.   Or use the fol-
loAving ointment:  purified beef marrow, sixteen parts ; sulphur ointment,
sixteen  parts; turpeth mineral,  tAvo  to four parts;  essence  of lemons
sufficient to scent  it.   (Ricord.)
  Mucous Tubercles.—Use a  dilute solution of chloride of sodium; dry the
parts and sprinkle them over  Avith calomel.  Great cleanliness  is necessary ;
do not use ointments.
  Eczema Impetiginoides.—Cut the hair close, and apply water dressing,
or lint dipped in an aqueous  solution  of opium;  do not  apply  ointments.
It should be a rule never to apply greasy substances to any eruption
attended with oozing  of fluid, since it mixes Avith the secretion, becomes
rancid, forms a crust,  the edges of Avhich become excoriated, and Avhat
was an  effect becomes a cause of irritation.   Paint gummata  and  nodes
with tinct. of iodine ; it may also be applied to unhealthy tertiary ulcers.
  Give internally, in secondary forms of syphilid, iodide of potassium or
mercury: some prefer the former, as Dr. Williams, others the latter, as Sir
B. Brodie.  The following should be  our guide in giving the iodide of
mercury:  Secondary symptoms occurring after a course of mercury, will
be  benefited  by a course of iodide of potassium.  Secondary symptoms
occurring  where mercury has not been used, will  not yield to "the iodide,
but Avill to mercury.   In order to prevent the iodide from causing pain at
the pit of the stomach, or heat at the back of the throat soon  after swal-
lowing it, dissolve tAvo drachms in  three ounces of Avater, and  let the
patient take a teaspoonful of this solution night and morning in  a large cup 
614:                            8YPHILI8.
of tea, and the same quantity in half a pint of beer, or other fluid, at mid-
day ;  the dose to be continued and increased according to circumstances.
It is of no  use increasing the dose, or indeed of continuing this  remedy
beyond a week or ten days, if no  amendment is visible.  If mercury ha's
not been given for the primary symptoms, begin Avithit immediately when
secondary  symptoms appear.  Ricord gi\-es  the pure mineral, but the
hydr. c. creta will answer best.  If the organs of digestion be impaired,
use friction ; direct the size of a horse bean of ung. hyclr. to  he smeared on
the inside  of each calf of  the leg every night; do not rub it in, as you
irritate the hair bulbs by doing so, and you produce subsequent tenderness.
Direct your patient to sleep in  old  drawers, so as to keep  the bed clean.
Do not use the ointment to the thighs, as is usually recommended; it gets
between the thigh and the scrotum, producing eczema ; it also dirties the
patient's linen, and  excites the attention of the  A\rasherwoman.  Get the
patient firmly under its influence before you discontinue the use  of mer-
cury.
   Chancre.—Wash  the part well  with warm wrater,  and then apply the
solid  nitrate of silver ; it will completely destroy the affection, if not more
than  of three days' standing.   If  it  be a pustule, evacuate its contents,
and the walls of the pustule are  to be avcII cauterized.  When there is a
chancre of the frenum, 'it is  more readily healed by dividing it, and caute-
rizing the  whole  of the divided  surface.  To  check  discharge,  apply a
solution of pure tannin—tAvo grs. to the ounce of water ; or sulphate of
zinc solution, in private practice, as the former tells tales by staining the
linen.  The caustic should  be reapplied as soon as the eschar is removed,
or about once in twenty-four hours.   If lint  have been applied after the
caustic, take care to soak it Avell before you remove it, or the eschar may
be detached, and the part made to  bleed.   If the case be seen early, one or
two  burnings will  suffice ; if  at  a more advanced  period,  it must be
repeated at intervals of twenty-four  hours—for a week or ten days, or as
long  as we consider any virus is secreted by the  sore, which is known by
the ulcers  remaining stationary, and the surface being covered Avith  ayelloAV
pellicle; ivhen becoming healthy,  granulations  spring up  and the sore
heals.  Caustic is not  so  efficacious when the chancre is situated on the
frenum, orifice of the urethra, around the prepuce, or on  the fourchette in
the female—enjoin  rest and strict  attention to cleanliness,  and  avoid
rupturing the cicatrix.                                 Part xiii.,/). 274.

  Treatment of Secondary  and Tertiary—Secondary form of Syphilis.—
M.  Ricord advises,  to  give the proto-iodide of mercury,  and should  it
occasion, irritation in the bowels with diarrhoea, combine  it with opium.
Let the diet be simple, avoiding all stimulants whether solid or fluid; the
diet, however, should not be debilitating but nutritious.  Cold  and damp
air is  very  injurious; fresh air is  highly necessary.
  Tertiary form of Syphilis.—The  characteristic of these symptoms, is
their  not being transmissible hereditarily.  They are manifested chiefly in
the subcutaneous  or submucous cellular tissue, in the fibrous,  osseous,
cartilaginous, muscular or  nervous tissues, and  organs in their  locality.
The remedy most to be depended upon is mercury.     Part xiii.,jt>. 280.
  Repellent treatment of Buboes.—The method  pursued by M. Malapert
is to apply a blister the size of a crown for twenty-four hours, then raise
the cuticle, and apply a pledget of lint of corresponding size, well saturated 
SYPHILIS.
615
with a solution of bichloride of mercury (a scruple of the salt to one ounce
of spt. vini rectif.);  keep it in situ from two to four hours, and then apply
cold applications  for  some, hours;  an  eschar  is formed,  which will be
throAvn off, and the tumor will be dispersed.            Part xiii., p. 283.
  Chancre.—If seen within three days, says Mr. Acton, apply nitrate of
silver freely, and secondary symptoms need  not be feared, and even after
this time, in nine cases out  of ten, the same results will take place.   There
are some indications,  however, against  the  use  of caustic, and these are
inflammation, or  great  irritation  of the part; but,  perhaps, the  most
important indication, against its use, is induration of the sore ; the consti-
tution is sure to be affected when this occurs, and mercury must be given.
                                                     Part xiv., p. 222.
  Secondary Syphilis— Pains in the Long Bones,  etc.—Mr. Ormerod
directs us to give hydriodate of potash, five to eight, or to fifteen grains
three times a day, and, if not successful in a few days, then mercury may
be had recourse to.   Where the secondary symptoms are  scaly eruption,
excavated ulcer of the tonsil, swelling of the testicle, excavated ulcer of
the tongue, acute ulcers of the  edges of the eyelids, iritis, purulent dis-
charge of the meatus  auditorius externus, papular eruption Avithout fever,
desquamating tubercular and pustular eruption, secondary ulcers, fissured
tongue,  ulceration round the nail, phagedenic ulcers of the skin, and foul
sloughy ulcerations of the pharynx, they will  be  benefited by mercurial
fumigations.                                          Part xiv., p. 227.
  Bromide of Potassium in Secondary Syphilis.—The low price of the
bromide  compared  Avith that of the  iodide of potassium,  has  induced
M.  Ricord to substitute that salt  for the iodide in the treatment of
secondary syphilitic affections.   The dose of the bromide  is the  same as
that of the iodide of potassium.   It  has produced the same therapeutical
effects, but more slowly.                               Part xiv., p. 229

  Bubo.—Prof. Porter  advises to open it as soon as matter can be de-
tected, and by a very free incision,  so  as to prevent  the lodgment of  a
drop of matter.                                        Part xv., p. 236.

  Treatment of Chancre.—Mr. Ormerod directs the use of the black wash
to the sore, and Avhen  it is healed, and  induration remains, rub on a little
6trong mercurial ointment, and keep constantly applied a piece of leather
smeared Avith it.
  Give in old cases small doses of hydr. c. creta, perseveringly, for a long
time. If a quick action is desired give mercury by friction; but usually
blue-pill is  the best preparation.  In phagedenic ulcers give calomel ana
opiam so as rapidly to induce mercurial action, and when  the phagedena
is checked  give a milder preparation.   Some phagedenic sores, however,
require depletion and  purgatives : others wdne and opium.  To unhealthy
and exhausted subjects give hydriodate of potash and sarsaparilla.
                                                      Part xv., p. 246
  Secondary Syphilis—Treatment of at St. Bartholomew's Hospital—
Papular  Eruptions.— Treat antiphlogistically  at  first, then  give mild
mercurials, with tonics and the warm bath.
  Scaly.—Give mercury, or, Avhen slight, iodine will do.
  Tubercular.—Iodine is the best remedy. 
616                           SYPHILIS.
  Pustular.— Give mercury cautiously, and  apply yelloAv  wash  to  the
nlcers intoAvhich the pustules degenerate: if, hovever^ these  are large and
shallow, give iodine :  or if round and excavated, give opium with  iodine,
and nutritious diet, and apply black Avash.
   Ulceration of the  Throat.—Give mild mercurials ; or, if sloughy, iodine
wdth wdne and good diet.  Use cinnabar fumigations, especially to  the ex-
cavated ulcer, but with caution.
   Ulceration of the Larynx,  Tongue, etc.—Give mercury  or iodine, or
both, according to the accompanying symptoms.
   Pains in the Bones.—Iodine is the best remedy; but in some cases re-
quire mercury, others incisions.
   Nodes.—Give iodine; if recent and  soft, apply mercurial ointment on a
piece of leather.                                       Part xv.,p. 247.
   Treatment of Syphilis.—[Mr. Christophers has been in the habit of
recording his experience of syphilitic  cases for some  years;  and  he has
been able to observe a considerable number of cases for years after their
treatment.  He has come to the conclusion that syphilis, in  the  present
day, is a disease wdiich, even without  treatment, produces few symptoms
of severity;  and which, itself  tending to its  OAvn  cure, is very amenable
to rational treatment.  In a case  of  real  chancre, unless  destroyed  by
excision  or caustic before the fourth day, secondary symptoms will certainly
supervene, whether the treatment have been "mercurial," cr "simple: " and
the severity  of the secondary symptoms is in proportion, not  to the  number
nor to  the severity of the  primary sores, but to their duration.  If this
be true, the best treatment is that by which the primary sore  is most
rapidly healed.   Mr. Christophers  says respecting treatment:]
   It has been observed that some sores are very slow to heal under simple
treatment, but that immediately the  system  is brought (though  ever so
slightly) under the influence of mercury, they rapidly progress toward a
 cure.  Now here I believe the advantageous use of mercury stops; pushed
beyond  this, it becomes a positive evil.
   I have treated cases of syphilis on  a plan differing  from  both the mer-
 curial and simple systems, and  in every case it has succeeded avcII.  Having
first convinced myself, by the  aid of inoculation (I am  speaking  of cases
 in Avhich the sore has existed beyond the period  assigned  it as a local
 disease,) that it  is a genuine chancre I have to treat,  I  prescribe  calomel,
 in one or two grain doses, till  the  gums give  the slightest  evidence of its
 effect.   This accomplished,' I  suspend it at once, and  begin wdth small
 doses of the hydriodate  of potass, Avith sarsaparilla; and  it is a curious
 fact, that  if the  gums are  made  slightly sore with mercury, that action
 will be maintained in them by  very small doses of the hydriodate, though
 it does not produce that  effect generally, if mercury have not been given.
 The object in giving the mercury is speedily to heal the primary sore; the
 object of the iodine and sarsaparilla, to put the system in the most favor-
 able condition to encounter  the secondary affection  that  must (in  some
 shape) inevitably ensue.                               Part xvi, p. 213.
    Comparative  effects of  Bromide  and Iodide  of Potassium in the
 treatment of Secondary  Syp)hilis— Some time ago, Dr. Egan's attention
 was directed to preparations of bromine as a substitute for those of iodine,
 which  had  attained a very high price.  His  experiments  led him to the
 conclusion that the bromide of potassium is comparatively  inert.
    To detect the Adulteration  of the Iodide with  the Bromide of Potas- 
SYPHILIS.
617
slum.—Take of the suspected salt one drachm, dissolve in two ounces of
distilled water, of sulphate of copper two drachms, dissolved in the same
quantity of distilled  water, mix, and  put both into a clean  oil flask, and
boil till the vapor from the flask will not produce any effect upon  a piece
of paper, to whose surface a solution of starch has been applied, the fluid
remaining in the flask, if impure, will immediately, on the  addition of a
few drops of a solution of chloride of lime, give the usual orange color of
bromine which will be rendered more apparent by the addition of a little
starch.  Bromide of potassium is not precipitated by sulphate of copper,
in which it differs from the iodide.                     Part xvi., p. 214.
   Urethral Chancre.—When secondary symptoms appear to follow blen-
norrhagia, this virulent blennorrhagia as it is called,  is the result of a ure-
thral chancre; this M. Ricord has  proved by observation both on the living
and  the dead.
   During the  first few days,  employ the abortive treatment.   The patient
having passed water, M. Ricord injects into the urethra a little of a solu-
tion of nitrate of silver, fifteen grains to the ounce, from a gla-^s  syringe ;
the only precautions needed  are to press the lips of the meatus so as to
bring them in close contact Avith the pipe of the syringe, and to make the
injection pass  suddenly, so as to take the urethra by surprise.  Repeat the
injection at the end of tAvo clays ; but if the first application does not cause
pain and sero-sanguineous discharge, followed by creamy suppuration, re-
peat it on the same day.  At the same time give copaiba  and cubebs.
                                                    Part xvii.,  p. 183.
   Treatment of Chancre.—M. Sisovics, chief surgeon to the general hos-
pital of Vienna, directs  at first,  to  use local emollients  and baths;  and
when the syphilitic  character of  the ulcer is manifest, give  diaphoretic
 drinks of decoction of sarsaparilla, or guaiacum, and then give the prepa-
rations of iodine, and use them externally in the form of local baths  and
fomentations.                                         Part xx'i\., p. 186.
   Treatment  of  Venereal Disease Generally.—[At the end of this course
 of lectures  on venereal  disease,  published in  the " Lancet," M. Ricord
gives the following recapitulation  of the doctrine he inculcates :]
   The great class of venereal diseases comprises tAvo very distinct orders—
first, the  non-virulent  diseases, the type of Avhich is blennorrhagia; the
 second, the virulent diseases, the  type of which is chancre.
   First  Order.—The blennorrhagic affections do not taint the constitution,
 are  not transmissible by hereditary, and  never yield any positive results by
 inoculation either on the skin or mucous membranes : they are contagious
 in the manner of irritants, the simple catarrho-pblegmonous discbarge be-
 ing the most common form.
   Second  Order.—The virulent  affections  OAve their origin  to a peculiar
 principle, to an ulceration which  can be reproduced at ivill, and inoculable
 within a certain period.  The ulceration always springs up at the very spot
 Avhere  the virulent matter  has  been implanted, and its evolution  takes
 place in a variable space of time.   The  virulent effect may remain strictly
 local, and merely give  rise to consecutive phenomena, of Avhich the most
 common is the suppuration of the inguinal glands ;  but  it  may penetrate
 into the economy, and determine in the same a set of characteristic symp-
 toms.  The general infection of the system is the result of an idiosyncrasy
 wdiich does not invariably exist  in every individual.  The most tangible 
618
SYPHILIS.
phenomenon of this infection  is the specific induration of the  chancre.
There is no such thing as a specifically indurated chancre, Avithout subse-
quent symptoms of constitutional syphilis.  Once or twice in a hundred
cases the induration may be ill-defined, and pass unnoticed ;  but if the at-
tention  be directed to the inguinal glands (which  inevitably suffer by the
infection), the existence of an  indurated chancre may, by their  state, be
inferred ; for a bubo, consecutive to  such a chancre, never suppurates spe-
cifically.  There is no  constitutional syphilis Avithout a primary local acci-
dent.  When the infection has taken place, we may look for the secondary
manifestations Avithin a tAvelvemontb.   But if a  mercurial  treatment he
used, these manifestations may be prevented or retarded for more or less
time, or perhaps forever.   When no treatment, howrever, has intervened,
there is an admirable order in  the succession of the manifestations, which
is denied only by those people  who Avill  not be convinced.  Primary, con-
secutive, secondary, transitory,  and  tertiary accidents follow each  other
with the most perfect regularity.  But I repeat it—a treatment breaks up
the order altogether.  If a mercurial course has  been gone  through, the
secondary manifestations may,  under its influence, be retarded for a varia-
ble time ; but it does not destroy the diathesis, and merely postpones the
secondary  symptoms.   On the  other band, you will  remember  that the
mercurial  treatment does not prevent  tertiary accidents, and these may
even appear Avhilst the secondary symptoms are being kept off by mercury;
the latter may then make their appearance after the tertiary accidents have
disappeared, and  thus the order of the manifestations may be totally in-
verted.  Constitutional syphilis  can be contracted but once—the diathesis
can  never be doubled.  The diathesis persists, but the manifestations are
not  certain or  inevitable.  This diathesis  is not incompatible with health.
Syphilitic  cachexia  is very rare.  The  non-virulent affections require no
specific medication, neither do the virulent primary accidents ; mercury is
used for the latter only in exceptional cases; namely, where the chancre
is indurated.
  Constitutional syphilis  demands a mercurial treatment;  but when the
later secondary symptoms and the tertiary have come on, mercury should
be abandoned,  and iodide of potassium be taken up.  The latter is then the
medication par excellence.  Whenever we have to treat any peculiar disor-
der or affection of the viscera, along wdth syphilis, we  should never lose
sight of the indications which belong  to that intercurrent disease, and
should even delay the specific medication,  if found necessary.
  [Dr.  de Meric, the reporter of these lectures, subjoins the follow ing list
of formulas used by M. Ricord  at the Hospital  du  Midi:]
  Non- Virulent Diseases.—1. Injection for Balano-posthitis.—Make three
injections a day between the glans and  prepuce Avith the following fluid :
distilled water, three ounces ; nitrate of silver, two scruples.
  2. Abortive Treatment of Blennorrhagia.—Make one injection only with
the following liquid : distilled  water, one  ounce;  nitrate of silver, fifteen
grains.   And  take every day,  in  three  doses,  the  following  poAvder :
cubebs, one ounce ; alum, thirty grains.
  3. Injection, for Blennorrhagia when the period for the Abortive  Treat-
ment is passed.—Make three injections daily with  the following liquid:
rose Avater, six ounces  and a  half; sulphate of zinc, and acetate of lead, of
each, fifteen grains.
  4.  Internal  Treatment of Blennorrhagia.—Take one tablespoonful of 
SYPHILIS.
619
the folloAving emulsion three times a day: copaiba, sirup of tolu, and sirup
of poppies,  of each,  one ounce ;  peppermint water, two ounces ; gum
arabic, a sufficient quantity ; orange flower Avater, tAvo drachms.
  5. Acute stage of  Blennorrhagia.—Twenty leeches to the perineum ;
bath after the leeches ; refreshing drinks ; rest in bed ; low diet; suspen-
sory bandage. Take one of the following pills four times a day ; expressed
and inspissated juiee of lettuce (lactuca sativa) and camphor, of each, forty-
five grains :  make twenty pills.
  6. Gleet.—Make  every  day three injections with  the  following liquid :
rose water, and Rousstilon Avine, of each, six ounces ; alum and tannin, of
each, ten grains.
  7. Subacute Epididymitis.—Rub the testis tAvice a day wdth the folloAA'-
in<r ointment: stronger mercurial ointment, and extract of belladonna, equal
parts of each ; a poultice to the part  after the ointment, and rest.
  8. Acute  Epididymitis.—Fifteen  leeches to  the perineum,  and the
same number in  the groin corresponding to  the affected epididymis; bath
after the  leeches;  barley-ivater for  common  drink; low diet, rest, and
poultice.
  9. Chronic Epididymitis.—Apply Vigo's plaster to the testes, and Avear
a suspensory bandage.  (Simple plaster, yelloAv wax, pitch, ammoniacum.
bdellium, ohbanum, mercury, turpentine, liquid styraxj and volatile oil of
lavender, are the component parts of Vigo's plaster.)
   Virulent Diseases—Primary Symptoms.—10. Abortive Treatment of
 Chancre.—Within the first five days of the contagion, destroy the chancre
Avith potassa fusa cum calce (pate de Vienne.)
   11. Regular non-indurated Chancre.—Frequent dressing with the aro-
matic Avine, extreme  cleanliness, occasional light cauterization ivith the
nitrate  of silver.  Rest, demulcent  drinks; ivhen there is inflammation,
antiphlogistics,  purgatives, and emoltient applications.  (N.B.—No lner-
CU1T-)
  12. Phagedenic  Chancre.—Complete cauterization Avith the nitrate of
silver, the liquid nitrate of mercury, the potassa cum calce, or the hot iron,
according to circumstances.   AfterAvard lotions with aromatic Avine, three
ounces; extract of  opium, three grains ; or, aromatic Avine, eight ounces;
tannin,  thirty grains; or, distilled Avater, three  ounces ; tartrate of  iron
and  potash, four drachms ; or, in  the  scrofulous  diathesis, distilled Avater,
three ounces ; tincture of iodine, one drachm ; or, sulphur ointments, and
sulphureous baths.  Internally : tartrate of iron and potash, one ounce ; dis-
tilled water, eight ounces.  One ounce three times a day.
  13. Indurated Chancre.—Three dressings  a  day  ivith the folloAving
ointment: calomel,  one drachm ; axunge, one ounce.  (N.B.—Mercury is
used internally for  the indurated chancre : as to the mode of administra-
tion, see secondary syphilis, No. 21, as the metal is given in the same man-
ner in both cases.)
  14. Acute, non-Specific Adenitis, vel Inflamed Bubo.—Twenty leeches
on the tumor, emollient cataplasms,  barley-water as ordinary drink, rest,
broths.   If fluctuation  be detected, let  out the purulent matter by a free
incision.
  15. Abortive Treatment of the  Bubo consecutive, by absorption of the
Virus, to the Non-indurated  Chancre.—Deep cauterization of ten minutes'
duration, Avith the potassa fusa cum calce, and await the fall of the eschar.
(X.B.—Analogous  to the early destruction  of chancre.) 
620
SYrHILIS.
  16. Bubo consecutive to the Non-indurated Chancre, which  inevitably
Suppurates.—Use antiphlogistics according to circumstances, and then free
the purulent matter by cauterization with potassa fusa; gradually destroy
afterward, by the use of caustics, the glandular mass which lies at the bot-
tom of the open bubo.  To the poultices used after  cauterization may be
added an ointment, of equal parts  of extract of  belladonna  and mercurial
ointment.
  17. Horse-shoe Bubo and Gangrene.—Horse-shoe and  phagedenic ul-
cers in the groin, resulting from a  suppurating bubo, require the  dressing
mentioned in  No. 12.  Gangrene: chloride of lime, one ounce;  distilled
water, three ounces.   This lotion  is to be used  several times a day.  Or,
powdered charcoal, powdered Peruvian bark, equal  parts of each, to  be
thickly applied to the sore.
  18. Phimosis.—Inject between the glans and prepuce the  aromatic Avine
Avith opium, as mentioned in No. 12, and use emollient and sedative appli-
cations ;  if gangrene be imminent,  operate.
  19. Paraphimosis.— Keep the  organ raised,  and surround it with cold
compresses.  Bland  diet,  refreshing drinks ; endeavor to reduce or free
the  constriction  by  an incision, according  to  circumstances.   After the
strangulation is relieved, use emollient and antiseptic applications combined
with opium.
  20. Scrofulous Complications.—Order every day the following emulsion
in  three  equal  doses : iodine, three grains; oil of  SAveet  almonds, one
ounce ; gum arabic,  a sufficiency;  almond emulsion, three ounces.
   21. Secondary Symptoms.—Order every  day three tumblers of decoc-
tion of saponaria leaves, and put  into  each  tumbler  one tablespoonful of
sirop de cuitinier (N.B. Sirop de cuisinier:  sarsaparilla, borage" and white
rose leaves, senna, aniseed, honey, and  sugar;) and take every day one
of the following pills : proto-iodide of mercury, inspissated juice of lactuca
sativa, of each, forty-five grains ;  extract of opium, fifteen grains ; extract
of  hemlock, one drachm and a half.  Mix, and. make sixty pills.
   22. Slight Stomatitis.—To gargle three times a day Avith the folioAving
liquid: decoction of lactuca  sativa, five ounces; honey, one ounce and a
half; alum, one drachm and a half.
   23. Mercurial Stomatitis.—To gargle three times a day Avith the folloAV-
ing liquid : decoction of lactuca satita, five ounces;  honey,  four drachms;
hydrochloric acid, fifteen drops.
  24. Salivation.—Order every day one drachm of flowers of sulphur in-
corporated Avith honey.  As a common  be\rerage, the nitric acid lemonade.
Gargle three  times  a day with decoction of lactuca sativa, five ounces;
honey, four drachms; hydrochloric acid, fifteen drops.
   25. Mucous Patches in the Mouth.—Gargle three times a  day Avith
decoction of hemlock, six ounces and a half; bichloride of mercury, three
grains.
   26. Mucous Tubercles around the Anus (Condylomata^)—Put twenty
leeches to the perineum.  Take every evening a small enema of a decoc-
tion of poppyheads, cold,  and mixed with tiventy drops of laudanum.  As
a habitual beverage, take liuseed  tea, sweetened with sugar  and almond
emulsion.
   27.  Vegetations.—Put twice a  day on the  vegetations the folloAving
 poAvder:  poAvdered  savine,  oxide  of' iron, calcined alum, of each  one
 drachm.                                            Part xviii., p. 205. 
SYPHILIS.
621
  Treatment  of Tertiary Symptoms.—[Tertiary  symptoms,  M.» Ricord
observes, will not inevitably occur in the course of syphilis, but they are
very likely to do so if the treatment of the primary and secondary symp-
toms  be not  conducted with the  greatest  care.  As soon as ever the
tertiary period  has  set  in,  mercury  must  be abandoned, and iodide  of
potassium given.  Nay, further, as mercury, taken in time, may prevent or
retard secondary symptoms, and  so  may  be  regarded as a prophylactic
against them, so may iodide of potassium  be  regarded as a prophylactic
against tertiary symptoms;  and therefore M. Ricord observes :]
 °To render the treatment of secondary syphilis complete and rational, it
should always be followed by the exhibition of iodide of potassium.   This
substance is, hoAvever, not only useless, when employed against secondary
symptoms and  those of transition,  but very  often hurtful;  yet,  when
secondaries have been of long  standing, it may produce beneficial effects;
it is  also useful as  an  adjuvant  of mercury, in those  affections wdiich in
some degree lie between the secondary and strictly tertiary manifestations ;
and, finally, it  is indispensable for combating the symptoms of a decided
tertiary nature.  In order  to  become well acquainted with  the proper
manner of administering the  iodide of  potassium, Ave  should take the
trouble of studying its effects,  independently of its curative action.   First
let us see how it acts on the skin.   It may produce on  the cutaneous sur-
face diverse psydracious and acnoid eruptions.  The pustules are generally
surrounded by a vividly red areola, and the usual  seat of these eruptions
is below the umbilical region, as the nates, thighs, etc., whereas the  com-
mon acne (not  to mention  its other characters) is mostly situated in the
upper half  of the body.  To these peculiarities, it may be added, that the
pustules Avill fall in immediately the administration of the iodide is inter-
rupted.  Exanthemata,  impetigo, and lichen, are very  apt to be produced
by the use of this salt;  and what you ought especially to keep in mind is,
that ecchymosis, and purpura  in  the  inferior extremities, are  sometimes
caused by the action of the iodide of potassium.  The  effects of the latter
on mucous membranes  should also be  carefully observed.  It may cause
inflammation of the conjunctiva, the sub-mucous cellular tissue lying under
Avhich gets then  infiltrated and  puffed  up;  the eyelids turn red and
cedematous, and when the  inflammation and  effusion are not arrested, the
internal parts of the eye become involved in the affection, and photophobia
is the result of this state of  things.  The normal mucous secretion is
always a little increased, but it does not take  the muco-purulent character,
as in the case of catarrhal ophthalmia.  Coryza, of a more or less severe
nature, often exists at the same time: it is preceded and accompanied by
headache, and a pretty abundant  mucous  secretion; but  this coryza never
reaches the suppurative state; it never produces more than a catarrho-
serous flux.  These affections  never give rise to any fever, and they disap-
pear as soon as the iodide is given up.  This coryza is an accident Avhich
we should not overlook, for it is of importance to avoid it when Ave have
 to treat a tertiary affection  of the nasal fossas.  As for the effect  of the
 iodide on  the  intestinal canal, I have to state that persons enjoying good
 health  can  bear very large doses of it;  I have given as much as fifteen
 drachms a day.  M. Puche has  often  given ten  drachms per diem, after
 commencing .vith six; and it has been noticed that it improves the appetite
 of the persons wdio use it.   With some patients a certain pleurodynic-sen-
 sation, corresponding to the cardiac extremity of the stomach, is felt after 
622
SYPHILIS.
its ingestion, but it nei'er causes vomiting.  The sub-mucous cellular tissue
of the stomach may, by the use of this iodide, undergo the same modifica-
tions wdiich Ave have noticed the conjunctiva to  be subject to—a sort of
hyper-secretion and  intestinal ptyalism takes place, and much of the fluid
wdiich ought to have been secreted by the skin is rejected by the mouth.
This liquid has a slight taste  of iodine; it is not fetid in  the least: the
gums are not swollen, and there  is no  fetor in the breath, as happens in
mercurial ptyalism.  The same effect may be produced on  the other por-
tions of the intestinal canal; the patients  are  then seized Avith  abundant
serous diarrhoea.   The iodine is  eliminated from the system by the kid-
neys ; half an hour after the ingestion of it, its  presence  may  be ascer-
tained in the  urine, and it should  be remembered, that the presence of
iodine in the blood increases the  renal secretion.  I ha\-e even observed a
case of polydipsia which lvent  on as long as the iodide was used, but dis-
appeared when the latter ivas discontinued, and gradually sprang up again
as the use  of the salt was resumed.
   The effects of the iodide of potassium on the  circulation are of a seda-
tive kind; it diminishes  the number of arterial pulsations and lowers their
force, but  they may regain their normal standard if the remedy act bene-
ficially on the system; the same arterial energy may also reappear when
the iodide causes a slight phlegmasia.   This salt is someAvhat antiplastic,
for it has rather a tendency to liquefy the  blood, and may even produce
the peculiar hemorrhages of purpura.   When the effect of the iodide on
the  nervous system is  carefully watched, it  is  found to cause  a certain
excitement of the nervous centres, followed by a little uncertainty in the
movements and in the intelligence.
   Doses and Forms.—If the efficacy of the iodide of potassium has ever
been doubted, it is  because no one would venture to give it in doses suffi-
ciently large to test it fairly.   Most practitioners confined  themselves to
three or four grains  a day—no wonder that no effects were produced.  The
daily dose ought  to be fifteen grains to begin with; tivo or three days
afterward, forty-five grams may be given every day in three distinct doses.
If the remedy has no pathogenic effect Ave  must be guided by  the thera-
peutic  action, so that if the curative effect be not apparent at all in three
or four days, the dose should be augmented.   The influence produced on
the  osteoscopes may very Avell serve  as  a criterion of the action of the
remedy, provided these osseous pains do not arise from suppuration, and
they  be strictly a  result of the diathesis.   I have had  patients in whom
the removal of these pains required as much as one drachm and a half, twro
drachms, and even three drachms per diem.
   Forms.—The iodide of potassium has been given in capsules, in solution,
in sirup, etc.; rarely in  the form of pill, for this salt is very deliquescent;
I generally give it in sirup, and I have found bitters to be the best adju-
vants—viz., sirup of gentian,  of saponaria, of  quassia, de cuisinier, of
sarsaparilla, etc.   One pint  of sirup is to be used for  one ounce of the
iodide,  which will give  about  twelve  grains  to the  spoonful;  the  same
quantity may also be given in the sweetened mistura acacias, or in the sirup
of poppies, or of lactucarium.   As to  the diet, it ought to be of a tonic
and regenerating nature—chops,  steaks,  wine, porter,  etc.   You see,
therefore,  that Ave know  pretty well what ought to be the daily dose
of the  iodide, but we are not so  well informed as regards  the absolute
 quantity Avhich can  be  given with safety; it  is impossible to fix this 
BYPHILI8.
623
 beforehand.  Neither do we know exactly how much time this medication
 may be continued in order to free the  patient from the possibility of a
 relapse.
   You must be  careful to modify the treatment just described, accord-
 iii"-  to  certain  peculiar manifestations.  For instance,  Avhen  you have
 to contend  against  syphilitic  sarcocele,  and  the  same  is exempt from
 complications, it will be sufficient to use the general treatment.
   But when there  is  much inflammation, you must have  recourse  to
 antiphlogistics and emollient applications; and if it were noticed that the
 testicle is suffering both from syphilis and struma, anti-scrofulous remedies
 Bhould he added to the  usual treatment  of such  cases.  The  plastic
 effusion Avill be efficiently controlled by  rubbing the part with the mercu-
 rial  ointment, and covering the whole Avith  a soothing cataplasm; and
 much benefit will likewise  be derived in  these cases by the methodical
 compression with strips of plaster, wdiich was spoken of when I considered
 epididymitis.  If you have elastic  tumors of the testis  to treat, the best
 practice is to open them as soon as fluctuation is detected, and you should
 have recourse to  sedative applications wdien you perceive  that they are
 surrounded by an inflammatory areola.  But when the ulceration presents
 no redness, nor any  symptoms of irritation, a very good wash may be
 made with a solution of iodine in the proportion of one half or a whole
 drachm to 12 ounces of distilled Avater; and when this solution is being
 prepared, a certain quantity of iodide of potassium should be  added, to
 prevent the precipitation of the iodine.   If the granulations of the tertiary
 ulcerations are  too prominent, they should be destroyed with the pate de
 Vienne, or any other caustic.
   When elastic tumors are not situated in the scrotum or testicle, they
 may  be  attacked by very  energetic  means—viz., mercurial frictions,
 Vigo's plaster, blisters foUowed by irritative dressings, as advised by Mala-
 pert, etc.; and where suppuration has  occurred,  the matter should be
 freed without delay.   As for  the  elastic tumors situated on the mucous
 membrane of the nasal fossas or mouth, they may be very beneficially acted
 upon by lotions containing a solution of iodine, in the proportion of two to
 six parts of this substance  to one hundred of distilled Avater; in fact, the
 proportion of the iodine may be increased as long  as no pain is produced
 by the application.
  The muscular retraction, or plastic degeneration of the muscles, requires
 local applications besides the internal remedies.  Topically, I use circular
 compression, carefully applied with strips of Vigo's plaster.
                                                   Part xviii., p. 206.

  Proto-Sulphate of Iron in Chancre and Gonorrhoea.—[An anonymous
 correspondent of the " Lancet" says :]
  The Avhole class  of  caustic agents, when applied to  the Hunterian
 chancre  (though the  potassa  fusa  cum  calce be  used  till  the  ulcer
 be "punched out," as recommended by M. Ricord) form au  eschar with
pus still  secreting; in fact, the morbid  cells  have not been destroyed.
 The alkaloids and hydrocarbons are equally inefficacious.
  If a chancre be perfectly freed from its  eschar and the inclosed pus, at
the bottom  of the excavation may be  observed minute white points or
germs, secreting, slowly, the morbid virus.  If, now, the proto-sulphate of
iron, minutely pulverized, be dropped into this excavation, the parts will 
624
SYPHILIS.
mstantly assume a charred appearance, the metal is absorbed into the tissue,
the morbid cells or germs will instantly cease to secrete pus, the cleared
cavity will shortly granulate, and  a  smooth  surface, without induration,
will be ttie result of the use of the proto-sulphate of iron.  The chancre is
destroyed.
  The proto-sulphate of iron, I  have observed to  be the most  powerful
agent for arresting decomposition in animal and vegetable substances.
Inflammation and decomposition in the living tissue is  likewise arrested
by it.
  In  gonorrhoea, we have noAV an agent arresting  the morbid cellular
action in the salts wdiich should  be used in solution super-saturated.
  In  leucorrhoea, and  in  simple ulcers, the morbid action is arrested or
peroxidized by this metallic salt.
  Large doses of this salt have  been  exhibited in obstinate diarrhoea, with
great benefit.                                          Part xix., p. 186.

   Creeping Bubo.—[Mr. Solly observes that there is a form of venereal
affection Avhich  has not  received an  exact name from systematic writers,
and wdiich he designates " creeping bubo."   It is that intractable sore
which arises Avhen chronic syphilitic bubo  proceeds to ulceration, unstayed
by mercury.  Mr. Solly says:]
   Its most  striking feature  is the manner in which it burrows under the
skin,  creeping onward from place  to place.  This creeping character has
induced me, for some time past, to  designate  it  in my clinical observa-
tions, as creeping bubo.  It often creeps upward on the abdominal parietes,
as high as the umbilicus; down the  thigh, as Ioav as the knee ; round the
thigh, to the anus ; and over the buttock, nearly to the spinous process of
the ilium.
   The formidable nature of this ulcer is best seen in those cases  where no
mercury has been administered ; for,  in these, there is scarcely any attempt
at the healing process.  Some years ago, I had an opportunity of Avitnessing
rc  ral cases of this kind occurring about the same time.   Their extreme
oostinacy astonished me.  I saw every local application in  the Pharma-
copoeia tried, but in vain.  Mercury  was not made use of and  they con-
tinued to extend.  One case sank under the disease, apparently exhausted
by its depressing effects.
   The appearance which creeping bubo exhibits in its early stage, presents
some peculiarities by Avhich it may be distinguished.  The surface of creep-
ing bubo is of a yellowish color, the  discharge is  thin  and  ichorous, the
edges are everted, overlapping, corrugated, in dotted points, white, hard,
and very irregular.  In its early stage it  is  most  like the  strumous or
scrofulous bubo, wdth its  oi'erlapping edges;  but it differs, inasmuch as
the edges of the strumous bubo are inverted, not  everted,  and soft, not
hard  and corrugated.  The distinguishing  marks, howrever, are not so
easily described  by the pen as by the pencil.
   In  this form of bubo, a mercurial treatment is almost invariably required.
We must give mercury steadily, until it  disagrees with the system ; then
abstain from  it, and give tonics;  and after  waiting a few weeks, or even
months, again return to the use of the mercurial preparations.
                                                      Part xix.,/). 195.
   Bransby B.  Cooper's Treatment of Chancre—Simple.—When called to
see a venereal sore, of only three or four clays' duration, apply concentrated 
SYPHILIS.                           625
nitric acid.   But if a sore has all the appearances of true chancre, begin by
usino" constitutional  treatment—giving five grains of blue pill and a quarter
of a grain of opium night and morning.   So long as the patient is taking
mercury, app'y no local remedy whatever, and then  the sore will furnish,
by its  appearance,  the  best possible indication of the effect  which the
medicine is producing.
  Irritable.—A\>nly nitrate  of silver to the sore, and give repeated doses
of opium.   If when the  irritability is subdued, induration  remains, give
mercury, as in a simple case.   In some instances  of irritable chancre,
calomel and opium will answer as well or better than opium alone.
  Phagedenic.—First evacuate the bowels, and then give repeated doses
of opium,  and  apply soothing  fomentations.  If the  vital powers are
depressed, give bark, ammonia, and even wdne;  hut if there is a plethoric
condition, adopt antiphlogistic measures.  If the progress of the ulceration
is not checked, apply concentrated  nitric acid.
   Gangrenous.—Keep the  patient in the recumbent posture, and  after
evacuating  the bowels, give  ammonia, bark,  or serpentaria, with Avine or
porter; and apply black  wash,  nitric acid lotion, stale beer grounds, or
stimulating poultices.
  When the healing of chancres on  the penis  is interfered wdth by the
occurrence  of erections,  give five or ten grains of lupulin at bedtime, and
repeat  it if necessary.                                  Part xxi, p. 269.

   Diagnosis and Treatment of Bubo.—[Mr.  Cooper lays especial stress
upon the importance  of  distinguishing between a  bubo arising from  a
virulent and one from a  non-virulent disease.   He says:]
   Non-virulent bubo is that which attends simple gonorrhoea, and may be
considered  as arising from common inflammatory action, extending in the
course of the absorbent vessels of the penis to the glands of the  groin ; this
disorder is  to be treated as phlegmonous swellings in other parts of the
body, either by repellents for the purpose of preventing the formation of
matter, or  by fomentations or poultices to produce suppuration, when that
termination seems to be threatened by nature.
   By repellent remedies, I  mean those Avhich  have a tendency to repress
the formation of matter, such as leeches and evaporating lotions ; by means
of these Ave may succeed in  preventing suppuration,  but there sometimes
yet remains a permanent indurated condition  of the  swelling,  which may
excite  apprehension in the mind of the surgeon as to its having been pro-
duced  by a specific  virus, a chancre existing Avithin the urethra.   A bubo
of this kind may, however, result from a mere strumous habit; and if so,
the hardness readily yields to the exhibition of iodine and iodide of potas-
sium, and such dietetic rules as generally improve strumous constitutions ;
Avhile,  on the contrary, if the hardness depends upon the action of a spe-
cific poison, a mercurial  course is,  in my opinion, the only safe  mode  of
treatment.
   A virulent bubo is  marked by the same  characteristic induration as a
chancre itself, and the presence of this induration must inevitably give rise
to the  question of the virulent  or  non-virulent nature of the disease.  The
mere phlegmonous bubo has always a tendency to suppurate ; Avhile the
virulent bubo,  on  the  contrary, seldom manifests this disposition ; and,
therefore, its permanent hardness, uncombined Avith any symptom of sup-
puration, is a further proof  of a wus  having been  the origin of a bubo.
     VOL. II.—40 
626
SYPHILIS.
The virulent bubo goes on to ulceration; but even this is not conclusive,
for strumous ulceration not unfrequently occurs in persons of a scrofulous
diathesis ; therefore,  as Ricord observes, there  is  as much difficulty in
forming a diagnosis betAveen the virulent and non-virulent  bubo as  between
the virulent and non-virulent sore.  In my own practice Avhen the bubo
puts on all the  characters of a virulent  or  specific action,  I commence at
once wdth the cautious  administration  of mercury,  not unfrequently com-
bining with it small doses of iodide of potassium, abstaining at the same
time from the use  of any local application to the ulcerated  bubo,  which
might tend to conceal the characteristic appearance of the sore.  If the
mercury be producing the  desired  effect, the ulcerated  surface of the
swelling  acquires a healthy appearance,  indicated by the growth of soft,
red granulations, by the absence of any tendency to eversion of the edges
of the sore, and by a general softness of the A\hole4)ase of the tumor;  in-
deed, the characteristics of  the  healing sore  are  as strongly marked as
were the peculiarities which had before indicated its virulence.  And until
the induration has completely disappeared, the mercury should be perse-
veringly continued.                                   Part xxi, p. 269.

   Venereal Warts and Condylomata.—In long standing cases of gonor-
rhoea you ivill  sometimes  observe  condylomatous groAvths  about the
scrotum, perineum, and verge  of the anus ; these, Bransby  B. Cooper
states, can generally be cured by an application of the yelloiv Avash. Warts
often folloAV also upon a gonorrhoea, in cases Avhere the disease commences
externally—that is to  say, in balanitis.  In the first instance they are found
in points where the mucous  membrane has been abraded;  warty granula-
tions spring up from these points.  Whenever these warts are present Avith
phimosis, the  prepuce must be  laid open immediately;  this is always
necessary.  Sometimes these warts are \ery difficult to cure.  When they
have narrowr peduncular necks, a ligature may be used to remove them; in
other cases caustic should  be applied to  them, and savine poAvder may also
be employed as an escharotic.  Sometimes, hoAvever, neither caustic nor
savine powder will remove these warty excrescences; they must then be
excised, and caustic applied to the surface from Avhich they are removed.
                                                      Part xxi, p. 210.

   Treatment of Secondary Constitutional Syphilis.—Surround the patient
wdth an  atmosphere of mercurial vapor, in a moist  state, by the  folloAving
method, recommended by Langston Parker:  Place the patient on a chair,
covering him with oil-cloth lined  with flannel, then fumigate him Avith the
bisulphuret of mercury, or the grey oxide,  or binoxide.  The patient may
remain in this mercurial atmosphere for  ten minutes or half an hour.  Let
the patient then repose in an arm chair for  a short time, and let him drink
a cup of warm decoction of guaiacum, sweetened Avith sirup of sarsaparilla.
                                                     Part xxii., p. 261.

   Phagedenic  Chancre.—Iron is the remedy, its effects are almost magical.
It is much used by M. Ricord.  The folloAving is the best mode  of giving
it.  Potassio-tartrate of iron, one ounce ; water, six ounoes.   Mix. Two
tablespoonfuls three times a day.
         ********
    Tertiary Symptoms.—Give the iodide of potash in large doses, which
 will benefit when small ones are of no avail.           Part xxii., p. 262. 
SYPHILIS.
627
   Treatment of Syphilis.—[Speaking of the definition of the stages of this
 disease, Mr. Cooper remarks :]
   If I might be alloAved to express my own opinion on the subject, I would
 give the following definition of the three stages or forms of syphilis :  Pri-
 mary symptoms—the  chancre or local affection; secondary syphilis—the
 sore throat and the various cutaneous eruptions; and tertiary—the ulcers
 and sores  which succeed  the eruptions,  and Avhich, like them, are the
 result of the constitutional manifestation of the disease.
   The diagnosis of a primary syphilitic sore or chancre is sometimes exceed-
 ingly difficult;  in fact, taking the physical characters of the ulcer alone, it
 is frequently impossible to  distinguish it from one of a non-specific nature,
 frequently out  of the surgeon's poAver to say AAdth decision and confidence
 this is venereal, or that is not.  There is but one true  poison of syphilis,
 which poison  produces different effects,  depending on the nature of the
 tissue affected,  and on  the  peculiarity of the constitution; and I believe,
 that all the different effects, and  all the varieties of sores, depend on one
 and the same morbific  cause,  the action of which is modified by the par-
 ticular state or disposition of the individual in wdiich the symptoms are
 developed.
   With regard to the treatment  of primary symptoms we possess, happily,
 a remedial agent—mercury, Avhich might be considered  to have almost a
 specific influence over the  disease, and I believe that syphilis cannot be
 thoroughly eradicated  from  the system  by any  other medicine, after
 absorption has  taken place  and  it has become a constitutional affection.
 If, however, you have a patient  come to  you Avithin four days after the
 appearance of a chancre—that is, before the syphilitic poison has had time
 to become absorbed, and implanted in the  system, no matter if the sore be
 of  the callous   or  true Hunterian  description, or however  ambiguou
 its characters, by the application  of  concentrated nitric acid  you avouIc.
 effectually  decompose or destroy, and render inert the specific poison.
  The healing of a chancre, by the application of local means, is no proof
 of the constitutional subsidence of the disease.  I therefore depend solely
 on  the  constitutional employment of mercury, and object to the use of
 black wash and similar applications,  wdiich are in themselves capable of
 removing the sore, and thus destroy the index which its  appearance  forms
 when its reparation is effected, only as a result of the constitutional eradi-
 cation of the disease.  The  healing of the sore under these indications is an
 evidence that the system has  been sufficiently mercurialized; and that its
 use may now be confidently abandoned.  Acting under this principle  and
 conviction, the  plan I in almost all cases  pursue, is to apply a simple piece
 of moist linen—not lint, for I have seen it (whether from the chlorine used
 iu bleaching it,   or wdiat I do not know)  excite such irritation round a
 chancre, as almost to produce balanitis, which all quickly subsided on the
 use of linen instead of lint to the sore, and administer internally gr. v. of
 blue pill with 1-4 gr. opium at bedtime, and v. gr. of blue pill alone  in the
 morning; directing  these  pills to be  made  up separately, and  labelled
 respectively " night"  and  " morning " pills.  I tell  the patient,  if his
 bowels become  constipated,  to  take only the morning pills both night  and
 morning ; if, on the contrary, relaxed, to take only the night pills. With this
 variation in treatment,  according  to the circumstances of the  case, I con-
tinue the mercury until the  sore  has  disappeared, and the hardness of its
base  subsided.   I learned this treatment from  my uncle, Sir Astley Cooper, 
628
SYPHILIS.
and have adopted it in almost every case that  has  come before me during
the last thirty years;  and I have never yet once got into a difficulty with
it, from the reappearance of the disease  under secondary  symptoms.
Trust to mercury, but give it cautiously, give it judiciously, watching your
patient during its administration, and seeing that he avoid all possible
exposure to cold, and if possible keep him within doors.
  Secondary symptoms are manifested in various morbid phenomena of
different parts, more especially of the skin, mucous membranes, and bones.
Affections of the latter, I believe,  are not the  result of syphilis alone, as a
specific disease, but  of its action, modified by the influence of mercury,
which, as far as I can learn, in such cases, has ahvays been previously ad-
ministered ; and I consider syphilis of  itself,  I will not go so far as to say
incapable, but certainly not as yet proved to have  the power of producing
such direful morbid conditions of  the osseous  system.
  With regard to the treatment of secondary syphilis, the iodide of potas-
sium  is the remedy held in most  repute, and the  one that in general  pro-
duces the most immediate beneficial and successful  results.  But, according
to my experience, iodide of potassium arid iodine, although they have the
poAver of arresting or suspending the disease pro tern., are incapable of eradi-'
eating or eliminating  it in toto from the system, and securing the individual
from  subsequent attacks.  Sir Astley used  almost invariably to prescribe
the bichloride of mercury, in doses of 1-16 gr., taken in bark or sarsapa-
rilla, two or three times a day ; and I myself  prefer and recommend  mer-
cury to be given.  It is true, its remedial effects are not so speedy as those
of iodide of potassium ;  but this  is more  than compensated for by their
being  of a more permanent character.   Cases  sometimes  occur Avhere
iodide of potassium  has been administered for some time, and the further
continuance of its use increases  instead of  diminishes the  symptoms it
was intended to relieve.  In such instances, I have  sometimes seen the
most marked effects  accrue from small doses of arsenic, especially Avhen
combined with mercury and iodine, in  the form of the liquor arsenici  et
hydrargyri hydriodatis, or Donovan's solution.
   [It was clear in the case before  them that the mercurial treatment Avas
abandoned  before the  symptoms thoroughly yielded.  After this  he was
iodized and mercurialized frequently, but with no ultimate benefit.  Had
he been a strong man, Mr. Cooper said he Avould  have given him mercury
and  used every precaution.   But  being  of a depraved  constitution, and
weak, he ordered him :]
   R Iodinii, gr. ss.; potassii  iodidi, 3ss.;  sirupi papaveris,  §ss.; infusi
gentianas  co., §x.   Misce, ut fiat  mistura, cujus sumantur cochl. ij. magna
ter die, cum morphias acet., gr. ss. omni nocte.
   I pursued this for  a few weeks, and at the  same time  enjoined  perfect
rest in bed, but found little  or no improvement in the sore;  ivhich, as is
the character of the specific  kind, healed in one part, but extended itself
hi another.  At the  same time, a number of tubercles appeared over his
head and face, which are anything but  a favorable indication of the condi-
tion of his system.  Tubercles and blotches—the difference between the
tivo feeing, that the former are elevated, but the latter even  wdth the sur-
face of the skin—may  depend on other causes  than syphilis; but, as a
result  of this disease, they are always unmistakable from their coppery hue,
their smutty or dirty appearance, the skin in fact conveying the impression
 of its wanting to be wadied. 
                              SYPHILIS.                           629

  Seeing that be made no progress under the  influence of the medicines
prescribed, I altered them, and gave him:
  It Liq. hydriodatis arsenici et hydr., 3iss.; extracti sarzas, 3j-; dec. sarzas
co., §viij.; cochl. ij. amp.  ter  die sum.;  pulv.  opii,  gr.  ss. omni nocte.
And since then, I must say, he has been slightly improving.
  In concluding these  remarks on syphilis, I may observe, that in sloughing
phagedena, mercury has  the effect of aggravating  rather  than mitigating
the symptoms, and is consequently decidedly prejudicial; the remedies are
the topical  application of nitric acid,  and the internal administration of
opium.  Nitric acid not only destroys the part in contact with it, but at
the same time induces a  more healthy action in those beneath.
                                                   Part xxiii., p. 203.
  Prophylaxis of Syphilis.—This preservative consists of a strong alco-
holic solution  of 6oap,  having  an excess  of alkali.   Dr.  Langlebert had
performed several experiments by inoculating Avith the poison of chancres,
and then employing his antidote within about five minute afterward.  The
effects of the virus had in every case  disappeared.      Part xxiv., p. 262.
  Borax as an Ap>plication to Gangrenous Buboes.—Dr.  Effenberger ap-
plied a solution of borax, in the proportion of from one to two drachms in
a pint of water, to a large number of patients AA'ho suffered from gangrenous
bubo, wdth great success.  He had  fifty cases in one year; not  one had
died, although  there Avere several Aery severe cases, and in one the femoral
vessels Avere laid bare.   The solution was applied by means  of charpie, so
as to cover  the edges of the  sore.  It was very  essential  that the charpie
should be very frequently reneAved by night and day;  and to the neglect
of this precaution, he attributed the failure of this practice in the hands of
other  surgeons.                                      Part xxiii, p. 212.
  Phagedenic  Chancre.—Give  iron.   M. Acton  trusts  chiefly in  the tar-
trate,  probably any other form would  do  as well.  If there is sloughing
phagedena, give opium  in large doses.  Destroying the surface of the
ulcer with nitric acid is useful in some cases.

  Bubo.—Give one grain doses of tartar  emetic every second hour, until
a marked effect is produced upon the inflammatory swelling.
                                                    Part xxiv., p. 268.
  Mercury—Substitute for, in  Syphilis.—M. Robin,  of Paris, substitutes
15 grains of the bichromate of potash divided into 80  pills, with extract of
gentian; one to be taken night and morning.           Part xxv.,p. 268.
  Bubo—Opening of, by Multiple Punctures.—M. Vidal strongly recom-
mends that venereal buboes should not be allowed to  open of themselves;
for when they are left to nature, the  skin becomes detached and thinned> a
great loss of  substance ensues, a tedious recovery takes place, and an un-
sightly  deformity is  left.   Opening by  caustic, too,  leaves  disfiguring
scars; and the same inconvenience results from large incisions, and cutting
away, by the bistoury, portions of skin that are too much changed to unite.
Still the  bistoury is much more easily managed than is the caustic, and M.
Vidal much  prefers removing by it a portion of half  dead, detached skin,
or a gland wdiich is an obstacle  to reparation, to attacking such  parts by
caustic.  By its  aid the  cicatrix may be rendered more regular, and  cause
less deformity.  But  cases requiring large incisions and excision are rare, 
630
SYPHILIS.
   especially if the bubo be early treated, and punctures are made as soon as
   matter is formed.  The bubo should be shaved.  If the abscess is recent,
   and suppuration not extensive, one puncture may be made at the fluctuat-
   ing point.  If other glands suppurate, they must be punctured in the same
   manner.   Bf the collection is extensive and superficial, several  punctures
   are required, not in the fluctuating centre, but at the circumference, by a
   straight bistoury passing  subcutaneously to the centre ; thus the skin is
   divided A\diere it is adherent, intact, and possessed of its vitality.  The
   bubo  must not  be  pressed for tAvo days, when it Avill gradually discharge
   itself.  Sometimes the punctures close before the matter is evacuated ; this
   may be prevented by gently pressing the abscess once a day. If  they all
   close, it is better to alloAv them to do so than introduce tents, making one
   or two neAV punctures if required.  By this  plan not the slightest mark, or
   only a very slight one indeed, is left.                   Part xxv., p. 269.

      Treatment of Syphilis.—Prof. Bennett enters into a comparison of the
   simple treatment of syphilis Avith the mercurial treatment, and gives statis-
^  tics to prove the great superiority of the former plan.  . Prof. B.  says:
      The simple treatment is divided into  internal  or medical,  and external
   or surgical.  The first consists in the observation of certain hygienic rules,
   and the employment of general therapeutic means.   The diet must be light
   and mild, meat  and all stimulating viands  retarding the cure;  even with
   the lightest diet the hunger should never be quite appeased.   The  regimen
   must  be  the  more  diminished and rigid in proportion to the youth and
   vigor of the patient.   Diluent beverages, decoctions of barley, liquorice,
   and linseed, alone  or mixed with milk, should be taken freely, to the
   amount, indeed, of several pints a day.  Perfect repose must be secured by
   confinement to bed.  Constipation must be obviated by the use of emol-
   tient clysters or mild laxatives.   The air should be maintained at the same
   temperature ; this is an indispensable  precaution in chronic, consecutive,
   and mercurial affections.   Exercise is only useful in the convalescent stage.
   In chronic  syphilis, hoivever, it may often be carried to fatigue with ad-
   vantage.  Tepid baths, repeated three or  four times a day, are ahvays
   attended Avith advantage.   General blood-letting is often required when
   the primary disease is intense, or the system excited and the patient ple-
   thoric, but should not be used indiscriminately.
      In the external or surgical treatment, strict attention to cleanliness and
   the position of the diseased parts should never be lost sight of.  Emollient
   decoctions or fomentations, or  dressings of simple  cerate, are the best
   applications,  and the dressings  should not  be  too frequently renewed.
   Leeches are generally necessary.   The greatest benefit is derived from the
   external use of a concentrated  solution of opium (in the proportion of
   about two drachms  to one ounce of water) ; it soothes excessive irrita-
   bility in all cases.  When the suppuration is moderated and the surface of
   the ulcer  cleansed, stimulating dressings, consisting  of solutions of the
   sulphates  of alum and copper, the nitrate of silver, and subacetate of lead,
   favor  cicatrization.
     In inveterate cases, more especially those laboring under tertiary symp-
   toms,  the  iodide of potassium has been used ivith benefit, in doses of five
   grains, three times  a day, conjoined with  emollient applications to the
   affected parts.
      The Mercurial Treatment consists in keeping up slight  salivation,  by 
SYPHILIS.
631
means of the internal administration of blue-pills Or some form of mercury,
sometimes conjoined Avith  mercurial frictions  or  fumigations, at least for
the space of a month.  This physiological action of the drug may be pro-
duced by administering any of its preparations  continuously in small doses.
If combined with opium, they act less on the boAvels and more on the sys-
tem generally.
  It is necessary during its action, that the patient do not expose himself
to cold.  A certain  irritability  is produced,  and the constant soreness
of the gums, the metallic taste in the mouth, not to speak  of the  incon-
veniences  of profuse salivation which  occasionally  occur,  render  this
species of treatment anything but agreeable to the patient.
                                                    Part xxvi, p. 278.
   Venereal Ulcers.—The following is the composition of Plenck's Mercu-
rial Balm for dressing  venereal ulcers : Mercury,  1 oz.; Venice turpen-
tine, \ oz.; lard, 3 oz.; calomel, 11\  grains ; elemi  ointment, 3 oz.  Mix.
                                                   Part xxvii., p. 162.
   Seton for Suppurating Bubo.—M. Bonnafont, chief surgeon of one of
the military hospitals of Paris, has lately proposed  to supersede the ordi-
nary modes of opening buboes by the following  method : A seton of a
very few threads, is passed through  the bubo in the direction of its long
axis, and left for several days, until a kind of fistulous tract is established,
The thread is then removed, and the purulent matter escapes by the small
apertures, either spontaneously or by pressure.   The advantages of  this
practice  are,  according to the author, the avoidance of  the  unsightly
puckered cicatrix generally left  when incisions are made, and the more
rapid healing of the bubo.
       ****       *$*$
   Bubo.—Dr. Clairborne applies collodion over a bubo when there is not
much local inflammation; the collodion  is applied layer after layer, until
considerable compression is produced.   Bf there be any amount of inflam-
mation, leeches are previously applied.              Part xxviii, p. 221.

   Syphilis  Congenital.—Mr. Wormald, of St. Bartholomew's, says: The
mildest preparations of mercury given to children  are apt to run off by
the boAvels; to obviate this, let  a piece of flannel  smeared with mercurial
ointment be worn constantly over the  child's belly.   If the child be at
the breast, mercury should  be administered to  the mother also.
                                                   Part xxix., p. 241.
  Syphilis.—There is  a great  difference, Mr. Acton believes, between
what is  called  the infecting chancre which is  an indurated  sore,  and
the unin dura ted sore.  The former communicates constitutional syphilis,
the latter does not.   The infecting indurated sore ought to be treated by
mercury, the unindurated form  need not be so treated.  Hence the diffe-
rence of  opinion  amongst  medical men is often founded on a misappre-
hension.
  In treating the former,  in Paris,  the proto-iodide  of mercury is used,
but this does not ansAver so Avell in this  country as mercurial friction, blue
pill, or the grey poiArder.
  Phagedenic  Chancre is treated by  Ricord,  by first  destroying  the
whol' of the unhealthy surface Avdth a red-hot iron,  previously placing the
patient under the influence of chloroform.  After the sloughs have sepa 
632
BYPHILTS.
rated, the surface  is covered Avith  strips of ammoniacum and mercurial
plaster, and doses of tartrate of iron are given Avith great success, in the
less obstinate cases.  The most frequent variety of sore in  London is the
phagedenic with induration.   In this the actual cautery does no good;
mercury must here be given, and the system supported by bark, Avine, or
steel.                                                Part xxx., p. 172.
  Bubo.—To prevent  a bubo from suppurating, Dr. Thompson, at the
Marylebone  Infirmary  employs counter irritation by means of a strong
solution of nitrate of silver, three drachms to the ounce of distilled water,
with twenty minims of strong nitric acid.  It may be applied with a  glass
rod or stick, or a glass brush.  The black  eschar will peel off in a few
days, and then it should be reapplied.                 Part xxxi, p. 229.
   Preservative Means Against the Syphilitic Virus.—It is stated that a
neutralizing liquid has been discovered for this poison, composed as fol-
lows : Distilled Avater, 3ixss.; perchloride of iron, citric acid, hydrochloric
acid, of each 3j.   Let a drop of this fall upon the part inoculated, and
alloAv  it to  remain fifteen minutes, or apply a bit  of lint  soaked in the
fluid.   If the lint  be applied for an hour the antidote is complete.
                                                     Part xxxi, p. 236.
   Plurality  of Poisons in Syphilitic  Diseases.—Mr. Skey, surgeon to
 St. BartholomeAv's Hospital, believes that there are a plurality of poisons
 in this disease depending upon the constitution of the person affected, and
 not on the source of the infection.  For the treatment of venereal sores,
 mercury, in  ninety-nine cases out of one hundred, is unnecessary. We may
 say that there are three different  kinds of venereal sores :  first, the com-
 mon venereal sore, Avhere mercury is quite inadmissible ; second, the pha-
 gedenic sore, ivhere mercury is positively injurious ; third, the true syphi-
 litic sore, dusky, cartilaginous, indurated; here mercury is useful, and it is
 the only  case in which it is admissible, but it is very rare comparatively.
 M. Ricord, of Paris, entirely and fully coincides ivith these views. In the
 exhibition of mercury, it is a bad  plan to  push it where it seems to have
 little or no effect.  It would be much  better to intermit its use for  a few
 days, and when resumed it ivill be far more likely to produce a beneficial
 impression.  When pushed to salivation, it too often produces a long train
 of complaints, ivhich last as long as life.             Part  xxxiii, p. 239.
   Tincture  of Iodine in Bubo.—M. Joliclerc states, as the result of much
 observation, that  tincture of iodine is the best application in bubo, prevent-
 ing, or dissipating  fluctuation,  and facilitating  healing if the bubo be
 already open.  He applies it by gentle friction,- so as to ai'oid vesication.
                                                    Part xxxiii., p. 242.

   Common   Sore  or Venerola.—Mr.  Skey,  of St. Bartholomew's says,
 There.are three stages  through which Ave may trace this sore: the first is
 ulcerative, the  pimple Avhich comes out on  the third or fourth day in-
 creases until it  is about the size of  a  pea;  in the  second stage, the sore
 throAvs up a border or elevated edge, granulations also spring up to the
 edge of the mound; in the third stage, these granulations are absorbed
 and cicatrize.  This is the ulcer  of gonorrhoea inoculation, and is never
 followed by  secondary symptoms.  Mind,  now, that  about  these sores
 there is no thickening, tumefaction, induration.  Indurated sores, that is,
 with edges like cartilages, are very rare indeed.  If your patient has true 
SYPHILIS.
633
syphilis bubo, you feel a distinct gland inflamed under your finger.  It is
not like common bubo, but inflamed tissue like an abscess, running along
the line of Poupart's  ligament.   There is no suppurative action in true
bubo.  None of these common  complications are at all bettered by mer-
cury.  The chief and abiding principle of treatment in venerola is, to keep
the parts  scrupulously clean.   The  sore will take a  certain time to heal,
and you cannot stop the ulcerative process either by mercury or caustics.
Above all things the parts must be kept clean, or your patient Avill have a
" crop of sores."   Simple spermaceti ointment and morphia is the nicest
application.   In the  second  stage give bark  or quinine, and  an extra
allowance of good wine.  At the end of four months you may look out for
secondary symptoms, but you will never find them.    In this special sore,
which produces no sore throat,  no eruptions, etc., mercury  is  never
required.  In fact, mercury is not more required for what are called syphi-
litic diseases, than for  any other cla'ss of  diseases.  Mercury, as regards
syphilis, is the greatest curse of a cure, and about the most useless thing
as a remedy ever discovered.                        Part xxxiv., p. 211.

   Obstinate Chancre.—Opium, says M. Rodet, acts  most efficaciously in
those cases in which mercury is of the least use,  and vice versa.   Thus in
constitutional syphilis it acts as a mere corrective, and  should only be given
in very small doses. When, hoAvever, the  chancre manifests any  tendency
to phagedena, mercury should be rigidly forbidden, wdiile opium is espe-
cially valuable in diminishing the irritability, pain, and suppuration.  It is
in the phagedenic  serpiginous  ulcers that large doses  of opium act almost
as a specific.  It should not be given too frequently, for if the stomach be
kept too  constantly under its action digestion will be interfered with ; the
entire daily quantity should be taken at two doses, morning and eArening.
Wine should  also  be  given freely wdth the opium as a corrective to the
stomach ; to  prevent its constipating effect on the boAvels, and to obviate
the tendency to sleep.                              Part xxxiv., p. 215.
   Secondary Syphilis.—[We sometimes meet wdth cases of secondary sy-
philis which resist the  usual preparations  of iodine.   The object  of this
paper is to bring before the notice of the profession a neAV compound, which
combines all the advantages to be derived from iodine, while it is devoid
of its  had effects, and has proved very valuable Avhen other combinations
have  failed.]
   Dr. Christophers' experience of  the action of this  remedy is  limited to
cases of secondary syphilis; but in the hands of some other surgeons, it
has been found  efficacious in cases of scrofula, anemia, and in the furuncu-
loid plague.
   There  are two preparations: the one found so useful in treating cases of
secondary syphilis) he  names  "liquor  cinchonas hydriodatus;"  the  other
(that which has been found useful in treating boils, anemia, and scrofula),
" liquor cinchonas hydriodatus  cum ferro."  The former contains in one fluid
drachm of liquor, twelve grains of cinchona flav.,- and one  grain and a half
of iodine, in the form of hydriodic  acid.  The bitter  contains, in addition
to the former  ingredients, one  grain of  protoxide  of iron in each fluid
drachm of the liquor. These preparations are produced by exhausting the
powdered  bark Avith  an  aqueous solution of  hydriodic  acid;  then with
water, and the  liquor is subsequently evaporated to the aboAre bulk.
  The dose varies from one drachm to  three drachms of " the liquor cin- 
631
SYPHILIS.
 chonae hydriodatus," and from fifteen minims to tAvo drachms of " the liquor
 cimdci.e hydriodatus cum ferro;" the use of the hot-air  bath in order to
 prodm-e profuse sweating, is a potent remedy for intractable and inveterate
 caor.s of secondary syphilis.                          Part xxxiv., p>- 211.
   Primary Syphilis—Ferruginous Treatment of .—Mr. Behrend, of Liver-
 pool, instead of the old mercurial treatment, uses the  potassio-tartrate of
tiron, to cure every type of primary sore:  of course  this does not exclude
 the use of caustics,   lie prescribes the salt in form of solution, in the pro-
 portion of one part to six of Avater, of which two tablespoonfuls are to be
 taken three times a day, and a solution of the same strength as a local ap-
 plication to the part.  The patient must be instructed, lest he remove the
 lint roughly, and so destroy an incipient cicatrice or healthy granulations.
 In the phagedenic form, generous diet, Avine,  and fruit, may  be allowed,
 but no pastry  or cheese.   He has  not had a single case of secondary or
 constitutional  syphilis after treatment Avith the potassio-tartrate  of iron
 alone, either in hospital or private practice, except in tAvo cases in which he
 combined the iron with mercurial treatment.          Part xxxv.,p. 111.

   Secondary Syphilis.—Of the different forms of eruptions, Ave  may men-
 tion, first, among the rashes, the annular form of roseola:  this  very soon
 yields to the iodide of potassium, if it be given before desquamation has
 taken place, and the copper-colored stain has formed.  Purpura must he
 treated by generous diet, iodide  of potassium, and decoction of bark.  Of
 papular eruptions, syphilitic lichen may be very obstinate, but it will always
 yield to a strong lotion  of the bichloride of mercury, ten grains to the
 ounce.  In the ulcerating foim of lichen, the iodide of mercury, one grain
 every night, with two or  three grains of the extract of conium, in the form
 of a pill, is the best treatment.   Syphilitic prurigo yields more  readily to
 sarsaparilla than to any other remedy.  In the scaly forms, such as lepra
 and psoriasis, Donovan's  solution, in doses of ten minims to half a drachm
 three times a day, is the most efficacious internal remedy.   The  best local
 remedies are,  the bichloride of mercury lotion, and in some cases, the mer-
 curial vapor bath, by surrounding the patient, seated on a cane-bottomed
 chair, Avith blankets, and applying a spirit-lamp  to the mercurial prepara-
 tion ; but  the  simplest plan is to beat half a brick in the fire,  put it in a
 chamber-pot  beneath the  chair, and throAV the mercurial preparation upon
 it.   If you use the bisulphuret of mercury, one or tAvo drachms wdll be ne-
 cessary ; if the iodide, ten grains or a scruple ; but perhaps a  combination
 of the two is better, say ten grains  of the iodide with  a drachm of the bi-
 sulphuret,  increasing the  dose to double this quantity.  At the Lock Hos-
 pital, ten grains of calomel is preferred.  The patient should be kept ex-
 posed to the vapor for ten or fifteen minutes ; and when the  blankets are
 removed, he should be rubbed  dry, and a wet sheet Avrung out of cold
 water thrown  over him, to diminish the sensitiveness  of the skin and the
 relaxing effects of the vapor bath.  The only vesicular form  of disease is
 rupia: here mercury is most dangerous, Avhile iodide of potassium inter-
 nally, with the red precipitate  ointment locally,  is almost sure to  cure.
 Among pustular diseases, Ave may mention ecthyma ;  this again is aggra-
 vated  by mercury, but sarsaparilla often cures it.  The tubercular erup-
 tions are always obstinate, but the mercurial vapor bath is the  best treat-
 ment.   Cutaneous  excrescences may be easily destroyed by strong acetic
 acid or the tine, ferri mur.; but Ricord's plan of using a chloride of soda 
SYPHILIS.
635
lotion for a few days, and then sprinkling the growths with calomel, is the
best treatment.  With respect to the syphilitic diseases of bones, it is in
the hard periosteal node that the iodide of potassium, in eight grain doses,
three times a day, is the specific remedy.  The soft or gummy node gra-
duilly yields to repeated blistering.  In chronic syphilitic  diseases of the
joints, the iodide of mercury is more generally useful than the iodide of
potassium;  these cases are very obstinate, and  it may be well to alternate
the remedies, at the same time giving good diet.  In syphilitic angina, if
not very severe, mercurial fumigation  may be used, or the vapor of the
grey oxide may be inhaled ; but iu very severe cases, the iodide of potassium
internally, with the red precipitate ointment externally, acts like a charm.  In
the treatment of syphilitic iritis, commence at once Avitb calomel and
opium, say  one grain of calomel Avith a sixth of a grain  of opium  every
three  hours, until the gums are slightly touched, but  do not carry it to
salivation.                                          Part xxxv., p. 174.
   Bubo. —Instead of opening these by the knife, Avhich is the plan ordina-
rily employed, Mr. Turner,  military  surgeon at Bombay, uses caustic
potass.  The slough soon  separates, and the result is much more  satisfac-
tory to  the surgeon,  as you avoid the constant opening  and reopening,
causing drain to the system and disgust to the  patient. Part xxxv.,p. 186.
   Venereal Inoculation.—Prof. Porter,  of Dublin, believes that secondary
symptoms may be produced in  the female by  the seminal  fluid of a man
Avho may have had syphilis previously, and  Avho may seem to have been
perfectly cured.  Thus the woman may be affected either primarily, or by
a fcetus, or  by the semen : were Ave not aAvare  of the last mode of commu-
nication, we should be sometimes  quite puzzled to account  for the  symp-
toms.                                              Part xxxv., p. 200.
   Calomel  Fumigation in Syphilis.—No mode of  mercurial treatment,
according to Dr. Lee, removes the symptoms of syphilis so readily as fumi-
gation ; none is  attended with  so tittle  mischief to the patient's constitu-
tion, and after none is a  relapse so seldom  experienced.   Calomel is the
best preparation to use for the purposes of fumigation; it is readily sub-
limed—is not decomposed thereby—and but a comparatively small quan-
tity is required.  It is found to ansAver the purpose better if combined with
vapor of water ;  therefore, in any lamp used  for this  purpose, prolusion
must be made not only for volatilizing the calomel, but a small amount of
Avater likewise.                                     Part xxxvi., p. 195.
   Cure of Syphilis without Mercury.—Dr. Marsden believes that secondary
syphilis may be  treated entirely without mercury, and on  the folloAving
simple plan :  and not one in a hundred instances will return with constitu-
tional symptoms.  Stomachic and tonic remedies must be administered, con-
joined  with a good diet  and the  folloAving formula, viz.:—Sulphur, one
drachm ; sulphuret of antimony and nitrate of  potash, of each five grains;
mixed into a powder, half of which must be given night and morning, and
persevered in until a cure is established.             Part xxxvi., p. 199.
   Chancre.—Dr. Coilman applies pure acetic acid by  means of a glass tube,
thoroughly to the part, preventing its diffusing itself around by means of
chaipie.  On the third day a Avhitish eschar  separates, and a clean, healthy
sore is left,  Avhich will rapidly heal by common dressing.   On the  first and
third day an active purgative is administered.         Part xxxvi., p. 200. 
636
TABES MESENTEKICA.
  Secondary Syphilis—Communication of—A case  is recorded by Dr.
Elliotson, in  which secondary  syphilis  Avas communicated from a lady's
maid (having cracks in the palms of the hands and other syphilitic symp-
toms), to her mistress, in whom it showed itself as an eruption at the  fore-
part of the scalp Avhere the hair is tldnnest.   There had been no breach of
surface to account for this.  The poison had probably been communicated
from the maid applying pomatums ~and  rubbing them in with the palms  of
her hands.
  The third  or cachectic stage of syphilis does not  require mercury, and
yields  generally to hydriodate of potass or sarsaparilla ; the hydriodate is
incapable of curing true syphilis in either its primary or secondary stage.
                                                  Part  xxxviii., p. 171.
  Primary  Syphilis. — Dr. Thompson,  of University College  Hospital,
says:  There  are tivo  entirely  distinct forms of  primary  sores—distinct
alike in course, results, and treatment.  First, the true Hunterian, or  indu-
rated chancre with hard indurated edges, feeling like a cup  of cartilage
imbedded in healthy tissues, and moving freely over the underlying parts ;
if followed by enlarged inguinal glands, these never inflame and suppurate,
and the  important point is, that this form is ahvays folloAved by constitu-
tional symptoms, unless  destroyed before  the  induration  appears, wdiich
happens generally in about from six to eight days.  Secondly, the soft, or
non-indurated chancre, Avith sharply-cut, even, slightly-undermined edges,
much inclination to spread from the highly contagious nature of the secre-
tion, not necessarily, though generally  followed by suppurating bubo ; and
lastly, there  is no constitutional  affection.  Both chancres should be  de-
 stroyed Avith caustic, as  early  as*possibIe, the soft  to destroy its specific
 character, and hence its aversion to heal; the hard,  for the same reason, on
 account of its tendency to infect the system.  If induration, however, have
 occurred, no cauterization ivill avail.   Thus, at the time when cauterization
 is of use, it cannot be determined to Avhich variety  the sore belongs. The
 best caustictis the Vienna paste or potassa c. calce made into small sticks.
 Ricord  uses strong sulphuric acid made into a paste Avith charcoal•; some
 astringent lotion, as a solution of tannic acid in Avater, should be used to
 restrain the  abundant secretion of the soft variety, and thus prevent  the
 spreading of the sore  by infection of neighboring parts.   Nothing hastens
 cicatrization so much  as  a mild form of iron given  internally.   Now, in
 this soft variety, mercury is wholly out of place and must  not be employed.
 In the indurated variety, mercury should be commenced at once (the iodide
 in doses of half a grain to a  grain and a half tAvice a day, is one of the best
 forms for administration), and it is undesirable to exceed  very slight mer-
 curialism ; a little opium may be combined with  it to prevent  relaxation
 of the bowels, and if the stomach is irritable, inunction may be substituted.
                                                    Part xxxix., p. 222.
                   TABES  MESENTERIOA.
  Tabes  Mesenterica, and Chronic Peritonitis in Children.—Dr. West
says : Chronic peritonitis, so often a fatal disease in children, differs from
acute inflammation of the peritoneum, not only in its  tardy progress, but
in being almost invariably associated Avith the tuberculous cachexia. 
TABES MESENTERICA.
637
  The occasional attacks of pain in the abdomen AAdiich form a prominent
symptom of this disease, may or may not be preceded by vague indications
of decaying  health.  But, however this may be, it is not long before the
appetite fails or becomes capricious, the boAvels become irregular, and the
motions unnatural, and thirst  and feverishness set in.  Occasionally the
stomach is irritable, but the tongue is usually clean throughout the disease.
The  abdomen  soon becomes large, tense,  and  tympanitic, and  manipula-
tion of it occasions uneasiness, or severe pain.   As the disease  proceeds,
though pauses  seem to take place  in progress, the symptoms increase  in
severity.
  The child loses flesh ; the face grows pale and sallow, and anxious; the
skin becomes habitually dry, and hotter than natural, and the pulse is per-
manently accelerated.   The abdomen does not groAv progressively larger,
but it becomes more and more  tense, although its tension varies without
any evident  cause, and sometimes  disappears for a day or two,  to  return
again as causelessly as it disappeared.  When the tension is diminished,
the abdomen yields a solid and doughy sensation, and  the union between
the contents of the abdomen and the abdominal walls become very percep-
tible. The superficial abdominal veins now  become  enlarged in many
instances, and the skin grows rough, and looks as if it were dirty.  The
pain  in the  boAvels retains the same colicky character as before, but  it
returns very frequently, and sometimes exceedingly severe, while the child
is never free from a sense of uneasiness.  The tenderness of the  abdomen,
however, but seldom increases in proportion to the increase of pain.  The
bowels are in general habitually relaxed, though the degree of the diarrhoea,
as Avell as the severity of the abdominal pain, vary much in different cases.
As the disease advances, the  child  becomes confined to bed, and is  at
length reduced to a state of extreme Aveakness and emaciation.   Death is
often hastened by the concomitant affection of the lungs; but should this
not be the case, the patient may continue for many Aveeks in the same con-
dition, till life  is destroyed, after a day or tAvo of increased  suffering, by
some-renewed  attack of peritoneal inflammation.
  In the first stage, rely chiefly upon dietetic and hygienicmeans.  In the
second, relieve pain by the application of a large  poultice, frequently re-
newed, to the  abdomen, avoiding if possible, the apphcation  of leeches.
As mild mercurials continued for a long time are of service, as soon as the
abdominal tenderness is sufficiently relieved to allow of it, let the belly  be
rubbed  twice a day Avith a liniment consisting of equal  parts  of tin. hy-
drarg., lin. sapon., and ol. olivas; and give  hydrarg. c. creta, Avitti an equal
quantity of Dover's powder once  or twice a day.  The  abdomen may  be
advantageously supported by a Avell-adapted flannel bandage, AAdth a piece
of whalebone at either side.   If there is  diarrhoea, give a mixture with
logwood and catechu.  If diarrhoea is slight, or is absent,  and there  is
much feverishness, use the tepid bath, and give small doses of liquor po-
tassae and ipecacuanha, wdth extract  of dandelion, and the mercurial Avith
Dover's poAvder.  If a mild tonic seems likely  to be borne, give a mixture
with extract of dandelion, extract of sarsaparilla, and carbonate of soda;
or give infusion of calumba, or liquor cinchonas. Chalybeates will not often
be borne ; citrate of iron, or the ferro-citrate of quinine  are the best, but
must be given with great caution. Change of air, however, and especially
removal to the sea-side, is the best tonic.  The diet  must,  of course, bo
fight and unstimulating throughout.                  Part xviii., p. 125 
633
TANNIN.
   Ody Frictions in Mesenteric Disease.—iu this paper Dr. Baur reports
 the great success that has attended the friction of the whole surface of th'
 body, night and morning, with a sponge imbued with tepid oil, the patient
 being kept in bed, wrapped in a blanket, for two hours afterTS
 effect produced  is abundant general sweating; the skin, losing its dry
 aspect, becomes  supple, tumescent, and of a fresh color, a rubeloid  erup!
 ion sometimes occurring.  A secondary and highly benefical cahnin- effect
 is produced, which is manifested in the production of tranquil sleep  As
 a third, there is increased secretion, especially of the kidneys and liver  It
 is evident that many affections may be rendered tractable by such an ajr'ent
 and Dr. Baur regards it as almost  possessed of specific properties in the
 diseases of scrofulous origin, as tabes mesenterica, or  glandular tumors
 lie beheves the frictions are powerful adjuvants in scrofulous hydrocephalus"
 and may even prove curative in phthisis, when steadily persevered in.  ''
   „  _     ,                                          Part xxxii., p. 99.
   l"berculosis and Tabes Mesenterica of Infants,-Prof. Nelson, in his
 ^ Clinical Observations on the Special Application of the Liquor Pepsinm
 in certain Diseases," says : The number of these cases that have presented
 themselves precludes my entering upon them individually.  Let it suffice
 to picture  them generally, and according to their broad features: to wit
 the wrinkled, discontented, fretful faces of the young children, rather re-
 sembhng those of old men and wonfon in the most unhappy humor possi-
 ble ;  the small shrunken chests ; the large toad-like bellies ; shrivelled ex-
 tremities ;  and bloodless, wax-like fingers.  Such patients often have vora-
 cious  appetites, without any good results ;  the food passing off in diarrhoea
 without having been  digested.  By means of hydrargyrum cum creta and
   i ^E    f' and the hquor PePsi»ise by itself after food, the chants in
 such children have  been very extraordinary, especially when the dhTt has
 been  consistent with  the other treatment, and goats' or asses' milk used
along with raw egg.   The same results ivill  accompany its  use amongst
the pot-bellied young of the lower animals.           Part xxxv   p  298
   Vide Art. " Marasmus."                                    *'r'
                           TANNIN.
   Use of Pure Tannin—-The use of tannin, or tannic acid, externally, will be
found especially valuable in sore nipples, excoriations about the anus and
scrotum, piles, leucorrhoea,  aphthous sores in the mouth, toothache, severe
salivation, and relaxed sore throat. For sore nipples, Mr. Druitt, uses it in the
strength of five grains to the ounce, on lint,  and the part to be covered
\Adth oil silk.  For that troublesome itching about the anus and scrotum,
so teasing to some people,  he prefers lemon juice.  In leucorrhosa, tannin
will be found useful as a suppository, ten grains being mixed  with a little
tragacanth, and introduced up the vagina sufficiently high that during its
solution and passage downward, it maybe smeared over the whole surface.
It is also one of the best applications for severe salivation and for  relaxed
sore throat, attended Avith an increased secretion of mucus.  But Mr. Druitt,
seems to think, also, that it is the best application for toothache;  a  piece
of information  Avhich he received from Mr.  Tomes.   " Let  the  patient
thoroughly Avash out  the mouth wdth a solution of carbonate of  soda in 
TEETH.
639
warm water ; let the gum around the tooth or between it and its  neigh-
bors, be scarified with a fine lancet;  then let a little bit of cotton-wool,
imbued with a solution of a scruple of tannin and five grains of mastic in
two drachms of ether, be put into the  cavity, and if the ache is to be cured
at all, this plan ivill put an end to it in nine cases out of ten."
                                                       Part x.,p. 139.
  Tannin—Employment of.—Dr. Cummings states, as the result of several
years' experience, that he  has  found tannin the  most valuable of astrin-
gents.  Thus, whenever, in dysentery, medicines of this class are indicated,
it acts admirably, either given alone or combined wdth opium.  He says,
he could refer to  more  than  a thousand cases  of  dysentery, diarrhoea,
cholera infantum, etc., in wdiich he has  employed it, never wdth regret, and
almost always with  advantage; while other practitioners, Avith Avhom  he
has communicated concerning it, express similar  opinions.  In the SAveat-
in^, or last stage of phthisis or low continued typhus, and even in the worst
cases, this accompaniment of diseases  of debility has been entirely or in
part relieved.  It is useful in almost all forms of hemorrhage, and most
remarkably so  in hemoptysis; and Avhen combined Avith opium and ipecac,
it forms a medicament Arery preferable to  acetate  of lead and other similar
substances. Among other forms of hemorrhage, over ivhich it exerts great
power, is that from the boAvels resulting from dysentery, and that  Avhich
occurs in threatened abortion.   In hemorrhoids,  it  is of great use as an
outward  Avash. In  epistaxis,  it  may be  snuffed up or blown through a
quill, and will almost ahvays arrest the bleeding.   No article in the  whole
class of astringents acts  like it in severe salivation.-  In aphthas and other
diseases of the mouth, in which  there  are spongy or bleeding gums, it
possesses no  equal.  Used as a gargle in relaxed  uvula and  tonsils, its
efficacy is great.  As an antiseptic, for cleaning old foul ulcers, the author
has extensively used it in the form of a powder,  especially when there is
disposition to hemorrhage. As an astringent collyrium, it is, in his opinion,
preferable to all other substances  in the purulent ophthalmia of infants.
He administers it internally in two-grain  doses.        Part xxiv., p. 350.
                             TEETH.
  Hemorrhage from the Socket of a Tooth— Use of Plaster of Paris.Some
interesting cases of bleeding after extraction of a tooth have been related
in the Journals, several of which have terminated fatally.   Mr. Roberts,
of Edinburgh, relates a case in which a friend of his completely succeeded
in stopping the hemorrhage by filling the bleeding  cavity Avith plaster of
Paris.  From the plastic nature of this substance when moistened, Ave may
conceive how readily and completely it may be pressed into every part of
the bleeding cavity, and by its rapid  consolidation  how it  may form the
most perfect plug.                                     Part xl, p. 114.
  Transpilantation of a sheep's Tooth into the Socket of a Child.—Mr. R.
Twiss, after having extracted  the remainder of a broken front tooth  from
a young lady, aged twelve years, put  in its place the front tooth of a year-
ling sheep, reeking from the jaAV of the- living animal, having  previously
shortened  its root about a quarter of an inch.  After the first week, during
which there ivas little promised  success (the tooth being much too small 
640
TEETH.
for the space, and the child not attending to  directions), it became moro
and more firm, Avith every indication of its having taken root.
  Mr. Twdss was led to select the sheep, on account of the extreme clean-
liness of this animal, and  the beauty and aptitude of the teeth for the pur-
pose.   He recommends that teeth be taken only from sheep tAvo or three
years old, as at that age they are about the size of adult human teeth, and
they are more likely to groiv Avhen transplanted.   The root,  he observes,
may be shortened or pared, if necessary, to fit its new situation.  The new
tooth may be kept in situ by waxed silk ligatures.        Part \l,p. 154.

  Different Cements to stuff decayed Teeth.—1.  Ordinary Tooth Cement.
—Is generally formed of a very concentrated etherial, or alcholic solution
of gum  sandarac, mastic, dammar, colophony, etc., in the proportion of
one-third of the  solvent to two-thirds of the resins  hy Aveight.  A very
usual  formula is: sandarac, tAvelve parts ;  mastic, six parts;  amber poiAr-
der, one part, to six parts of ether.  This  preparation is a balsam of the
consistence of copaiba; it readily dries  on exposure to the  atmosphere,
but remains for some time soft and compressible.   The mass  yields, Avith
alcohol, a milk-white solution,  the turbidity depending  on the masticine
Avhich is precipitated.
  2.  Gauger's  Tooth Bcdsam (Balsamum  Odontalgicum).—Is chiefly
in use in St. Petersburg.  The recipe is  as follows: Dissolve §ij. of picked
mastic in §iij. of absolute alcohol.  Pour the solution into  a bottle capable
of containing two pounds,  and add of dried balsam of tolu §ix.  Promote
the solution  by a gentle heat,  and frequently shake the stoppered bottle.
When the latter substance is dissolved,  place the Avhole in a Avarm situation,
to allow the undissolved particles to deposit.  This balsam is viscid, and
forms, when exposed to the air, a firm  mass,  which is neither acted upon
by the saliva nor by other watery liquids.  To  prevent tooth-ache arising
from exposure of the nerve, the decayed  tooth should be well dried by
means of cotton  or blotting-paper, and a piece of cotton or wool imbued
ivith the balsam i3 to be carefully inserted into the cavity.
   3.  Vienna Tooth  Cement.—Ilerr V. Wirth, apothecary of Vienna, first
conceived the idea of mixing with a viscid alcoholic solution  of the resins
poAvdered asbestos, AAdiich  perfectly  supplies the  place of the  pledget of
cotton.  His preparation  is generally sold along Avith a tincture for cleans-
ing the hollow teeth, and allaying tooth-ache.  The latter  tincture consists
of an alcoholic solution of guaiacum and myrrh Avith acetic ether.   Oster-
maier, an apothecary at Munich, analyzed this nostrum, and  has perfectly
succeeded in preparing it, but  Ave are not  at liberty to  publish his recipe.
It will, hoivever, he a sufficient hint to the scientific man  to  be reminded
that  powdered  West Indian copal gains considerably  in  solubility in
spirit by exposure to moderately Avarm  air, and that pure alcohol, to
which a few drops of any essential  oil are  added,  greatly  augments its
solubility.
  4.  Ostermaier's  Tooth  Cement.—The principle of this preparation is the
formation of phosphate of lime  in the  cavity of the IioIIoav tooth.  For
this purpose anhydrous phosphoric acid must first be formed by burning
phosphorus under a large basin, fifty-eight parts of pure unslackcd lime
in powder, are to be mixed with forty-eight parts of this flocoulent anhy-
drous phosphoric acid, and  the necessary quantity is to be pressed  into the
cavity of the tooth, after  the tooth has  been  Avell dried; for, if the latter 
TEETH.
641
proceeding be not observed, the mass will become heated, and, in expand-
ing, fall out of its place.   The  application should be quickly effected, for
the substance becomes quite hard and useless in the course of one or two
minutes.                                                Part x., p. 11Q.
   Treatment of Caries of the  Teeth.—Scrape  out  the entire of the soft-
ened carious  part of the  tooth, and rub its interior wdth a saturated  solu-
tion of nitrate of silver,  or Avith pulverized nitrate of silver barely Avet.
In this Avay the progress  of caries maybe effectually stopped ; and a tooth
thus treated Avill often remain for years, though Avithout any stuffing, and
exposed to all the variations of  food and  drink, Avithout  giving any trou-
ble or  pain, and Avithout  any reappearance of the caries.
                                                     Part xiv., p. 197.
   New Amalgam for stopping Teeth.—[Mr. Evans states that.he has em-
ployed this amalgam successfully for  a length of time.   He says:]
   It is composed of chemically pure tin,  prepared  Avith much care, to in-
sure its being free from any other metallic substance, and combined  with
prepared cadmium, in small  quantities, and mercury. xIn using it so much
mercury should be employed as may he  required to make it more or less
plastic.
   The cavity of the tooth betinr previously thoroughly freed from carious
matter, can be carefully filled with paste thus formed.   In the course of a
few minutes it hardens into  a solid, and  gradually  acquires  a still firmer
consistence and toughness, exhibiting a wdiitish  color, or, if cut or bur-
nished, a metallic lustre,  like that of pure tin.
   It retains its  color perfectly,  neither oxidizing on the  external surface,
 nor on that applied to the cavity, and, of course, it does not discolor the
tooth itself.   It fills each crevice of the cavity, and by effectually excluding
moisture and all kinds of deleterious matters, prevents the occurrence  of
caries, and becomes sufficiently hard  to withstand the friction of mastica-
tion.   To these most  important advantages may be added others—e. g. it
is easily and quickly prepared,  without the trouble  of beating it,  as is the
case with some of the amalgams hitherto used.  It ivill not amalgamate
Avith, or injure any gold clasps  or plate bearing artificial teeth, which may
be placed in  contact Avith it; and, incase of its removal being necessary, it
can be cut out as easily as gold filling, as  it forms a tough, almost  ductile
Bubstance, and  not a hard, brittle one, like the  ordinary amalgams.
                                                      Part xix., p. 322.
   Hemorrhage after  Extraction  of  Teeth.—In  severe cases  use the
actual cautery.   It  is  best  applied  by means  of a small rod of polished
iron, furnished  wdth  a sheath ; the  end  of the sheath is applied to the
bleeding  part,  and the  heated iron then inserted, and passed along the
sheath until it reaches the part.                        Part xx., p. 119.

   Material for Arresting  Alveolar  Hemorrhage.—The  difficulty that
sometimes occurs in  arresting hemorrhage after the  extraction of teeth,
especially in a person of hemorrhagic   diathesis,  is  well   knoAvn.   Mr.
Beardsley describes a composition which he found useful  as  a plug in such
case<, and also for other  purposes.
   The proportions of the ingredients used, are, gutta  percha, one ounce;
Stockholm tar, ounce and  a half to tAvo ounces;  creasote, one drachm;
shell  lac,  one ounce, or  more,  to harden it.  To be boiled  together in a
     vol.  n.—11 
642
TEETH.
small crucible, and constantly stirred or beaten, till it becomes thoroughly
blended into a stiff homogeneous mass.
  He has found the above composition a very ready and easy application
for  leech-bites, when the hemorrhage is at all troublesome."  It is very
adhesive when  warmed, and  firmly adheres all over the wounds Avhen  the
part is Aviped dry, and a small portion pressed on, just wetting the finger
before doing so, to prevent it adhering to it also.       Part xxi, p. 196.

  Teeth—Loosening of the.—Use a gargle  of tannic acid, three or  four
grains to the ounce of water.                          Part xxi, p. 326.
  New Preparation for Stopping Teeth.—[Mr. Davenport gives the  fol-
lowing recipe :]
  Pour a small quantity of collodion  on a plate or glazed surface; allow
it to evaporate till it acquires the consistence of a thick paste, or, in more
familiar language, a pill consistence ; let the cavity of the tooth be well
dried,  and  quickly filled Avith the paste; in the course of a feAv minutes it
will be hard and fit for mastication.   Very slight pressure is required, and,
being  of a vegetable nature, someAvhat analogous to the tooth itself, will
resist the action of vegetable juices, and remain colorless.
  [Mr. Davenport prepares  his collodion in a manner different from  that
usually adopted.  He tells us:]
  The chemical manipulation is extremely disagreeable;  the nitrous acid
fumes  are very abundant, consequently highly irritating to the respiratory
organs.  Great care is  necessary in' Avell washing the  cotton; also, a
moderate heat  in drying it.   The process is as under :
  Take  nitrate of potash,  4  lbs.; sulphuric acid, 8  lbs.; carded cotton
wool,  8 oz.; mix the nitrate and acid in a glazed  vessel, add the cotton,
and constantly agitate Avith  a glass rod for half an hour; then Avash  the
cotton thoroughly in cold water, so that no trace  of acid should be per-
ceptible to test paper ; then dry carefully, and the result will be a very
soluble gun-cotton ; then take 1 oz.  of  the cotton ; rectified  sulphuric
ether,  16 oz. fluid ; when dissolved, add 1 oz. absolute alcohol.  AHoav the
solution to stand twenty-four  hours, and  the collodion Avill be  ready for
use.                                                 Part xxi, p. 358.
  Teeth—Vegetable and Animal  Parasites of.—From  microscopic  ob-
servations  made by Dr. Bowditch,  he has, in a large majority of instances,
found  these parasites betAveen the teeth, or  at the juncture of the gums,
in persons  from different classes of the community, Jbut Avithout any disease
of the mouth.   He attributes their  presence  to a want of cleanliness; and
recommends thoroughly brushing the teeth after  each  meal.  M. Foy, a
French dentist, recommends  tinct. kino, tinct. catechu, aa.;  a teaspoonful
to be added to  cold or tepid water, and used every morning.
                                                     Part xxii., p. 366.
  Materials the  best Adapted for Filling  the  Teeth.—Dr.  Robertson
says:
  Pure and well-preserved gold leaf is undoubtedly the best and the most
durable material which has yet  been discovered for filling the teeth, and
particularly so  when the operation is  performed  in the early stages  of
decay, and  before the slightest tenderness has been felt in the  tooth.  I
should therefore recommend gold to be used in r.ll cases  where it is prac-
ticable, in  preference to any other filling.  But we have  numerous cases 
TEETH.
643
which present  themselves where gold  cannot be used,  and where an
amalgam  becomes a necessary substitute.  The  consideration then is,
what materials are the best to form this amalgam ?  t               >
  I have given much time and labor to the investigation of this subject,
and after numerous experiments with the various metals, have come to
the conclusion  that gold, silver, platina,  and tin, in  their pure state, are
the be^t; because I have found in using them, either separately or  com-
bine 1, that they resist the acids of the mouth better than any of the other

  An amalgam of these, however,  cannot be formed without mercury,
but the smaller the portion the better, so that there shall be just sufficient
to unite and hold in permanent combination the purer metals above spe-

  The amalgams in general use, even those of the better class, which are
composed  of metals  above mentioned, contain a great deal too  much
mercury; and  I shall presently show that the cause for  this superabun-
dance of mercury  arises from  the incorrect proportioning of the metals,
and the improper  mode of mixing them.   The method generally adopted
in preparing an amalgam is to combine the  mercury at once Avith the other
metals, so that the compound may be ready for using, and Avhen a portion
is required it has to undergo a process of heating and rubbing, to  bring it
back from its crystallized form to  a  pasty state before putting it into the
tooth.  Instead of adopting this  method,  the mercury ought to be kept
separate from the other metals, and  only mixed Avith them at the time of
usin<*.  This mode of mixing, with  the  metals  rightly proportioned, aviII
produce a harder  and more durable filling, and the metals will "combine
with one-third of the mercury required in the former mode  of preparing
the amalgam.                 •                             .
  Some dentists use an amalgam of  palladium and mercury, Avhich makes
a firm and durable filling, but it becomes black in the tooth.  A few  years
ago cadmium Avas introduced as a filling, and for a short time it promised
well, and  appeared to  be  an improvement upon former amalgams, but
after a few months' trial it showed its defects, and has very properly been
discarded.  It neither retained its color nor its hardness,  for Avhen  acted
upon by the friction of the opposing teeth it soon Avore away, and Avhen not
acted upon became, in parts, yelloAv as saffron, Avith  the disadvantage-also
of having  a  strange  tendency to produce galvanic  action in the  mouth.
Objectionable as this compound is, it still continues to be used by a certain
class of practitioners, under the title of " Parisian filling."
  There are various kinds of amalgams used by the same class of indi-
viduals, A\diich  contain copper, lead, bismuth, zinc, and antimony, all of
which are injurious.
  The amalgam which I  am about to describe contains nothing novel so
far as the materials are concerned; but it  is in the proportioning  of
them, and by a different mode of preparing the compound, that I have
been enabled,  of  late years, to get rid of  two parts out of the three of
the mercury formerly required ;  and this I consider to be  an important
advantage.                                                        .
  The amalgam  consists of gold, one part ; silver, three parts; and tin,
two parts ; and it is of the utmost importance that the  metals should be
pure, free from the smallest particle of alloy.
  The mode of uniting the metals, is, first, to put the gold and silver into 
644
TEETH.
the crucible, and just as they are on the point of melting, add the  tin,
which  requires less  heat  than the former metals.   When they become
melted, but  not  over-heated, pour them from the  crucible, melt them a
second time, for the purpose of having them properly mixed, and then pour
them into an  ingot of a shape adapted for reducing the compound into the
finest poAvder.
  The mercury is  to be kept apart  from the poAvder, and mixed wdth  it
at the moment the amalgam is to be put into the tooth.  The mercury
must be perfectly purej and the quantity required will be equal  in Aveight
to the poAvder.
  In mixing the powder ivith the mercury, the exact proportions of each
can be ascertained to the greatest nicety, and by a  very simple process,
which Avill save time and materials, and Avhich makes a harder compound,
than by using a larger portion of mercury, and squeezing part of it out
again.
   A measure for the mercury may be made from a square portion of ivory,
by drilling in it three holes ; one may be  made to contain four grains, the
second eight grains and the third tAvelve grains. The mercury to  be poured
into any one of these, as more or less may be required to fill the cavity
of the tooth,  and by  draAving the finger across, so as to bring the mercury
on a  level Avith  the surface of the  ivory, the portion Avanted  may be
accurately obtained.
   The measure for the powder is equally simple and convenient.   It is a
metal  tube, ivith a  handle attached, calculated to hold four grains, which
is also got to  a nicety by filling, and then drawing  the finger across the
mouth of the tube, so as to make level measure.
   The mercury should be kept in a small bottle, wdth an india-rubber  tube
attached to its neck, and the mercury is feadily passed through the  tube
into the measure.  In this Avay the exact quantity of each of the metals is
readily obtained.
   The powder and mercury to be emptied from the  measures into a glass
mortar, and rubbed  till they become mixed.  The compound is  then to be
rubbed firmly Avith the finger in the IioIIoav of the hand, till converted into
a paste, which, before hardening, allows plenty of time for insertion into
the cavity of the tooth.
   I have found this  compound to be far superior to the former class of
amalgams.  It does  not, like palladium, and some of the other metals that
have been used, become  black in the mouth.  It retains its hardness and
firmness, and is not, like cadmium, liable to  be Avorn away by  friction of
the teeth.
   Formerly,  in fixing artificial teeth  upon a gold plate, it was necessary
to avoid bringing the gold  in contact Avith  a tooth filled with amalgam,
because  a portion of the mercury united with the  gold and  injured  it.
This evil is now remedied by the compound containing so small a quan-
tity of mercury, which is  held in permanent combination ivith the other
metals, so that not a particle of it is abstracted by the embrace of a gold
clasp.   With these important  improvements upon   former  amalgams
another advantage is, that it is used with much greater facility.
                                                    Part xxvi., p. 172.

    Cauterizing the Dental Nerve.—[Dr. W. A. Roberts, before the  Edin-
 burgh Medico-Chirurgical  Society, described the  folloiving  metiiod of 
TEETH.
645
applying the actual cautery by means of wdre brought to a white heat by
electricity.   He says:]
  After several experiments, I found that " Grove's " battery ansAvered
best, being more convenient than " Smee's;" it is much smaller, and con-
sequently more portable and more easily kept out of sight.  By this one
pair of plates I can produce a more decided result than I could arrive at
with six pair of " Smee's."  In the porous jar I have a mixture composed
of tAvo parts of nitric, to one part of sulphuric acid.  In the glass jar there
is a mixture of four parts of water to one part of concentrated sulphuric
acid.  At the end of each of the conducting wires, you Avill observe a fine
platina wire brought  to a point.  This Avire is fine enough to enter the
foramen of any tooth, and if required merely to cauterize the large cavity
of a decayed tooth, it can be easily rolled up to act as a small ball. When
the wire is  to be heated,  the communication is made by  gently pressing
upon the ivory knob while pressing doAvn the spring; the contact is made
instantaneously;  by taking off the pressure, the current is  broken off as
quickly.  I found some  difficulty at first in operating, from the Avant of
elasticity in the  wires,  as the thickness necessary to convey sufficient
quantity of the electric fluid to heat  the platina  Avire to a white heat, ren-
dered them very unAvdeldy.  This has been got over very ingeniously and
satisfactorily  by  a plan  of my son's, which  consists in filling  tAvo small
india-rubber tubes wdth quicksilver,  the ends of the  copper Avires being
inserted into the mercury at  both ends, and tightly tied; by this means
the communication is rendered  complete,  and  alloivs  of free motion.
Since this Avas done, Ave find now full freedom can be obtained by having
a bundle of very fine wires tied together instead of a single thick one.
  The advantages, then, to  be obtained by this instrument are, its  easy
application  to the desired spot in the mouth,  and  that  perfectly cold,
instead of alarming the  patient by holding a red-hot iron before his face;
its  being at once  raised  to the requisite heat, and no more  than the mere
point of* the Avire used being hot;  its  being  at once cooled on simply
removing the finger from the ivory  knob; and  lastly, there being no ap-
pearance of heat to alarm the patient.
  When to be applied for the purpose of arresting hemorrhage, or the
deadening of the dental nerve, the  cavity should be first Avell wiped out
with a piece of lint, and then the desired spot should  be rapidly touched,
so as not to come into contact Avith other parts.  This can be repeated if
necessary.   The  platina must  be at least red hot, as  it then acts instan-
taneously, and with little or no pain, otherwise it Avould cause much pain,
and subsequent inflammation.  I  need not say, with timid persons, the in-
halation of chloroform should be resorted to.   I have used this form of
the actual cautery Avith and Avithout  chloroform in many cases.
                                                    Part xxvi, p. 115.
   Teeth—Cement for making them Insensible  to  Pain.—Previous  to
stopping teeth permanently with any metal, use a cement composed of
Canada balsam and slaked lime, which is introduced into the hollow tooth
like a pill.  The  most sensitive tooth,  says Dr. I. P. Clark, of London,
may, by repeating this  application,  be  made quite insensible to the most
severe operative  proceedings.                         Part xxx., p. 131.

  Some of the Effects  Produced by Carious Teeth.—[The folioAving lee*
ture by Mr. Smith contains many interesting facts.] 
616
TEETH.
  On the present occasion it is my intention to describe to you some ol
the effects  produced by carious  teeth, the causes of which are occasion-
ally overlooked by practitioners;  and I am induced to do this by the occur-
rence of a case which came under  consideration on my last  admission-
day.
  Elizabeth H., aged 40,  was sent from some  distance in the country to
this infirmary, Dec. 12th, 1856, to be treated for wdiat  she was told by a
medical practitioner, Avas a cancerous tumor  in  the  cheek.  On examina-
tion, a tumor, the size of a small chestnut, was found, Avith an ulceration
of the mucous membrane, just fitting the sharp edge of one fang of a cari-
ous molar  tooth  of the loAver jaw, Avhich was  making its way from the
gum.  Being  fully  assured, from former experience of many  cases of a
similar kind, that this Avas the sole cause of the tumor and ulceration, I re-
moved the  tooth, and in your presence promised her it should be Avell in a
few  days.  A little lotion was  ordered for  the  mouth.  She  appeared
again on the next out-patient day, Dec. 17th.   The ulceration was healed,
the tumor  gone, and she Avas discharged cured.
   Now, I tell you, that if the cause  of that  tumor bad been overlooked,
no treatment of any kind ivould have been of the least use; it would have
continued,  it would have  increased, and gone  on from bad  to Avorse for
months, and possibly for years, unless the tooth had been removed by the
efforts of nature.  I could tell you of scores  of cases like the above.
   Sometimes instead of the cheek, the tongue suffers from the same cause.
I have detected many cases of this kind.  One interesting example shall
be sufficient to explain such cases to  you.
   More than'  thirty years ago, one out-patient's day, my senior colleague
(Mr. Hey)  informed me that a few days previously he had excised a malig-
nant-looking tumor from the tongue  of a young country-woman, who was
a private patient of his; that, to his surprise, in a few days the tumor had
sprouted out as large or larger than  before the.operation; that, as she was
not in circumstances to pay consultation fees, he  had requested her to be
in the house-surgeon's room at twelve o'clock,  in  order that he might ask
Mr. Chorley's opinion, along Avith my OAvn, on the case. On that day Mr.
Chorley did not  come to the infirmary, and  I  went wdth Mr. Hey to see
his patient.   There was a foul,  dark, fungoid  tumor,  which occasionally
bled, and  from which she  suffered  much pain during every  attempt to
speak or masticate food ; it Avas the size of a  small walnut.  On examining
it with the finger, I detected two broken incisors (the middle and left late-
ral of the loAver jaAv) leaning inward, and with sharp-pointed edges fitting
into the centre of  the tumor.   I was immediately convinced that  these
two teeth  were  the cause of all the mischief, and stated that opinion to
Mr. Hey, who appeared doubtful.   I said that he would not be justified
in applying the ligature or using any other means, wdthout first Avaiting
to see the  effect of the removal of the two broken carious teeth.   I never
saAV the young woman again, but I ivas informed by Mr. Richard  Hey
that  the teeth were draAvn, and  soon  afterward  the tumor entirely  dis-
appeared, wdthout any other means being resorted to.
   Sometimes carious teeth produce abscesses in the cheek, neck, and throat;
these burst or are opened, and  form fistulous sores, ivbich Avill remain
unhealed for months and years unless the cause  be removed, just in the
same manner as you ses fistulous openings hi the leg in cases of necrosis,
and which remain open for years  until the sequestrum is removed. 
TEETH.
64T
  A few years ago a middle-aged man asked my opinion about a fistulous
sore which opened on the middle of his whisker on the right  cheek.   I
introduced a probe, and it came in contact with the fang of the last molar
tooth of the upper jaw.  I persuaded him to allow me to draw it, on the
promise  that he should be Avell in a few days.  I requested him to write
by post on the tenth day, and let me know the result.  He Avrote to say
the discharge ceased the day the tooth  was drawn, and that it was per-
fectly well.
  Seven or ten years ago a young woman came under my care at the in-
firmary Avith a fistulous sore in the fore part of the throat, within an  inch
of the sternum.  It had been discharging upAvards  of a year.  I probed
it;  the instrument  could  be passed in the  direction of the  molar of the
lower jaAV on the left side.  On  inquiry, she  said  that  eighteen  months
before she had had a tooth drawn at the dispensary, but the fangs of the
tooth were left in the jaw.  Afterward an abscess formed, which descended
lower and lower till  it burst midway between  the sternum and  pomum
Adami.  I drew the stumps ; it still discharged for a week or  ten days,
when it  got well Avithout  any other  treatment.  I mention the above
case to impress  on  your  minds the possibility of the fistulous orifice
being at a considerable distance from  the offending' tooth.   The fistulous
sores proceeding from  carious teeth are generally in the cheek or at the
angles of the ja\v.   On the application of  the  probe you will often find
the instrument pass  readily to the interior  of the mouth; you have  then
only to select the proper  victim for sacrifice, and you will rarely err  in
this respect.  Where the  sinus from the sore to the tooth is short, the
discharge from the external sore  will generally cease in a day or two after
the extraction of the tooth, but where it is long, as in the above case, it
may be a week or tAvo.
  As abscess in these cases always precedes the formation of a fistulous
sore, it should be  your endeavor to detect these cases at this particular
period.
  A long time ago a near relative consulted me about  an  abscess at the
angle of the jaw, on  the right side.  I suspected its cause, for on pressure
I could make pus appear at the edge of one of the molars.   He refused  to
have  the tooth drawn  until I assured him the abscess Avould  burst ex-
ternally, and continue discharging till the tooth  wras removed, and that an
ugly looking  scrofulous cicatrix  would  remain for  life. The tooth  Avas
drawn ; the abscess discharged itself into the mouth, was soon Avell, and
left no mark.
  Now, if the cause had not  been detected Avhen it was, in ten or twelve
days the abscess Avould have burst externally, and a fistulous sore would
have been the consequence, which would have continued discharging until
the teeth had been removed either by nature or art.
  Whenever you extract a tooth in these  cases, always examine it care-
fully ; you will invariably find a fang deprived of its periosteum, and some-
times a little sac attached to its root, containing pus.
  Sometimes, where abscess forms from a, carious molar of the upper jaw,
the matter, instead of making its way to the cheek, gets into the antrum.
  Remove the tooth, and  if this  does  not give sufficient outlet for the
matter, perforate  the antrum with a  joiner's gimlet.  There has been a
very interesting case of this kind recorded in  the journals during the pre-
sent month. 
64S
TEETH.
  A horse was condemned to the knacker's yard as being' afflicted with
glanders, having a foul offensive discharge of purulent matter from  the
nostrils, and being in the last stage of emaciation.  A veterinary surgeon
finding that it could not masticate its food, examined  its mouth, and  de-
teeting a carious tooth in the upper jaAv, extracted  it   The discharge
ceased ; the horse soon began to thrive, and got well.   Here was a ease in
which there was as much professional credit due to  the  surgeon  as if
instead of saving a horse from the knacker's yard he had saved the life of
an alderman.
  Mr. Louis Oxley, the dentist, related to me a case of such interest, that
I requested him to write it  out for me.  Here you have it in his OAvn
words:
  A young woman, of rather strumous habit, complained of a dull, aching
pain under the orbit.  The pain lasted from three to four months, attended
by a gradual elevation of the orbital  surface of the maxillary.  The  eye
above this surface  became at length so affected as entirely to lose its func-
tions. At this stage of the case the young woman, who was attended by
a general practitioner, Avho ignored dental surgery and pathology, resorted
to leeches, blisters behind the ears, and drastic purges: I need not say in-
effectually.  After two or three months* loss of the sight the young Avoman
first perceived a discharge from the right nasal fossa of a  thick purulent
fluid. This discharge had existed  for eighteen months when I first  saw
her, even in spite of the aforesaid remedies !  An examination of the mouth
at once revealed the cause of so much  misery, and  the removal of three
roots in a state of periostitis Avas the  simple means by wdiich two most im-
portant organs regained their proper functions.
   There is another case in which swelling, inflammation, and ulceration at
the sides of the tongue take place, and Avhich does not appear, as far as my
 experience goes, except in individuals approaching to  or upward  of sixty
years of  age; but I have seen several cases of it, and shall proceed to
describe the cause.  If you wdll examine  the form  of the  molars  of the
lower jaw where  they come in contact with the sides  of the tongue, you
will find the line from the neck to the top of the crown gives a convex  out-
fine,  so that for thirty or forty years during the act of speaking or mastica-
tion, the sides of  the tongue come in contact wdth a smooth rounded sur-
face ; but the constant grinding of hard food, such as biscuits, etc., for  two
score years, where all the teeth have remained sound, wears aAvay one-third
of the upper part  of the teeth,  the bony part is ivorn away deeper by  one-
eighth of an  inch than  the  enamel, leaving a sharp edge projecting into
the mouth, so sharp that, by firmly  pressing the finger and drawing  it
along the edge, you might cut it to the bone.  The friction of the tongue
against this sharp  edge produces the effect I have  described. It  is  only
necessary to round off the edges by the use of a fine file, and the tongue
wdll soon heal.  The operation will require to be repeated in a few years.
                                                     Part xxxv., p. 95.

   Cements for Stopping the Teeth.—M. Vagner recommends the  folloAv-
ing :   A drachm of gutta percha, softened by hot water, is to be worked
up with catechu poAvder and tannic acid, of each half  a drachm, and  Avith
a drop of esseutial oil.  For use, a morsel is to be softened over the flame
 of a spirit lamp, introduced AA'hile warm into the cavity of the tooth, and
 adapted properly.   The mass  becomes  hardened, and even after  several 
TEND0N8.
619
months exhibits  no traces of decomposition.   M. Pouton states  that Ave
may also obtain an excellent cement by dissolving one part of mastic in two
of collodion.  Having ivell dried out the cavity, a  small ball of cotton
soaked in some drops of the solution is to be introduced.  It soon solidifies,
and may remain in situ, seeming also  to exert an influence on the further
progress of the caries.                                Part xxxv., p. 99.
  Application of the Electric  Cautery to Dental Surgery.—The  Electric
Cautery is a very safe,  rapid, and  effectual means of destroying  the ex-
posed pulps of decayed teeth.  The cavity of the tooth having been well
dried out and cleaned, and the mouth  protected by . soft napkin, the pla-
tinum point is introduced into the cavity of the tooth, and then heated,
which is preferable to heating it before introduction.   The part is distinctly
illuminated, and the pulp may be destroyed almost instantaneously.  In the
great majority of instances there is little or no pain beyond a momentary
twinge.   As a rule, the tooth should  not be  stopped on the same day as
the electric cautery has been employed, but the cavity should be filled Avith
a combination of morphine  and mastic for a day or two.  If the  tooth
should remain tender after the use of the  cautery, it is better to  wait till
this has entirely subsided.                           Part xxxvi., p. 291.
  Exposed and Diseased Dental Pulp.—Mr. Undenvood says: The nerve
may be either removed by means of some instrument to AvithdraAV it, as a
straightened  fishhook,  or  by  destroying it entirely, or by rendering  its
exposed surface  insensible; for the latter purpose a strong spirit  solution
of tannin may be applied, and  the nerve becomes coated and protected by
an insoluble compound formed by the  albumen and tannin.  As  an  escharo-
tic for these purposes, nothing  is better than four or five grains of recently
burned quick-lime mixed  with a grain of  morphia ; this should be taken
upon a piece of avooI, and placed on  the pulp, and the cavity  closed Avith
wax.  Next day the  application  may be removed,  and  if  any tenderness
remains the dressing may be applied again.   A strong, saturated solution of
camphor is a good anodyne application.  The actual  cautery may  often be
used with great success to instantly destroy the dental  pulp.
                                                  Part xxxa i., p. 295.
  Carious Teeth—Stopping for.—A very good and  easily applied cement
for stopping teeth, says M. Henriot, is soft  sulphur; it is not acted on by
any of the alimentary substances  or dentifrices.  Put  some  washed floAvers
of sulphur in a test tube, heat it over a spirit lamp to over  350° Fahr., and
pour  it into  cold Avater, when it will be a spongy mass, brown, soft, and
elastic.  A little ball  of this should be pressed into the decayed tooth.
                                                  Part xxxvii., p. 142.
                              —»-•-•---

                          TENDONS.
  Dislocation of the Long Head of  the Biceps.—Mr. Hancock, surgeon
to the Charing Cross Hospital, says:
  There are probably few  accidents so little noticed or  understood as dis-
placement of the tendons.  The subject is scarcely mentioned in any of the
numerous works  on  dislocations, although the consequence,  wdien  unre-
duced, is great inconvenience  to the patient, and  in  the case  of  displace-
ment of the tendon of  the long  head of the biceps, Avhich happens more 
650
TENDONS.
frequently than any other kind, the patient is deprived in a great  degree
of the use of the limb.
 ^ The principal signs of this accident are pain and tenderness in front of
the joint, corresponding to the bicipital groove;  acute pain in the course
of the biceps Avhen it is throAvn into action, the pain being referred more
particularly to its two extremities;  the patient is  unable to raise his hand
to his head, or his arm beyond an acute angle from his body; the appear-
ance of the shoulder is somewhat altered, the head of the  humerus being
drawn upward,  and  more forward than  natural, lying close beneath the
acromion process, Avhile the posterior and external part of the joint is some-
what flattened.  When Ave consider how much in appearance these acci-
dents resemble partial dislocations of the head of the humerus upward and
forAvard, we can entertain but little doubt that they have frequently been
mistaken for them.
  In the treatment of these cases you have three principal objects in view:
to overcome the action of the capsular muscles, to reduce the tendon,  and
to keep the 1 mdon in its groove Avdien you have  reduced  it.  I am  not
aware of an  particular symptom by which we can be guided with  any
certainty as to wdien the tendon is dislocated inward, or when outward;
but, as a result  of my experiments, I should imagine that it is more fre-
quently dislocated inward than outAvard, the inclination of the head of the
humerus, and the greater projection of the large tubercle, being unfavor-
able to the latter displacement.   Place your patient on a low chair, and let
an assistant fix his scapula by pressing upon the superior angle and cosla;
then  separate the patient's arm from his side, as far as you can; keep his
hand in the prone position, and make extension downward and outward
from the Avrist, until you have somewhat withdraAvn the head of the bone
from the acromion process.  Now let an assistant sit down on the floor,
underneath the injured arm, and, clasping both his hands over the  deltoid
muscle, draAv the head and neck of the bone  downward and a little hack-
ward, wddle you rotate the head of the bone inward and backward in the
glenoid cavity, by making the patient's arm  describe a circle, carrying it
backAvard, upAvard, forAvard  and inward, across  the chest.  Should  you
have reason to suppose that the tendon is displaced outward, separate the
arm as far as you can from the body,  and let an assistant make extension
in that direction best calculated to remove the head  of the humerus from
the acromial process, that is, downward and outward.  Unless this be
done, in either form of the dislocation, the bicipital tendon remains pressed
up by the head of the humerus against the acromial process, and is obvi
ously prevented from returning into its natural position.  Next place your
left hand Avell up in the axilla, and direct your assistant, while he keeps up
the extension, to rotate the arm strongly outward, and at the same time
to bring it to the patient's side.  Having reduced it, gently separate the
arm from the patient's side; keep it  steadily rotated outward, and the
hand  supine; place a  long splint, which extends from the shoulder to the
fingers, along the back of the arm and hand, and also a pad  or compress in
front, over the bicipital  groove.  Fix  the Avhole with a roller evenly and
carefully applied, and place your patient on his back in bed, Avhere he  had
better remain until you consider that the  parts have become sufficiently
firm to prevent a recurrence  of the accident.
  The reason Avhy I recommend  you to  separate  the  arm from the side
after reduction, is,  that by so doing you place the pectoratis major muscle 
TENDONS.                           651
 upon  the stretch,  and consequently make its  broad tendinous insertion
 press  more closely and directly over the bicipital groove.  In my experi-
 ments, the difficulty Avas not so great in reducing, as in keeping the tendon
 in its  place Avhen reduced, and certainly the plan Avhich I am noAV advocat-
 ing appeared to be the most  efficacious.                 Part xl,p. 157.

   Rupture of the Tendon of the Long Head of the Biceps.—This accident,
 says Mr. Hancock, may be occasioned  by falling upon the arm, by violent
 twists of the limb, Avithout external violence referred to the part, or by the
 sudden and  violent extension of the limb, as when Ave put out our arms to
 Bave ourselves in falling.  The patient experiences at the moment, a sensa-
 tion of snapping in the shoulder, soon succeeded by inability to raise the
 hand  to the head;  acute  pain is  caused by even slight pressure in the
 course of the bicipital  groove, or lower doAvn, on  the muscle itself; the
 latter becomes flabby, and the movement of the arm backward and forward
 produces acute suffering, mostly referred to  the  situation  of the  biceps,
 where it passes OA-er the head of the humerus.
   Treatment.—Your object in these cases should be  to  approximate the
 two portions of the tendon, to obtain union if possible, or  otherwdse to
 favor the attachment of the loAver portion to the head of the humerus, as
 Mr. Stanley has pointed out.  To do this effectually, place the hand in the
 semi-supine  position, that is, with the thumb upward, making your patient
 grasp the opposite shoulder; thus you effectually relax the biceps muscle.
 as you Avill at once perceive, upon recollecting that the biceps is inserted
 into the back of the tubercle of the radius, and that the first  action of the
 muscle, when the hand is prone, is to render  it supine before it  can effect
 flexion of the elboAv.  Noav apply a roller carefully,  beginning from below,
 carrying it up to the axilla, and fixing a compress over the course of the
 biceps tendon, by Avhich means you will keep the muscle quiet and prevent
 spasms;  and, lastly, secure the arm in this position by bandages.
                                                      Part xb, p. 159.
   Painful Crepitation  of the Tendons.—M. Velpeau  gives the following
 account of his patient: A week since he endeavored to raise a load, having
 his left hand applied to bis hip. Pie felt a violent pain in  his arm, and now
 Ave may perceive a slight swelling at the loAver and external part of the
 forearm, unaccompanied by any change of color or fluctuation.  Of a re-
 gular and elongated shape, it is  only  painful during motion,  while on
 applying the hand  over it we may perceive a fine characteristic crepitation ;
 and it is an  example  of the painful crepitation of the tendons wdiich was
 vaguely indicated by Boyer and Desault.  I first met  with it in a case in the
 hospital of Tours, where it was suspected to be a fracture of the radius.  The
 affection is especially observed among washerwomen, mowers, blacksmiths,
 locksmiths, and joiners,  and when it is  seated in the foot, among soldiers
 huntsmen, etc.   Excessive  friction is the condition necessary for its pro-
 duction.   In the forearm  and wrist, where it  is especially met with, its
 recognition  is very easy, the crepitation it gives rise to being  quite pa-
 thognomonic, being neither like that felt in fractures, that of cartilage or
 emphysema: but Avhich has been  compared to the ca-epitation of starch or
 of hoar-frost—such as is produced by walking on the snow. Its seat is
 evidently the sheath  of the tendons, and it is probably due to a slight in-
flammation,  first causing, too great dryness of the membrane, and after-
Avard giving rise to effusion.   It is generally in no-wise serious, disappear- 
652
TESTES.
ing in a few days by rest alone ; but it must not be absolutely neglected,
for I have seen it in some cases give rise to a  fungous transformation of
the sheaths ; and  indeed there is  no reason why all the changes which
occur in  diseases of the joints should  not  take place here.   If there is
much pain Ave apply leeches and poultices, and the resolvent  lotions and
compression ;  but rest is indispensable.                 Part xvi, p. 330.
   Tendons, Reunion of.—Mr. Adams, surgeon to the Royal Orthopedic
Hospital, states that the newly-formed connective tissue, or new tendon,
gradually assumes the character of the old tendon, so perfectly that no dif-
ference can be perceived ; it may be formed to the extent of two inches, and
it is through the agency of this that the required elongation is maintained.
       *        *  ^     *       *       *       #       *       *
   Tenotomy.—To perform  this operation cleanly and readily, you must
use a knife Avith a cutting edge considerably longer than the breadth of the
tendon.  You must place the patient on the stomach, and let  an assistant
put the tendon on the stretch, by endeavoring  to flex the foot, then intro-
duce the tenotomy knife Avith  its flat surface parallel Avith the tendon and
close to its edge, but rather toivard the posterior surface, pass  it obliquely
downward, keeping  the point  close to the  tendon, and then  by depress-
ing the  handle a'ou  carry  it  beneath  the tendon ;  this done, turn the
cutting edge toward  the  tendon, and divide it  transversely;  the division
is  indicated by a sudden audible snap and the yielding of the joint.  In
infants direct pressure of a  sharp knife  is often sufficient;  but in  adults
a little cutting manipulation is required.   On withdraAving the knife apply
instantly a compress of lint plaster and  bandage.   Some  surgeons recom-
mend the tendo Achillis to be  divided by passing  the knife flatwise poste-
riorly between the  tendon and the skin, and  then cutting from behind
forward ; but the other method described is perhaps the better.
                                                   Part xxxiii., p. 156.
                            TESTES.
   Scrofulous Diseases of the Testis.—The following is Mr. Curling's  ac-
count of the symptoms of scrofulous disease of the testis:
   " The disease commences insidiously, and is insidious in its progress. The
patient's attention is usually first attracted by a slight uneasiness in some
part of the gland, generally the epididymis, which on examination is found
to be somewhat enlarged, prominent, and hardened. Sometimes the Avhole
organ feels slightly enlarged and indurated, though it more frequently forms
a tumor wdth an unequal and irregular surface.  The state of the testis,
hoAvevrer, is  often  marked  by small local effusions  of fluid in  the  tunica
vaginalis, the surfaces of this membrane being partially adherent.  Very
little pain is experienced in the part, and there is but slight tenderness on
pressure.  After the disease  has lasted  for some time, many months, or
even a year  and more,  making little progress, and often remaining station-
ary, one of the prominences begins to increase so as to be observed exter-
nallv, and to feel painful and tender; the skin  over it becomes adherent,
changes to a livid hue, ulcerates and bursts, giving vent to a soft caseous
matter mixed ivith pus.  This is followed by the formation of a fistulous
sinus  which discharges a scanty, thin, serous pus, mixed wdth particles of 
TESTES.
653
tubercular natter and often w ith semen, particularly after venereal excite-
ment.  Similar changes may take  place in other parts of the testis, occa-
sionino- two or more  sinuses leading  to the interior of the gland.   These
sinuses sometimes communicate, and they may continue open and discharg-
ing for a great length of time.  After the deposit has all come away, if the
original disease be arrested, and no more tubercular matter formed, repa-
rative changes sometimes take  place; the discharge  ceases, the fistulas •
close  up, leaving the organ more or less  diminished  in  size, or entirely
wasted, according to the extent  to Avhich it had been disorganized by the
tubercular deposit.   The bursting  of  the abscess and escape of the tuber-
cular matter are  sometimes folloAved by a hernial protrusion of the testis,
as after chronic inflammation of the gland."
  The administration of liquor  potassm gradually increased to sixty or
eighty drops, three times a day, in combination  with iodide of potassium
(suggested.                                             Part ix., p. 179.

  Fungus of the Testicle.—This disease was ably treated on by Mr. Law-
rence hi 1808.  The testicle, from a variety of causes, as a bloAV, or gonor-
rhoea, enlarges and inflames—the  skin  at  last ulcerates, and  a fungoid
excrescence  sprouts  from the part.  This growth has its origin from the
glandular substance of the part,  a protrusion  of the tubuli seminiferi often
taking place.   Mr. Lawrence recommends the removal  of this substance by
escharotics,  the ligature, or the  knife.  Still, as Mr. Syme says, this could
not  be  considered as a very satisfactory operation,  although a great im-
provement on the old one of castration, for it Avas plain  that a portion of
the gland must be sacrified in order to preserve the  remainder.  In order
to remedy this evil, Mr. Syme proposes  an improvement in the  treatment.
He says:
   When the fungous growth  is divided longitudinally, that is from the
base toward  the circumference, it may be  seen to consist of two textures
distinguished by their color and  arrangement. One is broAvn and disposed
in straight lines, radiating  from the base, where they  are nearly, or quite
close together, toivard the circumference, where  they are more  or less
apart, according to the size of the excrescence.  The  other is white and
glandular, lying  in the spaces Avhich  are afforded  by the diverging rays.
The former is composed of the tubuli seminiferi, altered in situation but
not in structure, Avhile the latter is simply organizable lymph that has been
effused into the interstices.  The relative proportion of these textures may
be seen best by making successive sections of the fungus, parallel with its
base.  Here the substance of the testicle appears tittle  if at all altered, and
presents a mass of uniform brownish color.  But in proceeding toAvard the
circumference, each slice sIioavs more  and more of the white interstitial
substance, until it seems to be the sole  constituent.  In addition to these
facts, which are  Avithin reach of the naked eye, Mr. John Goodsir detected
iu a fungus which I gave him for examination, by the microscope, that it
was covered externally by a thin layer of substance possessing the charac-
ters of  a granulating surface.   So that the excrescence might be regarded
as merely an extreme degree of exuberant granulation, or what in vulgar
language is called " proud flesh."
   This  observation  suggested to  me the idea, that by the use of proper
means the fungus might be made  to  retrace its steps, through absorption
of the white substance and gradual approximation of the brown, and that 
654                            TESTES.
 the granulating materials of the  surface might  thus be enabled to com-
 >lete the healing process.  Pressure was  obviously the agent on  which
 reliance should be chiefly placed for producing the effect desired wdth this
 vieAV, and the most convenient mode of compressing the growth, seemed
 to be inclosing it within its proper covering of the scrotum.  There is no
 loss 01  bubstance in this part, as the fungus issuing through a small ulcer-
 ated orifice, merely presses  the integuments aside, so that  they are found
 lying in loose folds abcve the dense ring that encircles the  neck of the
 protruded mass.   It must therefore be easy to obtain from this source, an
 abundant supply of materials for the purpose.
   Case.—Admitted on account of sores upon his legs, and a fungous ex-
 crescence from  the testicle, about the  size of a filbert. I cut round the
 fungus, and extended the incision upward as well as downward, so as to give
 it an elliptical form.  The integuments were then separated on each side,
 and brought over the groAvth, where they were retained by three stitches.
 The scrotum Avas supported by plasters and a bandage.   It appeared at
 first as if union by the first intention had-taken place completely; but part
 of the wound suppurated, without, however,  show ing the  slightest dispo-
 sition to protrude.  The patient might have been alloAved to go home soon
 after the operation, but ivas retained until the wound had fairly cicatrized.
                                                      Part xl,p. 122.
  Fungus of the Testiele,  treated by  Professor Symes' Method.—Dr.
 Cormack says: When in Glasgoiv, w7e saw, in the Royal Infirmary of that
 city, under the care of Dr. LaAvrie, a case in ivbich this" operation had been
 performed with  complete  success.    The  patient,  a lad,   had   been
 kicked  on the scrotum  twelve months before.   Suppuration, ulceration,
 and profusion of the  Avhole anterior and inferior portion of the left testicle
 folloAved; the surface and a great part  of the  substance of the fungus
 appearing to consist of yellow strumous deposit.  On the  12th May, Mr.
 Symes'  operation was performed; and on the  25th, the patient Avas  so
 Avell as to be anxious to return home, but Avas prevailed on to remain a
 few days longer, that the cicatrization might be more secure.  Dr. Lawrie
 remarked to us,  that  where the skin was most deficient, and with the
 greatest difficulty made to cover the protrusion, there the cure was soonest,
 and apparently most securely effected.  The  case was  altogether a  most
 satisfactory testimony in favor  of the new method  of treating fungus of
the testicle.                                            Part xii, p. 213.

  Syphilitic Affection of the  Testis.—[Syphilitic affection of the testis,
says M. Helot, may be  distinguished from  gonorrhoeal affection by the
following circumstances:]
  In the gonorrhoeal epididymitis, the  attack  comes on suddenly with the
attendant  train  of inflammatory symptoms ;  it shows itself during the
course of gonorrhoea, or at the moment  of its disappearance.  On  the con-
trary, the commencement of the syphilitic testicle is essentially  chronic;
it appears, as we have above remarked,  long after the primary symptoms,
constituting a consecutive affection.  The  gonorrhoeal  and  syphilitic  affec-
tions are thus tAvo distinct complaints, except  where the one terminates in
the other ; but the course, lesions, and terminations of these two affections
show no further  relation between  them.
  In the syphilitic affection of the testis, the organ is, even at  tb ' com-
mencement,  hypertrophied;  in the gonorrhoeal form, the testis,  n  the 
TESTES.
655
contrary, commonly preserves its elasticity and its size; the  epididymis is
principally affected, and if, in exceptional cases, the testis itself participates
in the inflammation, an inflammatory swelling follows, quite at variance
with the chronic enlargement  of the  syphilitic complaint.  In the gonor-
rhoeal orchitis, the  tumor is painful, the skin of the scrotum red, tense, and
shtiiino-; the cord, Avhen  it  is  affected, becomes painful to the touch.  In
the syphilitic testicle, the enlargement is most commonly indolent from the
commencement to  its termination, and pressure with  the hand on the testis
and cord is unattended with pain.  The anatomical characters of the two
affections are  equally opposed;  thus, in the  gonorrhoeal affection,  it is
always the epididymis in Avhich the complaint commences, and in the
majority of cases, the body  of the testis  remains free from disease; the
contrary happens in the syphilitic affection of the organ.
  [Simple hydrocele can scarcely be mistaken  for the syphilitic testicle; it
is not, however, so  easy to distinguish Avhat has been called by Pott, Boyer,
Velpeau, etc.,  "hematocele."  M. Helot observes:]
  The scrofulous affection of the testicle may, under certain circumstances,
be mistaken for syphilitic affection of the testis, and  the diagnosis  may
present great difficulties.   Thus, for example, a patient having had syphilis,
may be attacked wdth a scrofulous affection of the testis; Avhat  then are
the characters drawn from tumor which may tend to  clear up the  case, and
decide Avhether we have to treat one  or the other affection ?   First of all,
in the scrofulous testicle  there  are two varieties of SAvelling, one formed
by the tuberculous infiltration  of the whole organ, the other formed by the
development of encysted tubercles, either in the epididymis or in the body
of the testis.   We have remarked, that in the syphilitic  affection of the
testis the epididymis is rarely  diseased ; in the scrofulous affection, on the
contrary, the complaint commences usually in that organ, and extends only
to the body of the testis at a subsequent period. The scrofulous testicle
commences by isolated enlargements ; but these nodules become chesnut-
shaped, very prominent, standing out in relief, as if  attached to the epidi-
dymis or testicle.  We have seen,  in the syphilitic affection of the testis,
the cord generally remaining  in  a  healthy  condition, or if it enlarges, it
does so in a gradual and uniform way, presenting no inequalities or promi-
nences ; Avhereas, in the scrofulous affection, particularly in the  advanced
stages, it is not uncommon to find the cord studded with  tubercles, re-
sembling a bead necklace.  Although  the course of one  or the other
affection is  similarly chronic, nevertheless it presents differences which may
be  useful  in forming a diagnosis.   Thus  the syphilitic  affection  of the
testicle is more indolent than the scrofulous, Avhich presents, from time to
time, inflammatory accessions, characterized by a sense of tension of pain,
which is augmented by the  touch.  The ordinary termination, by resolu-
tion, of the syphilitic affection of the organ,  opposed as it is to the sup-
puration of the scrofulous disease of the organ, is likewise very important
in differential diagnosis.
  The syphilitic is often  difficult to  be distinguished from the cancerous
affection of the organ.  Hoav many tumors of the testis have been  removed
by the knife, which might have  been cured had the  true  nature of the
complaint been suspected.  The rapid development in the encephatic tumor
of the testis, the considerable size  it will attain, its softness, which may
often impose  on the  surgeon, leading him to believe it fluctuative ; the
unequal resistance  it presents, the darting pains  which occasionally come 
656                            TESTES.
on, mark a  striking contrast with  that  uniform hardness, indolent cha-
racter, and moderate size of the syphilitic enlargement of the organ.  The
cord in the cancerous affection is often knotted, hard, and unequal, and ive
knoAV  hoAv uncommon  the uniform hypertrophy of  the  cord is in the
syphilitic affection.   The engorgement of the glands in the iliac  fossa  is
observed sometimes in the cancerous affection  of the  testis, but never
happens  in the complaint Ave are treating of.  Authors, and, among others,
Sir Astley Cooper, have described, under the name of scirrhus of the testis,
a variety of cancer wdiich might be more  easily confounded with syphilitic
affections of  the testicle, as its development is slower than in encephaloid
disease, and presents, from its commencement,  hard nodules;  but these
are hard from their formation, and become more  and more so in scirrhous
affections, which Ave do not observe  in  the venereal testicle.  Notwith-
standing the characters above given, the  surgeon, amid all his doubts, has
no other proof than a  rational treatment to follow, in extricating himself
from his uncertainty.
   [The syphilitic testicle is one of the consecutive secondary symptoms  of
syphilis; it may be said to border on the tertiary, hence it wdll require the
treatment applicable to  these periods.]
   Combine the mercurial treatment  Avith iodide of potassium.  Give three
quarters of a grain of  iodide  of  mercury in a pill every night, and one  or
two grains of iodide of potassium twice or thrice  during the day. Continue
this treatment for some time after a cure is effected.  When effusion  into
the tunica vaginalis occurs, the fluid is generally absorbed ; occasionally,
however, it remains, and  it is necessary to tap and inject the sac; before
doing this Ave should  endeavor  to procure its  absorption,  by mercurial
frictions on the  scrotum, or the application of bego plaster with mercury.
We should also try compression.                       Part xiv.,p. 229.
   Treatment of Swelled  Testicle  by  Narcotics.—Mr. Jackson  relates
several cases in the practice of Mr. Gay; cases of gonorrhoeal  orchitis,
some of them very acute wdth febrile symptoms.   The treatment consisted
in low diet, a purgative dose, and the administration of tincture of henbane
in the dose of one drachm three times a day.   The treatment was in  all
speedily successful.                             .      Part xviii., p. 214.
   Testicle, Enlarged.—When compression is wanted, use Hutchinson's air
compressor.   A kind of double nightcap, made  of impermeable material,
such  as  Macintosh, or oil-silk,  is folded over the  testicle, and then,  by
means of a stop-cock and force-pump, air is forced into the bag, by which
almost any degree of compression can be produced.  Some forms of* hydro-
cele may be treated in this Avay.                      Part xxxi, p. 169.
   Swelled  Testicle.—Dissolve gutta percha in bisulphuret of carbon, and
spread the substance  over  the  part affected.   (Recommended by M.
Ellefson.)   It immediately becomes dry and stiff, and forms a thin, tight,
and  adhesive covering, which loosens at the edges after three or four days,
when it  must be repeated.                           Part xxxii., p. 180.
   Belladonna in Orchitis.—M. de Larue recommends the folloiving appli-
cation, which, he says, promptly  relieves the pain, and leads to a cure in a
mean  period  of eight days.   Lard, 60 parts; aqueous ext. of belladonna,
16 parts.  It should be applied generally every  two hours in considerable
quantity, the parts being afterward covered with a linen compress, which
is to remain  unchanged.                            Part xxxvii., p. 311. 
TETANUS.
657
                         TETANUS.
  Opium Smoking—By means of the common pipe,  suggested by  Dr.
James Johnson, as a remedial agent in tetanus, hydrophobia, tic douloureux,
etc.                                                    Part v., p. 56.
  Belladonna in Tetanus.—The value of belladonna in cases of tetanus
has been repeatedly pointed out.  It is surprising what large doses of the
different sedatives may be given in this disease.  Dr. Hutchinson, of Not-
tingham, publishes some cases of this description, in one of Avhich five grains
of the extract were successfully administered, and in another the dose was
ultimately four grains  every two  hours, until the disease was completely
subdued.
  From the success of this treatment  in tetanus, Dr.  Hutchinson  recom-
mends that large cfoses of belladonna be given in cases of hydrophobia, so
as to relieve the spasms affecting the muscles of the glottis and larynx.
                                                       Part x., p. 29,
   Treatment of Tetanus— Use  of Indian Hemp,  Croton  Oil, Opium,
Emetics, etc.—In the first case recorded, Mr. Miller used the  tincture of
the hemp and the resinous extract.  It was in a girl seven years of age, la-
boring under traumatic tetanus.  She took three grains  of the resinous
extract every half hour—a full dose for an adult, under ordinary circum-
stances, without  repetition.   Narcotism Avas usually produced  by a few
doses, but only  continued a short time,  when  the  doses  were  recom-
menced.                                            •
  Under ordinary circumstances, Mr.  Miller doubts the efficacy of this me-
dicine as an anodyne and hypnotic, and considers that its chief value rests
in its power to subdue inordinate muscular spasm.  We suspect that if the
experiments of Mr. Donovan had been knoAvn to Mr. Miller at the time, he
would have preferred the tincture of the resin instead of the resin itself, not
only on account of its more certain  effects, but also for its easier mode of
administration.  In a case of idiopathic tetanus in Guy's Hospital, Dr. Bab-
ington prescribed the  tincture of  the  extract in the proportions of three
grains to half a drachm of rectified spirit, to be given every half hour. The
effects were variable, but upon the Avhole beneficial.  This patient took in
the space of five days 248 grains of the extract, although a  single grain
produced powerful effects in a healthy individual.  Five doses of three
grains each were given before any good effects were produced, and  after
that  five-grain doses were administered every tAvo hours  for some time.
This case shoAVs that in cases of tetanus we must not be deterred from ad-
ministering very large doses if smaller ones fail. Another authority on the
use of this drug is Dr. Clendinning.   He  disagrees with Mr.  Miller, and
asserts that he has found it to be a  valuable hypnotic and anodyne, both
conciliating sleep and lulling pain; and another valuable quality is its power
of allaying cough  without  the pernicious  effects  of  opium.   We  protest
most seriously  against the baneful practice of giving opium in one form or
another in bronchial affections, with the vieAV of allaying cough.  It  may,
indeed, allay this symptom, but it acts most prejudicially upon the mucous
membrane, producing a stoppage of secretion  and an increase  of conges-
tion.   We hope, however, that the resinous extract of Indian hemp may
afford considerable relief in a most troublesome class of bronchial disorders,
in which the practitioner is incessantly called upon by his patient to give
    vol.  it.—42 
653
TETANUS.
relief, which, by opium, he can only do by protracting the disease.  In ar-
ticular rheumatism, or seArere bronchitis, we may be able,  by means of
hemp, to put the patient at once under the double influence  of a diuretic
laxative, and an anodyne  antispasmodic; a saline solution, Avith or Avithout
colchicum, correcting the blood and secretions, unimpeded by the narcotic,
whose whole influence appears to be expended on the tissues, seats of pain
and irritation.   Another class of cases in which Ave may find this medicine
useful is that of low fever,  by securing the enjoyment of that  great restora-
tive—tranquil sleep—without any neutralizing inconvenience.   In the
treatment of another case  of tetanus, by Mr. Stapleton, the effect of all re-
medies seemed perfectly useless; and this gentleman had recourse to pro-
found intoxication.   Under  any other circumstances Ave should say that
this remedy was improper, but in the case alluded to it was successful. Mr.
Stapleton proAdded himself AAdth  a mixture of alcohol  and water in equal
parts.   He gave six ounces of this mixture at once, and four ounces more
in a quarter of an hour.  In twenty-five minutes the patient laid on his side
and fell  into a  profound sleep—every muscle Avas in a state of quiet relax-
ation, and the  sense of pain had vanished  as if by a charm.  For seventy-
two hours he Avas kept under the  influence of the remedy; Avhen it Avas
withdrawn the tetanic symptoms returned  and ivere as  quickly relieved,
when the alcohol was again  resorted to.   The relief, howrever,  was  only
temporary, as  the patient  eventually died.
   [The  following case of idiopathic tetanus is given by Dr. NeAvbigging:
The patient Avas a baker, wdio, Avhile perspiring profusely, went out to chop
wood, at a time ofintense cold.  In the evening of the same day he com-
plained  of tetanic symptoms, Avhich gradually increased.  Dr. N. saAV him
first a Aveek after the  attack.  The pulse  was natural; bowels constipated;
urine scanty.  He was bled to 12 oz.;  a drop of croton  oil Avas adminis-
tered, and a large blister Avas applied to the upper  part of the spine.  The
bowels Avere opened by the oil, and he felt altogether relieved.  Three days
after he Avas again bled to 14 oz.; and a  strong dose  of  morphia wdth 30
drops of tinct. cannabis ind.  were given at bed-time. Three days after this,
spasmodic action had  commenced in the limbs ; the dose  of morphia was
then increased, and ordered to be given four times a day,  and elaterium to
be used as a purgative. Next day croton oil ivas  again  had recourse to,
the elaterium having  proved ineffectual.   Dr.  Abercrombie, at the same
time, recommended the use of arsenic,  which Avas given with the morphia.
He continued to improAre for a Aveek, when  he was suddenly seized ivith
great dysphagia and tremors, which Avere soon removed by placing him in
the erect position.  His medicines  having  been discontinued  for two or
three days, were renewed.  About five weeks after the commencement of
the attack, he expectorated  a quantity of pus mixed with  mucus, which
expectoration continued three weeks.   He bad afterward thickening of the
spinous  process of the cervical vertebras, and was attacked with anasarca,
Avhich was subdued by diuretics, actively administered, and in  about three
months  he was able to return to business.]
  The principal features of interest in this case of what is considered a rare
disease tir this  country, are the gradual affection of the different muscles
of the body, commencing  with those of the jaw, and the successful  issue
of the treatment which, however varied, may be considered to have resulted
from the persevering  employment of croton oil and opium  : for although
arsenic, Indian hemp,  colchicum, etc., were adi ninistered to him at different 
TETANUS.                           659
periods, I believe to none of these Avas so much benefit attributed by us—
and he Avas occasionally visited by Dr. Abercrombie, Sir George Ballingal,
and Dr. Duncan—as  from the exhibition of opium in full doses, Avith the
occasional use of croton oil; for,  Avhether we consider this medicine to be
endowed Avith any specific effect or not, as reasoning from somewhat ana-
logous cases of nervous affections, I feel disposed to do, it certainly seemed
to"be followed by greater relief to the tetanic symptoms than Avhen an or-
dinary purgative, such as scammony, gamboge, etc., was exhibited. I have
occasionally observed benefit from the Indian hemp in allaying irritation
and causing sleep, particularly when opium Avas contra-indicated ; but I am
somewhat doubtful of the value of this remedy in tetanus, and am disposed
to think, that no case where opium is  so decidedly indicated can be bene-
fited by the administration of hemp, .if the former  poAverful remedy has
failed to be of servdee.
  [It seems probable that in this  case  some degree of inflammation at the
upper  part of the spine produced the complaint, followed by formation
of matter which subsequently became  connected with the organs of  respi-
ration.]
   A case of traumatic tetanus, Avhich was cured by the use of emetics, is
published by M. Allut.   The patient Avas treated first by opium and musk,
turpentine liniment along the spine, and leeches to the neck, but hourly
grew worse.   It occurred to M.  Allut that he had seen the use of emetics
proposed, and in despair he administered a strong  dose.  On returning
four hours after, he found his  patient decidedly better, and the  urine,
which had  been suppressed  for 24 hours, had  returned.  The treatment
was continued for eight days, Avithout any vomiting being produced, or
more than one stool per diem, and the man made a rapid and perfect re-
covery.                                                Part xi, p. 22.

  Acupuncture in Protracted Lock-Jaw.— Vide Art. "Lock-Jaw."

   Treatment of  Tetanus.—With regard  to the treatment of tetanus—
opium has been given  in nervous cases, as  much as tAventy grains every
three hours.   In other cases, stupor has ensued if the tetanic spasm  had
not relaxed.   A case is recorded of a patient taking 110  bottles of port
wine in forty-two days, and he was cured.   Cold affusion has been said to
have cured a few cases.  Blood-letting is not curative, but it  appears to be
palliative in the acute cases.  Hydrocyanic acid, mercury, digitalis, and am-
monia, have been tried  without effect.  Dr. Elliotson gaAre carbonate of iron,
in enormous quantities  successfully.   Hamilton  and  Abernethy  have re-
commended purgatives, and each one  recommends  his OAvn hobby.   Tur-
pentine has been considered one of the most effectual  purgatives in this
disease; but this, like others, cannot  effect a cure.   Indeed, very feAV of
the remedies  that have been tried  have had  any effect  toward a cure.
Looking  rationally at the thing, says Dr. J. C. B.  Williams,  I should at-
tempt to  cure idiopathic tetanus  on the  same principles  as  rheumatic in-
flammation,  using tire  strongest counter-irritants,  liquor  ammonias, and
calomel and opium in very large doses, wdth  colchicum, my  favorite anti-
rheumatic remedy.  In  traumatic tetanus I cannot  say much about  the
expectation of curing this form of the  disease, but there are some cases re-
corded of cures having  been effected by Indian hemp.    Part xii., p. 47.

  Mitigation of the Symptoms in Fatal Cases of Tetanus.—Prof.  Colles 
660
TETANUS.
asserts, that ivhen cases of common tetanus are to become fatal avc do not
find the paroxysms groAV less frequent, but they become apparently milder,
and on the contrary, when the patient is recovering the intervals between
the paroxysms are lengthened; but the violence of the last paroxysm that
man may have  may be as great as that of any of  the  preceding  ones.
Sometimes on visiting a patient  he tells you  he is  better—he is noAV able
to put two fingers betAveen his  .teeth, Avhereas  a  little while  ago he was
only able to put one; he feels himself better, his jaw  can be opened more,
and his limbs are more  flexible; his friends meet you ivith a smiling  coun-
tenance, and everything is congratulation.  Now, Avhat are you to expect ?
Why,  that the  next paroxysm the patient gets  will carry him off—the
very next paroxysm will certainly be the fatal one.        Part xii., p. 47.

   Idiopathic Tetanus.—The patient, aged thirty years, had felt for  some
days unpleasant sensations, as  stiffness and  pain, in different  parts of his
body,  but on his admission to the  hospital the muscles of the jaAVS,  neck,
both extremities, back,  and abdomen were in a state of rigidity; the body
was curved forAvard in consequence  of the  head and  loins being drawn
backAvard;  every two or three minutes the pain and muscular  contractions
were increased, the paroxysms lasting about five or six seconds.  He had
not received a  wound, but had been much  exposed to cold and Avet.   In
the treatment of this  case, Dr. Watson, under the  impression  that the
spinal cord  or  its coverings were inflamed, ordered local bleeding and
counter-irritation.  The pain in  the  loins wras relieved, but there Avas  no
alleviation of the tetanic convulsions.  This led him to infer that the affec-
tion of the neiwous centres Avas functional and not organic, consequently
care should be used, lest, by too active treatment, the patient's strength
be wrorn out.  Do not depend  so  much on stimulants, but support the
strength on  nutritious  diet, such  as  animal  jellies.  Give opium in  large
doses with hydrocyanic acid ; also a Avell-sustained course  of purgatives, as
colocynth pills wdth castor-oil, cupping o\-er  the spine, turpentine glysters.
A colocynth  pill,  with  a  drop of  croton-oil,  and occasionally  an  ounce  of
castor-oil, and on two occasions ten  grains of calomel Avith the aid of pur-
gative enemata sufficed.  The character of the fecal evacuations in relation
to the spasms is*interesting: whilst they were natural  there Avas no relief
of the symptoms; but when, by the use of purgatives, they  became thin
and offensive, there was a very  marked alleviation of the man's sufferings,
and from the stools becoming again more natural, the spasms, both per-
manent  and convulsive,  speedily gave way.  This case, therefore, is one
corroborative of the opinion, that whatever else may be judged necessary
for the relief of the patient, much reliance must be placed in respect of a
cure on a decided and well-sustained course of purgatives; and this, not-
withstanding the  at first  ordinary character of the evacuations.  We  all
knoAV what a difficult thing it is, in  many instances, thoroughly to unload
the boAvels, and when this is at last effected, what a Avonderful ameliora-
tion is produced in many convulsive diseases not very dissimilar in some
of their  characters to the  present.  No doubt, it must be acknowledged,
that this is more likely  to occur in idiopathic than traumatic tetanus,  where
we have another and obvious source ofirritation.         Part xiii.,  p.  57.

   Traumatic Tetanus—Recovery.—In the earlier stage of this case, under
care of Dr. Greenhowr,  calomel  and  opium carried to  ptyalism  nearly re
moved the symptoms:  not so, howrever, in the more advanced stage, and 
TETANUS.
661
from the success which frequently results from the use of opium and tartar-
ized  antimony, a trial Avas made, which  produced  a most  tranquillizing
effect, causing sleep, the relief of spasms, and the general soothing of the
system.  Patient took half a grain of tartarized antimony, Avith one of
opium and three of calomel, every three hours, having a double dose every
night, and an enema in the morning.                     Part xiv.,  p. 54.
  Electricity in Tetanus. — Try electricity.  Use  a continued  current,
passed down the nerves in the direction of their ramifications. According
to Prof. Matteucci,  the tendency of this direct continued  current, when its
application is sufficiently prolonged, is to diminish the excitability of the
nerves, and thereby to produce  ^temporary paralysis.  Part xvi, p.  100.
  Traumatic Tetanus cured by  the Destruction of the Cicatrix by a Red-
hot Iron.—A robust youth, aged twenty-tAvo years, was seized Avith  tris-
mus on the ninth day  after the receipt of a Avound on the temple, when it
had almost healed.   He experienced a painful constriction of the chest,
folloAved by reiterated convulsions  and  opisthotonos.  Suppression of
urine, delirium, dysphagia, and  unconsciousness folloAved.
  All other means  having failed to abate the severity of the disease, M.
Remy, on the seventh day of the attack, determined to  have recourse to
the mode  of treatment advised by Larrey, viz., cauterizing the cicatrix in
its whole extent Avith  an iron heated to a Avhite heat.  The symptoms im-
mediately underwent a great  improvement: the convulsive movements
became less  frequent, and soon ceased  entirely; consciousness returned,
and the urinary excretion reappeared; but the muscular  rigidity  con-
tinued, the slightest movement  or attempt at the deglutition of fluids pro-
duced a sense of suffocation; the recumbent posture had become impos-
sible, and the patient  exclaimed against a breath of air.  This condition,
Avhich lasted from four to five days, disappeared under the use of digitalis
in large doses.  In fifteen days more convalescence Avas complete.
                                                       Part xx., p. 62.

   Tetanus—Traumatic.—Bransby  B. Cooper  advises,  when tetanus is
threatened in consequence of  a punctured Avound, to convert the latter
into an incised wound by laying  it freely open to the same depth as the
original puncture ; and if it is then found that a branch of nerve had  been
punctured or partially divided, cut it completely through.  The plan of
cauterizing the Avound, Avith a vieAV to promote suppuration, is unadvisable.
Amputation is not generally advisable after tetanic symptoms have  set in;
there are cases, hoAvever, in Avhich it may be resorted to, especially when
the injury is so severe that the  limb is not likely ever to  be a useful one.
                                                      Part xx., p. 114.
  Idiopathic Tetanus treated by Galvanism.—A case of idiopathic tetanus
successfully treated by galvanism,  applied in the form of shocks from an
electro-magnetic apparatus, along the spine, over  the masseter muscles,
and in the course of the great sciatic nerves, is related by Mr. II. Hailey.
                                                       Part xxi, p. 91.
   Case of Traumatic Tetanus treated by strong Voluntary Action of the
 Respiratory Muscles.—[The folloiving case is  from Cruveilhier's Avork on
Pathological Anatomy.
  The case  Avas one of a  peasant Avho labored under tetanus produced by
 the forcible separation of the thumb from the hand.] 
662
TETANUS.
   The patient Avas young, and full of life and courage, and I ventured tn
 assure him of being cured if he submitted to my Orders.   I placed myself
 before him, and instructed him to respire in a measured time, making as deep
 inspirations as possible.  To direct him  in this fatiguing exercise I beat be-
 fore him the measure d  deux temps.  During an hour there was an attack
 of suffocation or strangulation.   My place  ivas taken by assistants, avIio
 relieved each other, and at the end of four hours  the patient fell into a
 profound sleep.  On his  AATaking, the same system Avas recommenced, which
 was again followed by sleep.  After the suspension of this treatment, there
 were slight  exacerbations, but  they speedily gave Avay, and  he was com-
 pletely cured.                                           Part xxi., p. 96.
   Treatment of Traumatic Tetanis.—Mr. De Ricci  thinks Ave are justified,
 with the view  of removing the exciting cause, in  amputating the entire
 part, or dividing the nerves leading to it.   In tetanus the energies of the
 brain are minus, and those of the spinal mzxrow]ylus / therefore we must
 increase the  first by stimulants, wine, brandy, and Indian hemp, and reduce
 the latter by the careful use of  tobacco enemata and fomentations (fifteen
 grs. of tobacco to eight ounces  of boiling water) every half hour, so as to
 keep up a state  of nausea.   The spine should also  be well rubbed with a
 liniment of croton oil and turpentine.  It is right to say that idiosyncrasy
 in some instances renders  the use of tobacco extremely dangerous.  The
 Symptoms in this case, are, the countenance assuming a deadly hue and ghast-
 ly appearance, and the pulse becoming qidvering and intermittent.  When
 these  occur  the administration should be stopped, and stimulants  imme-
 diately resorted to.  These means, with  paying attention to the state of
 the bowels  by  croton  oil or other strong purgatiire, and bringing the
 patient under the influence  of tobacco, as rapidly as possible, are the
 principal means upon which Ave have to rely.          Part xxii., p. 88.
   Treatment of Tetanus—Traumatic.—M. Bresse, surgeon at the Military
 Hospital  at Rennes, has cured cases by the use of frictions with the tinc-
 ture of belladonna, composed of five parts of extract to eleven of alcohol,
 applied all over the  body, more particularly  over the rigid parts.
                                                      Part xxii., p. 9U.
   Indian Hemp in  Tetanus.—In three cases of this dreadful disease the
 cannabis indica  seemed  to Prof. Miller to  answer  effectually.  In other
 cases of the  disease, although it failed to cure, it never  failed  to relieve.
 The dose was three grains of the extract, or thirty drops of the tincture,
 to be repeated every half hour, hour,  or two hours, the object being to
 produce and maintain narcotism.  There is  a very marked tolerance of
 the remedy.                                         Part xxiii., p. 287.
   Traumatic Tetanus.—A  case of this  disease was treated locally by
 Mr. Eddows, and with the  best  success.   It ivas traumatic, arising from
 injury  to  the ball of the thumb.  The jaws became closed with  slight
 general tetanic symptoms, a blister was applied over  the back of the hand,
and  acetate  of morphia, and afterward  the tincture  of aconite Avere
applied until mxv. of the  last were applied at one time.  There remained a
contraction of the flexors for some time, but this was removed by a splint.
                                                    Part xxiii., p. 323.
   Treatment  of Tetanus.—Use  frictions of chloroform all over the body
 Recovery Avas thus brought on in a case in four clays. 
TETANUS.
663
   In  a  case under Mr. Cock, that gentleman pursued the tonic plan  of
 treatment.  Three grains  of disulphate of quina Avere given every fourth
 hour, and twelve  ounces of Avine allowed per day.   RecoATery gradually
 took place.
   In  the  Hotel Dieu of Marseilles, a case of tetanus from wound of the
 toes was arrested by large  doses of disulphate of quinine, maximum forty-
 five grains in one day.  The cure Avas completed in about a fortnight.
                                                     Part xxiv., p. 67.

   Worrara Poison as a last resort in Tetanus.—Mr. Campbell, surgeon of
 the 55th  regiment, India,  says  he thinks the Worrara poison has been
 proposed  justly as a last resort in tetanus, by inserting the poison in the
 finger, and tying a ligature above the wound, so as to regulate its action
 and effect in the system.                             Part xxiv., p. 336.

   Tetanus and Hydrophobia.—From the  experiments of Dr.  Marshall
 Hall, he arrives at the two  following practical conclusions :  1st. That the
 tetanic  patient  be preserved from  all  external  excitement  absolutely.
 2nd. The hydrophobic  patient, whilst equally preserved from excitement.
 should be submitted to  efficient tracheotomy.          Part xxvii.,/). 59.

   Tetanus following Lesions of the Uterus, Abortion and Parturition.—
 [From  a  series  of twenty-four cases, Dr. Simpson proves that traumatic
 tetanus does occasionally supervene as a secondary obstetrical disease.   He
 then enters upon the]
   Nature of Puerperal Tetanus.—It ivill  be granted,  I believe, by all
 pathologists that the existence of an injury or a Avound upon the external
 parts of the body, is by far the  most common cause of tetanus.  After
 abortion and parturition wre have the existence, upon the interior of the
 uterus,  of a similar state of lesion.   All authorities  seem  now generally
 agreed as to the facts (l) that the human decidua is, as was maintained in
 the last century by Krummacher, the thickened and hypertrophied mucous
 membrane of the  uterus, (2) that the epithelial or superficial  layer of it
 separates from its  basement or outer  layer in abortion and after delivery ;
 and (3) that this separation or  solution of continuity of tissue, as well  as
 the rupture of the organic attachments  of the placenta from  the uterus,
 leaves the interior of this  organ so far  in  the condition  of an  external
 wound, or with a new or raAV surface for the time-being exposed.  Obste-
 trical tetanus has, in this respect, an exciting cause essentially similar to
 surgical tetanus. And perhaps the great reason Avhy this state of  lesion of
 the interior of the uterus does not more  frequently give rise to tetanus is,
 simply this, that the uterus is itself principally, or indeed almost entirely,
 supplied by nerves from the sympathetic  system, while apparently,  as
 stated by Mr. Curling and  other pathologists, tetanus is an affection far
 more easily excited by lesions of parts supplied by nerves from the cerebro-
 spinal system,  than by lesions  of  parts  supplied by nerves from the
 sympathetic system.
  Tetanus is known to follow wounds very various in their  degree and
 severity.  " Whether (says  Professor Wood) the wound is trifling or severe
 seems to be of little consequence," as far as regards  the supervention of
 secondary tetanus.  By  what pathological mechanism a wound or lesion of
a part can, under any circumstances, lead  on to an attack of tetanic disease,
is an inquiry regarding  which Ave as yet possess little information; and in 
fc'64
TETANUS.
this respect, the production of obstetrical tetanus is not more obscure than
the production of surgical tetanus.
  The disease, Avhen developed, essentially consists of an exalted or super-
excited  state of the reflex spinal system, or of some segment or  portion
of that system.
   Treatment of Puerperal  Tetanus.—In obstetrical  tetanus, no kind of
local  treatment to the seat of the original  uterine lesion  could  be Avell
applied, or Avould probably be of any  avail, if applied.  And, as to consti-
tutional means, perhaps the most important are—
   1st. The greatest possible quietude and isolation of the patient from all
irritation, corporeal or mental,  during the course, and for some time even
after the resolution of the disease.
   2nd. The special avoidance of painful and generally impracticable attempts
at opening the mouth in order to swallow ; but sustaining the strength of
the patient, and allaying the thirst by enemata, or by fluids applied to the
general surface of the body.
   3rd. If there is any well-grounded hope of irritating matters lodged in the
boAvels, acting as an exciting or aggravating cause, to sweep out the intes-
tinal canal at the commencement of the disease with an appropriate enema.
   4th. To relax the tonic spasms of the affected muscles, and dimmish the
exalted reflex  excitability of the spinal system by sedatives, or antispas-
modics  ; wdth the prospect of either  directly subduing  this morbid reflex
excitability, or of warding  off  the immediate  dangers of the disease, and
allowdng the case to pass on,  from an acute  and  dangerous attack, to a
sub-acute, and far more hopeful and tractable form of the malady.
   Various  sedatives and  antispasmodics  have  been  recommended to
fulfill this last  most vital and  important indication  in  the treatment of
tetanus— as belladonna, stramonium, hemlock, henbane, musk, camphor,
indian  hemp, hydrocyanic  acid, valerian, etc.  Perhaps  the two drugs of
this class that  have hitherto been most used,  and  relied upon, are opium
by the  mouth, and tobacco by enema.
   Latterly the antispasmodic action of sulphuric ether and chloroform has
been  repeatedly employed to allay that exalted state of the reflex  nervous
system, and to relax that resulting tonic contraction of the maxillary and
other muscles, ivbich  constitute the essence of  tetanus.
   Chloroform  in  sufficient doses acts as  a  direct sedative  upon  the
reflex nervous  system, and upon exalted muscular contractility.  In conse-
quence  of this action, it affords us one of our surest and most manageable
means of allaying common convulsive attacks ; if used in tetanus its action
will require to be sustained for many hours, or oftener perhaps for many
days.   And there is abundant proof of the safety with which its continuous
action may be kept up under jiroper care and  Avatching.  For instance,  a
few months ago I saw, with Dr. Combe, a case of convulsions of the most
severe and apparently hopeless kind in an infant of six weeks.  The disease
at once  yielded, and ultimately altogether disappeared under the action of
chloroform, which  required  to  be  used almost continuously for  thirteen
days; as much as 100 ounces of the drug being used during the period.
                                                      Part xxix., p. 65.

   Tetanus.—Dr. Hodges, of Somerset, recommends to  apply a solution of
morphia to the wound instead  of giving it internally.   The following is a
good formula: Hydrochloride of morphia, one scruple; tincture  of hyos- 
TETANUS.
665
 cyamus, two drachms; wrater, three ounces.  Moisten a piece of lint with
 this solution and keep it on the Avound.                Part xxx., p. 39.
   Tetanus.—Dr. Hobart, of the Cork Dispensary, recommends, on the first
 appearance of this disease, to try to  remove the source  of irritation, by
 dividing the nerves going to the part; or, if the Avound be in the skin and
 very trifling, either make deep incisions around it or excise it altogether;
 but if the wound be such as Avould materially injure the limb independently
 of the tetanic complication, it is better to amputate at once.  If this does
 not suffice, Ave  must  use  some  agent to  render the nervous system less
 sensitive to the irritating cause, its effect being long kept up—such  agents
 we have in chloroform, nicotine,  and ivourali.   Chloroform  causes conges-
 tion of the bronchial  tubes, and nicotine has an extreme depressing influ-
 ence on the circulation.  Noav wourali does not act  on the heart or other
 involuntary muscles at all, and preference should be given to it.  Artificial
 respiration will be necessary, if that function become seriously embar-
 rassed.                                              Part xxxvi., p. 40.
   Traumatic Tetanus.—A case of traumatic tetanus was lately treated at
 St. Thomas's, w ith some  degree of success by the administration of nico-
 tine.  At first, one-twelfth of a minim was given hourly, continued  with a
 little brandy and Avater;  this  dose was gradually increased.  The  effects
 were found to be very transitory.  It  produced, at first, giddiness, profuse
 perspiration  and nausea, together a\ ith a sloAver and feebler pulse, and
 marked alleviation  of the muscular spasms.   In  about a quarter of an hour
 the  pulse  became  fuller  and  stronger, the face  flushed, and the tetanic
 symptoms as severe as ever.   When given too freely, it produces faintness
 and sickness, eA'en an intermittent pulse, Avithout alleviating the symptoms.
                                                    Part xxxviii., p. 46.
   Tetanus.—In  acute tetanus, Prof. Erichsen says that all drugs are utterly
 useless in  retarding,  mitigating, suspending, or  arresting its  progress.
 Division of the nerve, leading to the Avound Avhen  it  can  be found and
 isolated, has been done Avith success, and it is better to do this pretty hio-h
 up in the limb, beyond the sphere of the local  irritation.   The occasional
 inhalation  of chloroform  will alleviate, though it  ivill not cure, acute
 tetanus.   We must remember that Ave  have an exhausting disease to deal
 with, and the patient will soon sink unless supported.  If the case, hoAvever,
 assume the subacute or chronic form,  calomel and opium, and even bella-
 donna may be employed Avith advantage.  Keep the  patient quiet and
 support his strength.                                 Part xxxix.,  p. 62.
  Hypodermic Injections.—In very violent cases the injection of a third
 of a grain  of acetate of morphia  beneath  the skin, says Mr. Hunter, will
 procure sleep and cessation of the movements for some hours.  It is  only a
 palliative,  but in this manner may be used to procure  the rest, the absence
 of which causes so much exhaustion.                  Part xxxix.,  p. 51.
  Tetanus—Poisoning by Strychnia.—Wourali poison is a direct sedative
 to the muscular system, causing complete relaxation  to the fibre. It is a
 direct antidote to  strychnine.  It does not appear to have been used in
poisoning  cases  in  the human subject, but  Dr. Harley has succeeded in
saving the  lives of animals to wdiich strychnine had been administered in
poisonous   doses.  M.  Vella, of Turin,  has  successfully used woorara in
cases of tetanus at the Frencl  Military Hospital during the late  Avar.  In 
666
THROAT.
one case, Avhich  proved successful, two grains of woorara were  dissolved
in nine drachms of Avater, and compresses  moistened with the solution
were  applied  to the wound, the strength  being gradually increased to fif-
teen grains in fourteen drachms of water, and "the compresses renewed
every third or fifth hour.   This mode of treatment requires and deserves
extensive trial.                                         Part  xl, p. 42.

                              ---•-+-•---

                           THROAT.
   Treatment of Sore Throat, or Angina, by Alum.— Vide Art. " Alum."
   Phagedenic  Ulceration of the Throat.—Dr.  J. J. Ross observes as
follows on the topical use  of iodine :   Another case, in Avhich the local use
of the tincture of iodine is of signal efficacy,  is that of ulcers of the tonsils
and fauces—specific or non-specific.  I have seen the ugliest sores in this
situation  put  on quite a  healthy appearance in a feAv days under its use.
It is  highly recommended by Ricord, and certainly I do not know any
thing equal to it in such cases.   It  is best used in the form of  a gargle;
thus :  R Tinct. iodini, 3j. to 3ij.; tinct. opii, 3j.; aquas, §vj. Mix.   Use
three or four times a day.                              Part vl, p. 119.
   Treatment of Malignant Sore Throat by Emetics.—In a paper "On the
present state of Therapeutical Inquiry," Dr. Arnott mentions a remedy for
malignant sore throat, which, like the invaluable discovery of Jenner, Avas
found out by accident at a time when an endemic  and supposed contagious
species of malignant  sore throat (diphtherite ?) was very prevalent at St.
Helena.   A sergeant's wife had four children laboring under this affection,
at the same time that she was suffering from some illness for which an
emetic mixture had been  prescribed.]
   It consisted of a strong solution of tartrate of antimony, a certain quan-
tity of Avhich Avas to be taken at intervals until vomiting should be excited.
The woman, supposing that this mixture had been  sent for one of her
children, the last attacked ivith sore throat, not only administered it in the
large doses intended for herself, but continued to exhibit it during the day
so as to keep up a frequent and severe vomiting.   I accompanied her me-
dical attendant in his evening visit, when we found the child in a state of
extreme  exhaustion, but  in  all other respects  much relieved.   It rapidly
recovered; and the  practice of  seArere and  continued vomiting  was
adopted  during my stay on  the island in many subsequent cases of the
same disease, ivith equal  success.  I have learned also that severe and
continued vomiting was employed by the medical officers of our army in
Egypt to arrest the rapidly disorganizing ophthalmia Avhich then prevailed ;
and  it is manifestly applicable to other  diseases of  the  same character,
requiring the adoption of prompt and decided m • isures.  Part xi.,p. 59.
   Wound of the  Throat.—[Remarking upon the difference of opinion
wdiich exists as to the treatment of cut-throat, Mr. Park relates a successful
case AAdiich 'he lately attended.  He found his patient, a woman aged 54,
of melancholy temperament, lying on the  floor in  a state of syncope.   The
wound of the throat Avas four inches in length and gaping; and the larynx
was opened to such an extent, as to admit the point of the finger betAveen
the thyroid  cartilage  and the os hyoidcs.  Mr. Park's account of the
treatment is as follows :] 
THROAT.
667
  Having cleansed the ivound, and adjusted its mangled parts, I proceeded
at once to stitch it up, and to strap it closely Avith adhesive plaster.  I ap^
plied a layer of lint and a bandage, and placed the head elevated upon the
pillow, so as to keep the divided parts in juxtaposition.   The pulse Avas so
feeble, that I administered a little brandy-and-water, Avhich revived her ;
and after giving  the necessary instructions to the attendants, I  left, and
sent the following mixture :  Tincture of opium, forty minims;  tincture of
henbane, a drachm : camphor mixture, four ounces ; mix : to take a fourth
part every four hours.  The wround was dressed daily, the general health
attended to ; and it Avas  surprising to wdtness how speedily the wound
healed.  On the first day, she could not speak at all; on the  second and
third, she could,  but in a  Ioav, husky whisper: and  on the fourth,  she
articulated very  well.  I Avas  careful in requesting  the attendants  to
watch and keep her perfectly quiet; and thus the case proceeded most
favorably for fourteen days, when  I pronounced her convalescent, and
ceased to attend.
  In the account of the preceding case, I trust the question, whether union
by the first intention in these cases can take place, will be completely set
at rest; for, notwithstanding the magnitude of the Avound, there Avas very
little suppuration, and that merely superficial; and the short space of time
ere the wound  had perfectly cicatrized  bears  out the assertion, and  con-
firms  the opinions of Sir  Charles Bell and Mr. Fergusson.  Of course, in
all cases of this description, it Avill be essentially necessary for the surgeon
carefully to watch the effect of closing the wound on the organs of respi-
ration, Avhether the epiglottis be injured.                Part xv., p. 203.

   Treatment of Cut-TJiroat.—[Speaking of suicidal cut-throat, as discussed
in Mr. Ellis's lectures on  clinical surgery, the reviewer in the u Monthly
Journal " says:]
   Now, if (as Ave are led to infer from the manner in AAdiich the cases are
detailed) Mr. E. advocates immediate closure  of the Avound, Ave consider
the practice as  at  once dangerous and useless.  Dangerous, because under
any circumstances there  is  risk to be apprehended from swelling of the
divided parts from infiltration, and this  is necessarily increased by stitch-
ing the Avound closely.  Besides,  after the active hemorrhage has been
arrested, there  is always more or less oozing of blood, Avhich, if it does not
escape readily  by the wound, is apt to trickle  down the air-passages,  and
may prove fatal by suffocation.  Mr. Liston relates  a case in his Avork on
Practical Surgery, Avhere the patient, except for his timely aid, would have
been  suffocated from the  pressure caused by confined  coaguia,  although
the air-passages had not been  opened into.  The addition of compresses
and plasters must of course add to the danger, on the  interruption  they
cause to the  breathing  and  circulation.   And  the practice is useless,
because the constant separation of the deeper seated parts of the wound,
caused by the  slightest motion of the head, by attempts to  swallow or
cough, together with the passage of air and mucus betAveen xhe divided
surfaces, all render immediate union of such Avounds impossible.   Sewing
up the  Avound, then, can only  serve  to render  the  appearance oi th<j
unfortunate  patient  less  frightful,  Avhilst  it  greatly  increases  hi.5  real
danger.   The insertion of a single point  of suture  near each  end ot the
incision, in extenshe transverse  Avounds, for the purpose of diminish'j;? ihe
exposed surface, is not liable, of course, to these objections. Pan xv., p. „"JS. 
668
THROAT.
  Foreign Bodies in the Mucous Canals.—A portion of an ear of barky
slips into the nostrils, wdth the stalk end  foremost.  The least touch of a
body so formed, in  such a  situation, thrusts it  further inAvard.  For one
or tAvo days it produces considerable irritation, which, however, at length
subsides ; and  the  foreign body, coated  with thick mucus, is ejected
without effort.   A small piece of leaf of a vegetable gets into the ventricle
of the glottis;  and  causes  great irritation and  coughing for some hours.
It is soon enveloped in mucus, and conies quietly aAvay next day.
  These facts show what  the  surgeon  should do  under similar circum-
stances.   He should not with his forceps irritate still more  parts already
too much irritated.   He is  not to alloAv even any effort of sneezing, in the
one  case, or unnecessary  haAvking in the other.  He is to require the
patient to be kept quiet, that the body  may continue in one situation, so
as to acquire as soon as possible the coating which facilitates the ejection.
                                                     Part xix., p. 157.

   Treatment of Wounds of the Larynx  or Trachea.—It has been a sub-
ject of much discussion,  whether, in cases  of free transverse division  of
the larynx or  trachea, Ave  ought to bring the wound together by sutures,
or to leave it open.  If the wound is closed by sutures there is danger of
asphyxia from  accumulation of blood and  mucus in the tubes ; and if, on
the other hand, the Avound is not healed at an early period, the  patient
will seldom recover.  Mr.  Eves says :
   The treatment which I  should  adopt in a case  in which the larynx or
trachea has been freely divided, would  be, after all hemorrhage Avas per-.
fectly stopped, and  after Avaiting a  short  period to be  assured on that
point, to  bring the parts accurately together by sutures, introduced even
through the cartilages, if necessary ; then, if great difficulty of breathing
should arise, so as  to threaten immediate asphyxia, either from derange-
ment of the rima glottidis, or from accumulation of fluid in the bronchial
tubes and cells, I should immediately adopt the suggestion thrown out by
Mr. Porter, of Dublin, and open  the  trachea  by a longitudinal incision ;
of course, this must not be thought of,  except there appears an absolute
necessity for such a step;  but it is satisfactory to know, that we have  the
means in our power of rendering that line  of treatment, which is certainly
the best,  free from  the dangers which have hitherto been apparently con-
nected with  it.  I  would  also strongly insist  upon  the  necessity of pre-
venting a drop of nourishment from passing by the mouth for a few days,
and the necessity of nourishing the patient by  enemata.  To prove  the
sufficiency of this mode of conveying nourishment, I would refer to a case
treated in the Meath Hospital, in which  Mr. Porter states, the patient was
thus supported for several months,  positively refusing  all food by  the
mouth.                                                Part xx.,p. 275.

   Throat—Relaxed.—Employ a gargle made with  three or four grains of
tannin to the ounce of water.                           Part xxi., p. 326.

   Inflammation and ulceration of the  Throat and Tongue—Nitrate of
.Copper.—Dr. Moore reports a case in which the uvula and soft palate, wdth
the  structures posterior to these, had  been  removed by the  ulcerative
process, extending  deeply  also at the base  of the tongue, partially destroy
ing the epiglottis.  The  mucous membrane presented an ulcerated  and
abraded appearance.  A trace of tonsil remained ;  but from pain affecting 
THYROIDAL AFFECTIONS.                    669
the right ear, it is natural to suppose the ulcerative process had extended
along the Eustachian tube.
  A  variety of means having been used, the patient was eventually cured
by the  administration of the mistura ferri composite, with  iodine, and
locally, the use of a gargle  of dilute hydrochloric acid and tinct. catechu.
The  ulcerations Avere touched with nitrate of copper.
  Precaution in  Use of Nitrate of Copper.—Dry the ulcer  or part to
be cauterized before applying the nitrate, and afterAvard smear it with oil.
                                                     Part xxv., p.  116.

   Throat—Erysipelatous Affection of.—Dr. Todd  has  related several
cases of this affection, which is characterized on  its first approach by symp-
toms someAvhat resembling  lockjaw ; in one case  the patient was not  able
to open his mouth by the most violent effort. Then follows great difficulty
of sAvallowing  any fluids, even a little water.  The best treatment seems
to be,  the application of  the solid nitrate of silver to  the  fauces,  and
enemata of strong beef-tea,  with  ten  grains of quinine  in each, to be
administered every four hours.                        Part xxvi, p. 11.
                              ---ui  -

                                           m
                 THYROIDAL  AFFECTIONS.

   Biniodide of Mercury in.—Dr. Maj'sisovics, having long enjoyed a large
 share of practice in Vienna, where scrofulous and other diseases requiring
 the  use of iodine are very prevalent, has had ample  opportunities of
 administering this remedy in various forms and  wdth variable success.
I   The effects of saturation ivith the remedy are described as the exanthema
 iodicum, Avhich shoivs itself in  dark red definite spots of various  sizes,
 spreading over the whole  body, remaining without the formation of scales,
 and  disappearing only after a long time.
   [Iodide of mercury, from the facility with which it undergoes decompo-
 sition, and its  liability to produce inflammation of the stomach and bowels,
 is seldom used internally,  but]
   In the form of ointment, it is exceedingly useful in promoting absorp-
 tion ; the strength recommended by the author is, gr. x. to  3ij« (that of
 the London Pharmacopoeia is, gr. xv. to 3ij.), which quantity is to be daily
 rubbed into the part affected.  The  biniodide of mercury is also but tittle
 used internally,  it is, however, an  excellent external application, in  the
 strength of 3j. to half an ounce of simple ointment, rubbed in three times
 a day.  (The strength of the preparation in the  London Pharmacopoeia is,
 3j.to|j.)
   The action of this ointment, applied as a plaster spread upon leather, is
 the  following: In the  space of half an hour,  varying  according to the
 spot where it is applied, or according to the individual constitution, burn-
 ing pain comes on, which in some persons lasts tAvo or three  hours, but in
 very sensitive subjects even longer.   In the third hour  the cuticle begins
 to shrivel, and then  rises in little  vesicles filled with transparent fluid.
 They increase in size, and form at length  a single bladder, and the fluid
 becomes opaque.  On the second day, the raised epidermis is thicker, the
 quantity of fluid lessened, and upon  the  third day the  thick and solid 
670                    THYROIDAL AFFECTIONS.
epidermis separates in the form of a yellowdsh white crust.   When this
has fallen off, the part underneath is seen to be already covered with iicav
epidermis, and entirely healed, but slightly red and sensible.   This is the
course when the bladder is not opened ;  Avhen it  has been torn, the part
becomes painful, and discharges pus for a long time.  After three days
have elapsed, the application  may be made  again.  The  patient may be
alloAved to walk about during the  painful stage, if it be not applied upon
the perineum or the lower extremities.   In  bronchocele its poAverful effect
may be mathematically shown, if the tumor is measured before the appli-
cation of the plaster; for upon the falling off of the dried cuticle the size
is found to have diminished  sensibly.  In  this disease no preparation of
iodine is comparable with the biniodide  of mercury.  It performs in one
month what the other forms will scarcely do in  three or four.   I  have
treated goitres of enormous size AAdth this medicine, and at the first appli-
cation all the threatenings  of suffocation or apoplexy (Avhen they existed)
ceased.  Soft  or so-called lymphatic tumors of the thyroid body can be
entirely cured, whatever  is their size. Those Avhich are indurated,  as Avell
as endemic goitres, are harder to cure than those which are soft, and those
which occur sporadically.  Condylomata about the anus and perineum, or
even Avithin the rectum or vagina, are cured by this ointment; and unless
they are  exceedingly extensive and indurated,  a single application, al-
though very painful, combined wdth the internal use of iodine, lias  been
found sufficient.                                       Part xl,p. 176.
  Bronchocele.—Mr. R. Hey, of York, says that in some cases, where
surgical interference seems  called for, the seton will be a legitimate and
proper mode  of treatment.   In  performing the  operation, do not use  a
common seton needle, but get a curved trocar made, fixed in a  handle, and
grooved like  a lithotomy staff, and having an eye behind  the shoulder, j
Having threaded this eye with a single silk, which has  a skein attached,
enter the trocar at the upper part of the tumor in the median line, carry
it on in a semicircular direction, so as  to  embrace a good deal  of the
tumor, and bring out the point in the median line below.  Get hold of
the silk thread, then withdraw the trocar, and pull the skein through.
                                                     Part xx., p. 274.
  Bronchocele.—A case  is recorded by Dr. Terzi wdiich was  successfully
treated by electro-acupuncture.  The number of plates used Avas from six-
teen to twentyvand upon the intervening discs of cloth, dipped in an acid
or saline solution, a little  tincture of iodine  was dropped.
                                                    Part  xxi., p. 85.
  Diseases of, and Operations on,  the Thyroid Gland.—[In describing
the post-mortem appearance of the gland after inflammation, Dr. Handfield
Jones remarks  :]
  " I  have  more than once  found the veins issuing from the gland, and
passing its inferior margin, implicated in  the inflammation and full of pus,
or obstructed by a clot.  In one case the coagulum completely obliterated
all the principal venous  trunks ;  even the  lymphatic vessels, in  cases of
thyroiditis, often appeared inflamed, varicose, tinged with rosy lymph, or
puriform  matter, and with opaque  parietes.  The glands to  which they
pass are swollen, red, sanguineous, and buried in  masses of plastic  lymph.
The ramifications of the thyroid nerves are interlaced on the surface of the
injected capillary vessels." 
THYROIDAL  AFFECTIONS.
671
  [The medical and surgical modes of treatment <^^\^°^t





in water mixed with laid  may De  umai.   x                nnnlication



&s^                                                 -

" i^rp'atictTof S;i:ST mistaken for mere^ge

r ni?^str r:;=rof ^^  r s ^ir^^s in
abou S.S^successnir Professor Portahas performed it four tunes, every
about 1 alt succes^u   Th  d   er ari8es from the hemorrhage, denu-
Sn of veSSs and nerves of neck, or trachea and larynx, and diffusive
^Srati^OTfrom acute inflammation of the air apparatus; or from
 Ue  o fexhauTtiom  The  operation of extirpation o  the wdio eor part
nf the "land should be discarded from surgical  practice.  Small isolated
 un  rsbmay' be easily and safely removed.  Small  accessory^lobe* or
,*nkted  annendices  may  increase and  form tumors, the gland itseii
rSl^r^r Vro^ssor Porta has  repeatedly excised such tumors
w te p'usct'safety and success, a simple linear ™^™™m&T of
  Method of theAuthor.-Conxineed of the difficulty  and  danger of
isolating the thyroid gland from the  part  surrounding it, Frolessor
Itt has  follovved a plan which  he  strongly recommends as safe and

^Edying the thyroid gland, my attention  ^ ^ i^teZZl
facts which  have especially interested me   Firstthat  the arteiiei are
inserted at the  extremities of each lobe,  and that their tii« ^™ £™£
the superior, inferior, and  external margins of the  lobes  ^o that the
large branches before penetrating the  parenchyma, generalJ/™**™£
into a dictation of smaller branches.  Thu^although the thyroidawe
externally fonr considerable arteries, ^thin^e ^Btte^eeS^
are merely branches and anastomoses of  small catibre and the ■^arias^
ment and danger of severe hemorrhage  from injury to large a essels, aie
scarcely met with when we isolate the external portion of the tumor.  In
the second  place, that the greater number of broncboceles, as I have fully
explained before, do not  arise from degeneration of the proper gtodulai
tissue, but from the generation of one or more non-malignant sai conmteus
or encysted tumors hi the midst  of the parenchyma  of the gland itself
that these  tumors  increasing, at last invade the whole space, andReduce
the organ to a simple envelope or matrix on dividing which thenewjio
ducts Ire exposed^and may be  extracted with the greatest ^se, mjuimg
only small vessels, and leaving behind a fleshy sac, which, when so e>acu-
ated, falls together, and no trace of the tumor remains.    .  . . .■  U*
result of these observations was the foUowing reflection : If the pupation
of the tbvroid gland, and even one lobe  of it, is so difficult and dangeious,
wouhiit not begetter to invert  the  plan of operation],  and evacuate th
contents of the tumor,  without touching its  external  portion, without 
672.                   THYROIDAL AFFECTIONS.
 lacerating the surrounding cellular tissue, Avithout injuring  the arterial
 trunks, and Avithout dividing the principal organs of the neck ?   On these
 grounds the neAV plan of operation consists in the simple incision of the
 external envelopes, and of the anterior surface of the tumor,  at some dis-
 tance from the direction of the arterial trunks; in the evacuation of the
 tumor by means of  separation and extraction, or by excision  of  the cysts
 and nodules contained in it, Avithout separation of the outer surface."
   We are not told in how many cases the author has  performed his opera-
 tion, but  he has selected six as illustrations, stating that in these, and in
 all his  other cases, it succeeded  perfectly in removing the tumor, and
 curing the patient.  In only two cases did inflammatory symptoms require
 prompt antiphlogistic treatment.  In one case a coriaceous cyst, and two
 sarcomatous tumors were removed from the  substance of the gland.  In
 another, the  gland did not  contain  new products, but  the enlargement
 was owing to simple hypertrophy.   In  this patient, the whole fleshy inter-
 nal part of the tumor was cut away, leaving a sort of surrounding bark,
 about two lines in thickness.  The bleeding  Avas very slight.  Cysts and
 sarcomatous tumors  were extracted in all the other cases recorded.
   The instruments for this operation are merely scalpels, blunt-hooks, dis-
 section and torsion  forceps, scissors, etc.  There are three  steps  in the
 proceeding.  First: division of the integuments  of the  neck and  of the
 second belly of the omo-hyoid muscle,  which  is  almost always necessary.
 Secondly: incision of the tumor parallel to the external incision,  avoiding
 the branches of the thyroid arteries, or on division,  at once applying the
 ligature or torsion, which is very easy, because  the branches are mere
 secondary ones, running along and adhering for some distance to the sur-
 face of the tumor.  Thirdly : by means of the forceps, and  the  back or
 handle of the knife, cysts or tumors are removed.   When very deep and
 adherent, they are excised  on the base.  In  case of simple hypertrophy,
 the wdiole internal texture  of the gland  may be removed.   Should any
 arteries be injured in this  last step of the  operation, torsion should be
 employed.                                            •
   Sometimes the wound heals by the first intention, but more frequently
 it suppurates,  and cicatrizes in  a few weeks.  Occasionally it  becomes
 sacculated, and requires dilatation, or  becomes converted into  a  fistula,
 which does not close for a considerable  time.  The great object  of after-
 treatment is to moderate  inflammation which may arise, adopting active
 antiphlogistic measures, should  its  extension to  the chest  or  head be
 threatened.                                          Part xxiii., p. 290.
   Use of Iodine.—Instead of applying iodine by means of friction, in the
form of ointment,  to  the neck in the  case of goitre, M. Hannon  recom-
mends it to be tied over the part, between two layers of cotton wool in a
bag.  To  prevent its staining the linen, a small piece  of gummed silk may
 be placed  over the bag.                              Part xxvi., p. 348.

   Goitre.—Dr. Mouat, of Bengal, states that  upward of 60,000 cases of
goitre  have  been  treated in  that  country on the following  plan, which
generally  effects a cure at  once,'if not, a  second repetition next year
suffices: Melt 3 lbs. of lard or mutton suet, strain and clean ;  when nearly
cool, add 9 drachms of biniodide of mercury, taking care to make  the pow-
der fine by trituration in a mortar.   Work in a mortar until no grains of
red are apparent in  the  ointment, and put  in  pots for use, taking care 
TIBIA—TOBAOOO.
673
always to keep both poAvder  and ointment  from the rays of light.   Use
as follows: About an hour after sunrise apply the ointment to the goitre
with a spatula  made  of ivory, or thin, broad, smooth bamboo, quantity
according to size of tumor—rub it well in for at least ten minutes.   Let the
patient then sit Avith his goitre held well up to the sun, and let hiin remain
so as long  as he can endure it.  It is probable that about noon he wdll suf-
fer severe  pain from the blistering effect of the ointment, although no pus-
tules are raised on the skin.   About 2 p. m., the ointment should again be
applied with a very careful and  tender hand, and the patient should be
dispatched to his home with  orders not  to  touch the ointment on any
account with the  hand, but to  allow it to be gradually,absorbed, which
absorption wdll be complete on the third day.       Part xxxvii., p. 264.

                              ---»«»

                            TIBIA.
   Nodes on the Tibiae-Actual  Cautery.—We are disposed to agree with
Mr. Fergusson, that as a means  of producing counter-irritation, the actual
cautery is too much neglected;,  people  are too much  afraid of  a heated
iron approaching them to allow of the  popular objection  to this remedy
being very easily overcome.   The operation  resembles too much that of
firing horses, to become  fashionable, but wdien properly managed, it is an
equally efficient, more manageable, and  less painful counter-irritation than
either the  caustic, potash, or the moxa.  It is also of the greatest service
m arresting hemorrhage.  Mr.  Fergusson has found it  of use in  some
obstinate cases of nodes on the tibia.  He brings a large  extent of sur-
face under the  influence of the heated iron in these cases, not so as to
cause a slough, but someAvhat  in the Avay Avhich is adopted in firing horses,
by wdiich  means a sudden excitement is produced over a large surface,
while at  the same time  the  skin is not  destroyed, or converted  into  a
slough.                                               Part vii., p. 215.

                              —•-++---

                         TOBACCO.
   Tobacco taken Moderately.—Tobacco taken moderately, says M. Raspail,
is a condiment to Avhich some  people inure themselves.  In whatever form
it is employed, the tobacco acts  evidently by property, the base  of which
is formed  by ammonia.   In fact, if Ave moisten common  tobacco with  a
little ammonia, we give to it a flavor  Avhich increases its value. Pound
some Avalnut leaves with potass  in a heated mortar, and then place them
in a drying stOAre, and you will have a powder very similar to tobacco, for
the purpose of smoking, and which has even a stronger flavor, especially
if a few drops of  ammonia be added to it;  and there is every reason to
believe that common  tobacco  is  thus  adulterated to a great  extent.  The
Avalnut leaves may be replaced by  those of the potato,  henbane,  helle-
bore, aconite, by the grains of elaterium and of colocynth, etc.
                                                       Part ix.,p. 81.
   Use of Infusion of Tobacco.—The  infusion of tobacco has  been used
with much  success in many cases of  prurigo.  In purulent ophthalmia,
also, and the scrofulous conjunctivitis of infants, it has been used ivith de-
    vol.  n.—43 
674
TOBACCO.
cided success, and may be resorted to Avith  confidence, when other reme-
dies have failed.  The strength of the infusion for these purposes is double
that used for enemata—viz., 3j. to Oss. of boiling water, and shag tobacco
proves more efficacious than pig-tail.                    Part xii., p. 301.

  Injurious Influence of Tobacco in Insanity.—[Dr. Woodward's expe-
rience is quite at variance Avith that of the physicians to our asylums.  It
must  be questioned, however, whether depriving some patients of the en-
joyment of  this luxury may not lead to a good deal of irritation, and thus
aggravate the disease.  Dr. W. observes:]
  Alcohol is not the only narcotic which thus  affects the brain and ner-
vous  system.   Opium produces delirium tremens, and  probably insanity.
Tobacco is  a  powerful  narcotic agent, and its use is very deleterious to
the nervous system,  producing tremors, vertigo, faintness, palpitation of
the heart, and other serious diseases.   That tobacco certainly produces
insanity I am not able positively to observe; but that it produces  a pre-
disposition to it I  am fully confident.  Its influence upon the brain  and
nervous system generally, is hardly less obvious than that of alcohol, and,
if excessively used, is equally injurious.  In our experience in this hospi-
tal, tobacco, in all its forms, is injurious  to.the insane.  It increases  excite-
ment of the nervous system in  many eases, deranges  the stomach, and
produces vertigo,  tremors, and stupor in others.         Part xiv., p. 65.

   Tobacco  Smoking—Effects of.—From a few experiments instituted by
M. Malapert, it Avas found that, in the smoke of tobacco extracted by in-
spiration, there is 10 per  cent, of nicotine.  Thus a man who smokes a
cigar of the weight of seventy grains, receives in his mouth  seven  grains
of nicotine  mixed Avith  a little watery  vapor, tar, empyreumatic  oil, etc;
Although a large portion of this nicotine  is rejected, both by the smoke
puffed from the mouth, and by the saliva, a portion  of it  is nevertheless
taken up by the vessels of the buccal and laryngeal mucous membrane, cir-
culated with  the  blood, and  acts upon the  brain.   With those unaccus-
tomed  to the use of tobacco, the nicotine, when in contact ivith the latter
organ,  produces Arertigo, nausea, headache, and somnolence ; whilst habitual
smokers are merely throAvn into a state  of excitement, similar to that pro-
duced by moderate quantities of wine or tea.
   From further investigation it was found  that the drier the  tobacco the
less nicotine reaches the mouth.  A very dry cigar, whilst burning, yields
a very  small  amount of watery vapor;  the  smoke cools  rapidly, and
allows  the  condensation of  the  nicotine  before it reaches  the mouth.
Hence it comes that the first  half of a cigar smokes more  mildly than the
second, in wdiich a certain amount of condensed watery vapor and nicotine,
freed by the first half, are deposited.  The same remark applies to smok-
ing tobacco in pipes, and if smokers were prudent, they would never con-
sume but   half a  cigar  or  pipe,  and throAv away  the  other.  Smoking
through water, or Avith long  tubes  and small bowds, is also a precaution
which should not be neglected.                      Part xxxii., p. 283.

   Tobacco.—The use of tobacco  should be forbidden  during the preva-
lence of an  epidemic of typhoid  fever;  it  has the effect  of relaxing the
mucous membranes, and diminishing the vital force, and is very apt to pro-
duce  or predispose to diarrhoea and intestinal lesion.  Catechu is the best
remedy for  diarrhoea arising from this cause.          Part xxxv., p. 34i. 
TOE NATL.
675
                          TOE  NAIL.

   Inverted  Toe Nail.—In many, though by no means in the majority of
 cases, the cutting the nail too short, is the primary cause of the  affection.
 The soft parts, being no longer kept doAvn by the projecting free edge of
 the nail, are forced, by the pressure of the boot or shoe in walking, against
 and even over the truncated end of the nail, and, as this again increases in
 length,  it may be made to even penetrate into them—giving rise thus to
 inflammation, swelling, ulceration, and fungous granulations, with a degree
 of suffering which  often  renders  the slightest  motion of the foot un-
 bearable.
   [Many of the operations hitherto proposed  are extremely painful, and
 while few of them afford more than temporary relief, some even  tend  to
 increase the evil.  Dr. Zeis has had frequent  opportunities of seeing pa-
 tients operated on by Dupuytren's method of extraction of the  offending
 portion of the nail, and  he found that in every case it was ineffectual, the
 free edge of the nail expanding laterally, and keeping up a constant irrita-
 tion.  The new modes  of treatment  constantly met with in the  medical
 journals are mostly mere modifications of the older plans.  The most pain-
 ful is that of Neret, who directs a spatula to be forced down beneath the
 nail to its roots, and then for the nail to be torn out.   Larrey's  operation
 differs from the former only that  the third of the nail  is thus treated.
 Baudens removes the whole of the inverted edge, together with the spongy
 flesh in  which it is imbedded.  Others advise the destruction  of the  nail,
 or a portion of it, by caustics, for Avhich caustic potass and lime, and burnt
 alum have been used.  Labat  destroyed the root of the nail at once oy the
 actual cautery.   Donzel dissected back the skin from the root of the nail,
 filled the wound Avith charpie, and the next day Avith pate  caustique; re-
 moving the edge of the nail Avhen the slough separated.   Others, objecting
 to  the  destruction  of any portion  of the nail, propose various plans by
 which it may be kept from contact  with the inflamed portion of the soft
 parts until these are completely healed.   Martin recommends a triangular
 portion  to be cut out of the middle of the nail, the base being at the free
 edge, and then  the cut edges of the nail to be drawn together by a suture
 of brass-wire.   This, however, from the constant  growth of the nail, can
 only afford temporary relief.   Others propose to give the nail  a flatter
 form, by thinning the centre, and applying compresses of different kinds,
 whilst Bressy,  after shaving the nail as  thin as possible, touches it six or
 eight  times  Avith lunar  caustic, until  it shrivels up, and its edges are in
 consequence drawn  out of the soft parts; tills, hoAvever,infallibly produces
 entire destruction of the nail]
  Dr. Zeis considers it all-important to attend to the general health, which
 will usually be found more or less deranged.   So soon  as the nail acquires
 the slightest projection, he is in the habit of introducing  beneath it, by
 means of a fine probe, a small portion of charpie, and  to prevent the fall-
 ing out  of this, he covers the eml of the toe Avith adhesive plaster, spread
 upon gold-beater's skin,  Avhich adapts itself better to the parts, and pro-
duces a less amount of pressure than Avhen it is  spread  on silk or linen.
The toe is then to  be bathed  frequently, during the day, in Avarm water.
If the soft parts at the point of the toe, are in  so SAVollen a condition  as to
interfere wdth the dressing just directed, or completely to cover and con- 
676
TOE NAIL.
 ceal the edge of the nail, Dr. Zeis is in the habit of removing them by the
 knife.
    " Much  more obstinate, however, are those  cases in AAdiich the disease
 affects, at  the  same  time, or is entirely confined to, the  side  of the nail.
 These  are, especially, the cases in Avhich the destruction of the Avhole, or a
 part of the nail, has been considered indispensable to the cure.  I have
 however, in such, seldom failed to secure the entire  and permanent  relief
 of the patient by rest, the frequent use of the foot-bath, and the removal
 by the knife, of the fungous granulations or spongy and morbidly sensible
 flesh, by Avhich the edge of the nail  becomes  covered.  I will not, how-
 ever, pretend to deny," he adds, " that cases of a Arery aggravated charac-
 ter may occur,  in which the unhealthy condition of the ulceration, seated
 beneath the nail, will require the loosened edge of the nail to be cut away,
 that our applications may be applied directly to the ulcerated surface, and
 also to prevent the constant irritation Avhich is kept up in it by the de-
 tached portion  of the nail.  It is never  necessary to destroy  the whole,
 or any part of the nail, even under such circumstances."
                                                      Part xl, p. 163.
   Toe  Nail—Ingrowing of the.—In order to heal  the troublesome  ulcer
 arising from this cause, says Dr. Newman, separate the soft parts from the
 nail so as to expose the whole surface of the ulcer,  and sprinkle it  freely
 with powdered charcoal, mixed with a little acetate of lead or oxide of
 zinc; bind  a piece of lint over it, and let the patient wear a wide shoe, and
 keep quiet.  Every day bathe the toe with tepid water, and sprinkle fresh
 charcoal over it, without  disturbing that previously applied.
                                                      Part xxi., p. 260.
   Onychia.—The late Mr. Colles, of Dublin, in a paper on some morbid
 affections of the great toe nail, divides them into three kinds : 1. The com-
 mon onychia, or nail growing into the flesh, on its external edge.   2. The
 inner angle of the  nail resting on a hard Avhite mass of laminated horny
 cuticle, Avhich may be picked out  in bran-like scales,  exposing a small cup-
 shaped cavity,  Avithout ulceration.   3. Onychia maligna  depending  on a
 morbid condition of the secreting matrix of the nail.  In the first disease,
 only so much of the nail as is separated from the matrix, and imbedded in
 the fungus, is to be remo\red.  This is done by pressing on the fungus
 ivith a  spatula, raising the nail from it by a pair of strong forceps, and then
 by means of  curved scissors passed underneath it, cutting it completely
 out.  In the second  it  is  to  pick  awray the laminated scales and remove
 the bulbous end of the nail.  In the third, the  treatment is to keep the
 patient  in  bed,  poultice the part for two or three days, then cleanse the
 ulcer thoroughly by means of a syringe and a stream of tepid Avater, and
 afterward cutting aAvay as much of the loose  nail as can be done wdthout
 irritating the  surrounding sensitive  surface.   Lastly, fumigate, night and
 morning, by means of a funnel,  wdth the mercurial candle, which contains
3j. hyd. sulph. rubrum to gij. of Avax.   After  each fumigation, the toe to
be enveloped in  a piece of lint spread Avith spermaceti ointment.
                                                    Part xxvi., p. 328.
   Onychia.—If you see this disease early, Dr. Hamilton, of Dublin, ad-
vises to poultice until  you can insinuate a small shred of tint under the
angle and side of the nail, by means of a small probe ;  you must then Avet
 this Avith a solution of nitrate of silver (5j. ad §j.).  Keep the  lint in for 
TONGUE.
677
forty-eight hours, and by reneAving two or three times the disease will be
cured.  To prevent a return, caution the patient against rounding off the
angles Avhen cutting the nails, and direct him to cut them straight across.
                                                   Part xxxii., p. 191.
  Ingrowing Toe-Nail.—The chief pain  in the operation for the cure of
this affection is caused  by the necessity of forcing away a portion of the
nail from attachments rendered excessively tender by inflammation.  It is
not generally known,  says Dr. Long, surgeon to Liverpool Royal Infir-
mary, that by rubbing the nail well  with nitrate of silver along the line of
intended division, about two days before  the  operation, this tenderness is
done away with,  and the operation rendered nearly painless, as the caustic
causes the nail to loose its attachment to the parts beneath.  The  best
plan of doing this is to gently introduce a bit  of cotton wool along the
edge of the  nail, thus separating  it from the overgrowing  granulations,
and along the edge of  this  to apply the  nitrate of silver. If the nail  be
very thick, it may be  necessary to scrape off the blackened parts, and
apply the caustic a second time......There is no such thing as
ingroAving toe-nail; it is the upgroAving of the quick through exposing the
same, and taking away the natural protection and support of the nail itself.
Therefore do not remove the nail, but soak the part well in hot Avater, and
delicately remove all discharge,  pass  in  plenty of very finely powdered
burnt alum, cover all the fungus ivith the  same, and on the next and every
day do the same  until no longer sensitive, then  strap down the alum, first
putting on the top, not  under, a piece  of lint.        Part xxxvii., p. 176.
  Ingrowing Toe-Nail.—After fomentation, Dr. Alcantara interposes be-
neath the nail a small piece  of  lint,  upon which some ointment  of per-
chloride of iron has been spread; all the surface of the excrescence, de-
prived  of its epidermis, is covered over Avith  this,  and  the dressing is
renewed twice a day.   At the end of four days the excrescence becomes
dry and mummified, and is  easily detached.  The wound then assumes a
regular aspect, and the cure is completed  at the  end of a Aveek.
                                                  Part xxxix., p. 233.
                           TONGUE.
  Diseases of the Tongue.—On diseases of this organ we find very little
attention has been paid by authors, except on  those Avhich are malignant.
The  tongue is sometimes  swollen in  dyspeptic  persons, or it becomes
cracked on the surface.  These cracks or fissures are sometimes very deep,
and will generally be durable.  They often  arise  from profuse salivation
at some former period of life, but, when slight, maybe owing to dyspepsia.
If owing  to mercury, the best remedy, perhaps, is sarsaparilla, or nitric
acid.  We sometimes find little ulcers on the tongue, often the consequence
of syphilis, and accompanied, perhaps,  with  tittle  spots  of syphilitic pso-
riasis, on the body or on  the scalp.  They soon  disappear by means  of
small doses of mercury;  and in one case, mentioned by Sir B. Brodie, the
hyd. c. creta Avas given  in small  doses for  nearly two  months  before a
radical cure could be effected.   Small doses  are much to be preferred to
large ones.  Sir Benjamin prefers  five grains of the hyd. c. creta Avith one
or two grains of Dover's poAvder; and Avhere this fails, he gives the iodide 
678
TONGUE.
of potassium, two or three grains given twdce daily, dissolved in plenty of
water.  If these ulcers arise from dyspepsia, wdiich is frequently the case,
one or tAvo applications of the nitrate of silver will be sufficient  to cure
them.   Sir Benjamin continues: "There is a disease of the tongue Avhich
I have seen every now and then, and wdiich I am sure is very often mis-
taken for cancer, though it is of a different nature.  It is a curable  disease,
although it looks like a malignant one in many respects.   The first thing
of which the patient complains is  enlargement of the tongue, w till some
pain.   On examination you find a  tumor in one part of it, not very well
defined, nor wdth any distinct margin. It is a softish tumor,  and increases
in size, and perhaps another tumor appears in a different part of the  tongue,
and that increases also.   There  may be three or four of these  soft elastic
tumors, with no very defined margins, in various parts of the tongue. This
is the first  stage of the disease.
   " In the second stage there is a small formation of matter in one  of these
tumors—a little abscess, wdiich breaks externally, discharging two or three
drops of pus.   When the abscess has burst it does not heal, but  another
forms  in one of the other tumors.   These  abscesses may assume the form
of ulcers, and the ulcer has  a  particular  appearance.  In the first instance
it is a very narrow streak of ulceration, but on introducing a probe  you
find that the ulcer is the external orifice  to a sort of fissure in the  tongue.
The probe passes  in obliquely; the tongue is, as it Avere, undermined  by
the ulcer, a flap of the substance of the tongue being over it.
   "The disease noAV becomes more painful, and at last these ulcers may
spread externally.  In  some instances  they occupy a  very considerable
portion of the  surface of the tongue,  but generally they burrow  internally,
and do not spread  much toward  the surface.  This is a very distressing
state of things, and a man may remain in  this state for a long time.  The
glands of the  neck do  not become affected, nor does the general health
suffer, except from the difficulty of sivalloAving food.   This  is one incon-
venience experienced by the patient,  and he also labors under a difficulty
df articulation.  The tongue, from its enlarged state, may become stiff, not
sufficiently pliable for the purposes of speech, and the patient either speaks
thick or lisps.
   " In some instances the disease may be relieved by a course of sarsaparilla,
with small  doses of bichloride of  mercury.  A strong decoction of sar-
saparilla, with  from a quarter to half a grain of bichloride of mercury, may
be taken in the course of the day.   Of course, if there be anything wrong
in the  general health, you should endeavor to get that corrected, and
attend especially to  the state  of the boAvels and the secretion of the liver.
If the  secretions of the digestive organs be unhealthy, a dose of senna and
salts may be given every other morning, and blue  pill  every other night.
When the patient is brought into this state, one remedy, as I have said, is
sarsaparilla Avith  bichloride of mercury,  but, according to my experience,
this is  not the best remedy.  The remedy best adapted  for these cases is a
solution of arsenic.   Give the patient five minims three times daily, in a
draught, gradually increasing the dose to ten minims.  It should be taken
in full doses,  so that it may begin to produce some of its  poisonous effects
on the system.  When  it begins to act as a poison, it will sIioav  itself in
various ways.  Sometimes there is  a sense  of heat, a burning pain in the
rectum; sometimes griping, purging,  and sickness, and nervous tremblings.
A patient who  is taking arsenic, especially in pretty large doses, ought to 
TONGUE.
679
be carefully watched.  At first you may see him every two or three  days,
and then every day:  and  as soon as the  arsenic  begins  to  operate as a
poison, leave it off. When this effect is produced the disease of the tongue
generally gets well, but at any rate leave off the arsenic, and the poisoning
Avill not go too far; it will do no harm.  If, after a time, you find that the
disease is relieved, but not entirely cured, you  may try another course of
arsenic.  Perhaps it may take a considerable time to get the  tongue quite
well.   Sarsaparilla, with the bichloride of mercury, may be given at one
time; and at another, arsenic.   You cannot  give either of these remedies
forever, and indeed  the  arsenic can  only be given  for a  very limited
period; but it is  astonishing what bad tongues of this description I have
seen get Avell under these modes of treatment, especially under the use of
arsenic."
  [Sir Benjamin thinks that many of these affections, Avhich at first are not
malignant, may ultimately prove so; and when they assume the malignant
character, or when a disease is of a  malignant nature from the first, he
thinks it is the best plan to let it have its own course.  As in a cancer of
the breast it would be of no use to remove the  small portion  Avhere malig-
nancy first shows  itself, or part of a tibia affected Avith fungus hsematodes,
bo in cancer of the tongue the Avhole organ  is more or less diseased from
the first, and to remove the piece which  first  shoAvs symptoms of malig
nancy, would be of little avail.]
  "There is one other disease of the tongue, or rather a disease under it,
which remains to  be mentioned.  A patient comes Avith a sore mouth, and
you see the tongue pushed up to the soft palate.   It looks as if the tongue
were  enlarged, but that is not the case, it is lifted up.   You tell the patient
to put his tongue  against the incisor teeth, and on looking beneath you see
a tumor.  By feeling it you find fluctuation, you puncture it, and let out
a quantity of transparent fluid,  sometimes a teaspoonful or more. The
fluid  is a little glutinous, and  consists  of saliva.   There  has  been  an
obstruction to the orifice of the  submaxillary gland ; the saliva has been
secreted by the gland, but could not get out by the duct, and hence it has
remained till it  has formed a large tumor.   This is Avhat is called ranula.
  " You puncture the tumor with a lancet; the fluid comes out, and imme-
diately the patient is  Avell.  You see  him  a Aveek afterward; he is quite
well,  and there is  no saliva floAving out of the orifice you have made with
the lancet.   But you see him a  month afterAvard,  and the tumor has
reappeared,  the orifice has healed,  and the tumor becomes as large as
ever.   All you want  is, to get a permanent orifice from the bag into which
the duct has been converted; but that is a very difficult matter.   I have
tried  to effect it  in various ways.  I have  punctured the bag, and then
touched the edge  with caustic potassa to prevent its healing.   The patient
has gone on very  Avell so long as it did not heal, but as soon as I have left
off applying the caustic the orifice has closed.  I have introduced a tena-
culum into the bag of the ranula, and cut aAvay a piece sufficiently large to
admit the finger ;  the patient has then continued well for a longer time,
because the part  takes  longer to heal, but  contraction takes places, and
the patient is bad again.   I have run a seton through, and the patient has
then gone on Avell for a considerable time.   I  have introduced a gold or
silver ring, and kept  that in as a seton.   If the seton be kept in a conside-
rable  time it seems  to effect a  permanent  cure, but even that fails, and
you haA'e to perform  the operation tAvo or three times.  I know of nothing 
680
TONGUE.
better than  the  use  of a seton, and I believe that it is better made of
metallic substance than of silk.   It does not so soon ulcerate its Avay out,
and if it remain in for a long time, the edges of the orifice through w hich
the seton is introduced may become covered ivith mucous membrane.  If
you introduce a silk or india-rubber seton in the back of the neck, after a
great length of time a sort of skin forms on the inner surface of the canal;
there  is  a discharge of matter; and when you  take aAvay the seton the
part in which it lay remains pervious.   So if you keep a seton in a ranula
for a very long time the opening may remain pervious.  The advantage of a
metallic over a silk seton is, that it does not ulcerate its way out so soon, does
not get putrid in the mouth, and therefore may be kept in for a long time."
   [Sometimes the tongue is  affected wdth a tumor, which, if it occurred
in the female breast, Avould perhaps  be mistaken  for scirrhus ; hut still it
has not the character of scirrhus  of the tongue—it is  hard and circum-
scribed, and rather deeper than common scirrhus.   Sir Benj. Brodie would
ascertain the effects of iodine upon  such a tumor, before he pronounced
a decided opinion.  In one case he gave eight or ten drops of the tincture
of iodine three times a day, and gradually increased the dose to 20 drops.
The tumor ultimately disappeared.  In relating  this case he  cautions us
against the  too  long continuance of  iodine, without keeping our eyes on
the  patient.  After  continuing its use too long  he was seized  with
  aralysis, but on leaving off the medicine he recovered—thus shoAving
  ow powerfully iodine may affect the nervous system, if used for too long
a time.]                                                Part ix., p. 98.

   Diseases of the Tongue.—[As actual disease of the tongue is often
obscure, and seldom met  ivith in private practice, attention to the follow-
ing remarks taken from a lecture by Mr. Lawrence on the subject, wdll be
of service Avhen  such  do  occur.  Ulceration, swelling, and  thickening of
the mucous  membrane,  and  hypertrophy Avith  induration  of the Avhole
organ, are the  forms most  frequently met Avith.  With the two latter
ulceration is a frequent concomitant.  Syphilis and cancer are the more
formidable diseases,  the  first being by far the  most  frequent.  Serious
affections too, occasionally depend upon disorder  of the digestive organs.]
  Syphilitic disease of the tongue occurs most frequently in conjunction
with other venereal symptoms, such as ulcerations of the fauces or mouth,
and eruptions', particularly of the scaly kind. Here the nature of the
malady is too obvious to be mistaken.   A gentleman Avho had  a primary
syphilitic  sore some Aveeks previously, showed me an ulcer on the right
edge of the tongue, very similar to those frequently accompanying the use
of mercury.  The surface Avas raised and irregular,  excoriated and  par-
tially ulcerated.  There Avere two small superficial ulcerations of the palate,
and no other symptoms.   These appearances Avere entirely removed  in
three weeks under the mild use of mercury with sarsaparilla.   A female,
at present in the hospital,  has the mucous  membrane at the edge  of tho
tongue thickened, and  considerably raised, for a length of three quarters
of an inch, Avith alteration of the epithelium, giving it a white color.  It
has been in this  state, with  considerable soreness, for three months.   I
lately saAV a young person wdth thickening of the mucous membrane on
both sides of the tongue, occupying nearly the whole length of the organ.
It was reddened,  slightly fissured, but not greatly enlarged.  There was a
superficial ulcer, of elongated form, on each side,  about the middle of the
 
TONGUE.
681
 diseased portion of the membrane.  This affection, which had followed a
 primary sore, and ivas not attended with any other secondary symptom,
 was said to have existed in a more or less troublesome state for more than
 a ve-ir  I prescribed the hydrarg. c. creta, and conclude that it had the
 desired effect, as I have not seen the patient since.   A gentleman 26 years
 of a^e consulted me on account of an affection of the tongue.  There was
 a thickenin<>- of the mucous membrane on the middle line and at the back
 of the or«*an, constituting a flattened projection of circular form larger
 than a sixpence.  It was redder than the  rest of the mucous membrane,
 and had a slightly broken surface, like that of a wart.  It was painful,
 and smarted when acids, strong liquids, or stimulating condiments were
 taken into the mouth.  As he mentioned that he had felt some uneasiness
 about the throat, I inspected the fauces, and found a superficial ulcer, the
 size of a  sixpence, on the side of the pharynx, behind the root  of the
 tongue  I asked whether he had contracted any syphilitic complaint; he
 was surprised at the inquiry, but informed  me that  he had had a chancre
 several weeks previously, which  had healed in ten days under the useof
 mercury.  The tongue and throat soon became well under the use of that
 remedy.                                                 .    , . , .,
   Sometimes the dorsum of the tongue presents red patches, in ivnicn tne
 raucous membrane is denuded of its epithelium, and perfectly smooth, but
 not ulcerated.  These are sore when hot  or  strong things are taken into
 the mouth.  They may last for a considerable time, particularly if they are
 neglected, getting better and worse.  There is sometimes a combination
 of "diseased appearances in the same case.   A gentleman consulted me  on
 July 1st.  There had been a primary sore  ten months ago; then an erup-
• tion, which did not last long.  He had been plagued with a bad tongue for
 the last four or five months : it had been so swelled and painful that he ate
 with difficulty.  The surface of the organ, in its middle portion, and over
 more than half its extent, the  dorsum and edges being  included, was
 smooth, the epithelium being white and opaque, as if this part had been
 ulcerated, and partly having a raw appearance.  There  were three or four
 small superficial ulcers Avith grey  surfaces at the edges  and tip, and small
 superficial ulcerations of the tips, Avith  chaps at the angles of the  mouth.
 In both palms there were scaly eruptions in a slight form, but not else-
 where. This patient had frequently taken the iodide of potassium in rather
 large doses;  the tongue  would get better, but the mischief would return
 on leaving off the remedy.  I prescribed the hydrarg. c. creta, gr. nss.
 three times a day.  The  patient did not visit me again  for a Aveek, at the
 end of which time severe ptyalism had been produced, with more than the
 usual  degree of suffering.  He expressed bis belief, hoAvever,  that  the
 original complaint of  the tongue Avas  better.  Noav  (August) that the
 mercurial affection has subsided, the tongue is quite well, though having
 marks on its  surface of the  previous disease.  The benefieial influence of
 mercury on ulcers of the tongue, mouth, and throat, has ahvays appeared
 to mo to afford the most unequivocal evidence of its peculiar antisyphilitic
 virtues ; for while the  sound mucous membrane is inflamed and ulcerated
 hy the action of the remedy, Ave see the contiguous venereal ulcerations
 altered in character and healing rapidly.
   Venereal enlargement and induration of the tongue may be confounded
 with cancer,  in Avhich the substance of  the organ is also more or less har-
 dened.  There are several and sufficient points of distinction, so that if  the 
682
TONGUE.
history be investigated, and the symptoms carefully examined, there wdll
be no risk of mistaking the comparatively mild and manageable venereal
affection for the very painful, and, I fear, inevitably fatal cancerous disease.
I have always seen the latter begin on the edge of the tongue, generally at
the middle or back part.  It extends sloAvly into the substance,  and may
ultimately embrace the greater portion, or the Avhole organ.  The hard-
ness which, as in the scirrhous breast, is in the highest degree, renders  the
part incompressible; it  is accurately circumscribed, so that we imme-
diately feel the boundary of the disease.  The hardness is less marked in
syphilis,  more diffused, and not confined in its origin to the margin of  the
tongue.  Scirrhous induration does not last long, nor become considerable
in extent, Avithout the occurrence of ulceration ; while syphilitic enlarge-
ment may occupy one-half, or nearly the Avhole  organ, without breach of
surface.  The cancerous ulcer is deep, often Avith an ash-colored or par-
tially disorganized and bleeding surface.  Sometimes profuse  and  alarming
hemorrhage occurs.  The margin is  hard,  raised, and everted, or ragged
and excavated.  The induration is considerable in proportion to the ulcera-
tion, especially at the commencement. The secretion from the sore is thin
and offensive.  The  induration, in  syphilitic ulcerations, is comparatively
inconsiderable;  the  surface is of better character,  and  the  ulcer seldom
penetrates deeply.   Cancer of the  tongue is a hardened mass, which be-
comes ulcerated ;  syphilitic disease is an ulceration  of Avhich the base  and
edge are sometimes thickened, moderately indurated,  and raised.  The
pain of cancerous ulceration is most severe, and so much aggravated by
motion of the organ, that articulation, mastication, and SAvalloAving,  are
attended Avith the greatest suffering.  The aid of opium is absolutely neces-
sary to procure temporary ease.  The uneasiness in syphilitic cases is com-
paratively inconsiderable.  The absorbent glands  soon become  enlarged
and indurated in cancer of the tongue, while they seldom suffer in  syphilitic
ulceration ; if they do, it is simple enlargement.          Part xii., p. 188.

   Morlid States of the Tongue.—Dr. Wright says : As a rule the tongue
is a very faithful indicator of the condition of the alimentary organs ;  but
its evidences  are not unexceptionable.   A furred tongue, for instance, is a
common indication of dyspepsia, but it is not a constant one.  You some-
times meet wdth irritable, nervous subjects, whose tongues are habitually
furred, yet without  any signs  or symptoms Avhatever of gastric derange-
ment.   Others, again, will  have clean tongues, and of natural redness,
wdiilst they are suffering  from severe  stomach disorder.   I called your
attention to a case of this sort the other morning, in  the person of a female,
the subject of very  severe pyrosis.   During the three weeks that she has
been under my care, the tongue has never lost its cleanliness  or good color.
I once had a dispensary patient affected wdth scirrhus of the pylorus, of
which he died, yet up to the time of his  death the tongue was scarcely ever
furred or dry.  Various circumstances exert a remarkable influence upon
this organ.   Some people, otherwdse healthy, get a furred, clammy tongue
if their stomachs are empty a little longer than usual; others have their
tongues furred always when their stomachs are full; the coating  continues
only during digestion, and passes off as this function cea.ses.  Mental and
moral emotions affect  the condition of the tongue in a singular manner.
It  may  happen, that in dyspepsia, the  disorder the brain suffers, sympa-
 thetically with the stomach, has as much share as this organ itself in g'ving 
TONGUE.
683
the tongue its characteristic coating.  Certain it is, as I have said, that
the feelings of the mind wdll, in a very few minutes, render a clean tongue
a foul one.  Among the profoundly studious, among those terrified by sud-
den apprehensions, or shocked by the sudden advent of ill  news ; among
the hypochondriacal, hysterical, gloomy,  and desponding, you will find
many examples of the mind's influence, in this particular, upon the body.
  A few clays ago, in calling upon a patient, one  of the first things I did
was  to look at  his tongue.  I found it, as usual, very pale, flabby, and
moist, but without any coating   After having made other necessary in-
quiries, I was informed by my  patient that his heart, which has  long been
disturbed by mental emotion, the other night beat  wdth unusual vehemence
and irregularity.   On my asking if he could account for it, he told me that
he had just then  received  the  distressing intelligence that an uncle, from
whom he expected a competency, had not left him Avith a shilling!  This
pitiable tale, told with much earnestness and visible feeling, occupied little
more than twenty minutes; at the end of that time I again  looked at his
tongue, and found it coated with a thick white fur I
  I mention these things, thus generally, to you, not only as items in pa-
thology with which you ought to be made familiar, but also suggestive of
a discreet rule of practice, viz., to let the examination of a patient's tongue
be one of your first duties at his bed-side.
  Besides moral and mental  states, there are certain  physical ones, of
which the tongue is an occasional, though not an invariable evidence.  Our
hospital opportunities have lately given me the occasion of showing you
these pathognomonic facts someAvhat strikingly.   I have dAvelt with parti-
cularity upon them at the  bed-side, and have no doubt that they are still
fresh in you remembrance.  You have seen in  several varieties the dark,
dry  tongue of typhoid fever; the  glassy,  bright red  tongue, with its
elevated  papillas, in sub-acute  gastro-enteritis; the brown  furred tongue
of dyspepsia, Avith bilious derangement; the pale, flabby, furred, sodden,
tongue of chlorosis, habitual drunkenness, debility  of the  gastric apparatus,
etc.;  the pale or patched, trembling tongue of the hypochondriac, the dis-
sipated, the excessively iveakened, from  whatever cause; the dry, con-
tracted, dusky-red tongue of gastric irritation, etc.
  A morbid state of the tongue not only indicates (with rare exceptions)
the condition of the gastric apparatus, and of the system in general, but
an improvement  of its appearance denotes, also, that the patient is advanc
ing toward  recovery.  This change sometimes occurs with singular sud-
denness,  and the patient  as suddenly gets well.   You remember the  girl
Scandret, in the middle ward, whom we had some difficulty of relieving of
fever that had supervened upon dyspepsia.  Her tongue ivas broad, flabby,
indented at the edges, very trembling, and completely covered Avith dense
white fur.  She complained of a feeling  of holloAvness  or sinking of the
epigastrium, with frequent darting pains there, and occasional fits of
nausea ; her food always lay like a load in her stomach, and oppressed it
with  flatulence.   She  was ordered the twelfth of a grain of strychnine,
three times a day.  She had only taken five doses up to the time of our
next  visit, and you remembered how altered she ttien was.  Her tongue
had no indentation on it: scarcely any fur; its trembling was almost im-
perceptible, and  its size diminished.  She had no gastric pain or flatulence
after  the first dose of strychnine.   In four days afterAvard. she left the hos-
pital, apparently quite well. I told you that the appearance of her tongue, 
684
TONGUE.
and her expressed symptoms, indicated that her stomach was suffering from
irritability, the  result of local nervous debility: the manner in which she
improved under  the strychnine confirms me in that opinion.
  There Avas another case to which I called your particular attention, a
short time back, in the  person of a girl.   When convalescent  from fever,
she one day begged to be allowed some beef for dinner.  Her tongue Avas
very furred, but there was nothing else to prohibit the gratification of her
appetite; and she asked so imploringly that I ordered her some roast beef, at
the same time remarking to you that it ivas not improbable her anticipated
meal would clean her tongue.  The next day confirmed ivhat I had said ;
Ave found her with neither fur nor fetor in her mouth, and she required no
more medicine during the feAv remaining days that she was in the hospital.
It is not always safe to gratify the inclination of patients' appetites, for they
are sometimes disposed to crave for very strange things.  Inclination and
appetite have frequently a great share in promoting good digestion.  I have
known oysters, lobsters, pork, pastry, and  such  like  allowed  almost ad
libitum, for once, to patients, not only Avith impunity but ivith advantage.
I mention these  as curiosities of experience, not as examples for imitation.
                                                     Part  xv., p. 106.
   Tongue—Inflammatory and other Affections of.—Dr. Fleming says, that
sudden and alarming  swelling sometimes takes place in the tongue, which
seems to be merely an unaccountable and active hyperasmia, readily yield-
ing before  inflammation has had  time to be lighted up, by  incision, by
leeching copiously, both locally and under the chin.  Another affection is
" an inflammation, circumscribed or diffused, originating in the loose cellular
tissue  between  the geniohyo-glossi muscles," the treatment for which is
antiphlogistic, but if  it does not readily yield, Dr. Fleming recommends a
free incision to be made under the chin  in the median line, through the
integuments and fascia, and through the raphe of those muscles, delaying
the ad\Tancement of the suppurating process.  Dr. Fleming says, the best
treatment for the abraded surface of the  tongue, sometimes met with, and
for a peculiar kind of ulcer, Avhich is accompanied by a small tumor about
the size of a pea, and  which he  states  may occur Avithout the slightest
suspicion of a syphilitic taint, is the iodide of iron, with hemlock, and the
local application of the nitrate of copper.  Dr. Fleming thinks it a tuber-
culous disease, and says it is by  no  means  uncommonly met with.  The
nitrate of copper, he says, is almost invaluable also as an application to the
small excoriated ulcers, of a semi-phagedenic character, occurring in the
genitals of both male and female.  It is very deliquescent, and can be ap-
phed only  in its liquid state.  The surface of the ulcer should be Avell
dried previously, and afterAvard covered with oil.       Part xxii., p. 367.
   Tongue—Tumors of.—For the removal of these  tumors, the  surgeon has
choice of three methods.  Amputation by the knife gets rid of the mass at
once ;  strangulation by means of ligature prevents any loss of blood ;  and
excision  performed carefully by a  Avire heated by galvanism accomplishes
both these objects at  the same time.                  Part xxvi., p.  340.
   Percyanide of Mercury in  Syphilitic  Ulceration of the  Tongue.—Mr.
Wormald,  at St. Bartholomew's  Hospital, has  recently been employing a
saturated solution of the bicyanide of mercury, as an application to syphi-
litic ulcerations, abrasions, etc., on the tongue.  Without speaking very
enthusiastically respecting it, he states that he has obtained more Batisfac- 
TONSILS.
685
tory results from it than from any remedy he had previously employed.
The solution is painted over the affected part, care of course being taken
that the patient do riot SAvallow any quantity of it.  The extremely intract-
able nature of this form of syphilis is matter of general remark.
                                                   Part xxxii., p. 181.
  Tongue, Deep Fissures of—Dr. Fleming, surgeon, Richmond Hospital,
Dublin, uses locally the nitrate of copper to the  ulcerated surfaces, and
gives chlorate of potash in from five to fifteen grain doses, wdth bark and
sarsaparilla.   The  nitrate  of copper is almost invaluable in this class ol
ulcers,  and it will be found equally valuable in small excavated semi-phage-
denic ulcers which occur  on the genitals.  It is a very deliquescent salt,
and can only be applied in the liquid state, by means of a small piece of
cedar.                                             Part xxxiii., p. 118.
  Glycerine and Borax in Cracked Tongue.—Dr. Brinton  advises to apply
a lotion composed of tAvo  scruples of borax, one ounce of glycerine, and
four ounces of Avater ;  at the same time give the iodide  of potassium and
bark.                                                Part xxxv., p. 59.

                              ----HI -


                           TONSILS.
  Pulvis Aluminis et Capsici.—R Alum, three  parts;  concentrated tinc-
ture, of capsicum, one part.   Mix and dry.
  Dr. Turnbull has found a very small quantity of this powder applied to
the tonsils, more efficacious, in  some  cases,  than an alum  and capsicum
gargle.                                                 Part v., p. 84.
  Chronic Enlargement of Tonsils—Iodide of Zinc.—Dr.  J. Ross  says :
The first notice I saAV of the medical use  of" this compound wras in the
revieAv  of Dr. CogSAvill's  essay on iodine in " Johnson's  Journal"  (Jan.
1839, p. 118). It is there stated,  "During the tAvo last  years we  have
been in the habit of employing a strong solution of the iodide  of zinc, as
an application to the tonsillary glands, Avhen affected with  chronic enlarge-
ment, and AATe can recommend it to our readers as the best local remedy we
know for that most obstinate complaint."  To this statement I fully  sub-
scribe.   In those cases of hypertrophied tonsils Avhere  1 ha\"e used it, the
diminution in their size was most marked and speedily produced.   In two
patients in whom these glands were so much enlarged  as almost to fill up
the  isthmus of the fauces, and interfere materially with deglutition, they
were quickly reduced to nearly theii natural size, and gave  no further in-
convenience.  A solution may be made of 10,15, or 30 grains to the ounce
of water, and apphed  to the tonsils daily, by a piece of sponge tied to  a
quill or thin  piece of wood.  After using this for some time, I  employ the
substance itself, undiluted; a little of it  is exposed to the air till it deli-
quesces, and then applied in this state to the tonsil, by means of a camel's-
hair brush.   This is a much more effectual plan than Dr. Cusack's mode of
applying the nit. argenti point by point; indeed, it is superior to every
local application I know of being used  in  such cases, ahvays, of course,
excepting the knife.                                    Part xl, p. 124.
  Chronic Congestion of the Tonsils.—Dr. Becker has found  extract of
green  walnut shells of great efficacy in  congestion of the tonsils.   The 
G36
TONSILS.
mode in Avhich he uses it is in the form of a solution of the extract of one
part to fifteen of distilled Avater, to be applied externally with a brush.
                                                       Part xi., p.  59.
  Excision of the Tonsils—Follicular Disease of.—Extirpate (as also  the
uvula) if much hypertrophied and indurated, and apply strong solution of
nitrate of silver.  (Dr. H. Green.)
       *       *       *       *****
  Hypertrophy and induration of the  tonsils  occur frequently in  youn^
persons and  children, independent of follicular disease of the throat.  In
some instances, the affection appears to be congenital, or  is hereditary  • in
others, it is the result  of repeated attacks of chronic inflammation of  the
tonsillary glands.  When the hypertrophy is accompanied by induration
whether this condition  coexists ivith follicular disease, or is the effect of
chronic tonsilitis, excision of the enlarged gland is almost the only method
of treatment by which permanent  and effectual  relief can  be obtained.
This fact ought to be better understood by the profession than it seems to
be, for the practice of painting these morbid growths with the tincture of
iodine, or of cauterizing them with the solid nitrate, is still continued,  and
patients are daily being subjected to this still annoying and useless practice,
often month after month, wdth the apparent  expectation on  the part of
their attendants that enlarged and indurated tonsils may be discussed by
these applications.—(Rev.)                            Part xvi., p. 126.
   Tonsils—Chronic Enlargement of.—Apply nitrate of  silver, either  the
solid caustic, or a  solution gradually increased from  three grains to  two
drachms to the ounce of water ; paint the tonsils twdce or thrice at one sit-
ting, and then  let the mouth  be well washed with water.  Dr. Naudin
makes the application every two or three weeks.         Part xvii., p. 94.
   Evils attending Excision of the Tonsils.—With respect to enlargement
of the tonsils affecting the permeability of the Eustachian tube, Mr. Har-
vey said that he considered it to exist much less frequently than had been
supposed ; and in  cases ivhere this occlusion  did  exist, it Avas not from
the enlarged tonsils pressing upon the mouth of the tube, but from thick-
ening, the result of inflammation of the lining membrane.
   Excision of the tonsils Avas not, therefore, expedient;  indeed, in  many
cases which  he had examined,  that proceeding had been attended with
enlargement of the follicles of the pharynx, continued heat and thirst,  con-
stant desire for deglutition, disturbance of the general health, and impair-
ment  of the voice.  Enlarged tonsils were  more frequently found in
females than males; and when  enlarged  in childhood, generally assumed
their natural size at  puberty.  They appeared to the author  to have some
intimate sympathy wdth the sexual organization. The treatment of enlarge-
ment of the  tonsils consisted of small doses of the  bichloride of mercury
and colchicum; the latter, with guaiacum, was most efficacious.
                                                      Part xix., p.  160.
   Tonsils—Enlarged.—Do not remove them  by the knife in children, as
the  operation is troublesome, and  sometimes serious; and, besides, they
often diminish in  size spontaneously after puberty.  When  the patient is
old enough to exercise self-control, the operation is  safe enough.
                                                       Part xxi, p. 25.
   Tonsil—Enlarged.—The excision of enlarged tonsils  is recommended, 
TOOTHACHE.                          687
as performed by  M. Lisfranc, of Paris, by grasping the tonsil  Avith the
forceps, pulling it imvard from the side  of the fauces, or  merely held
steady in its  natural position, and  then pas-ing a straight narrow blunt-
pointed bistoury,  the  blade  being sheathed except rather more than an
inch from the point, through its base.  It may be done wdth perfect safety,
with immediate relief, and with little hemorrhage succeeding.
  Mr. Harvey recommends the bichloride of mercury, in small and divided
doses, with tincture of rhubarb and of bark, to be taken at bedtime; also
the tincture of colchicum, to be taken internally, and applied  externally
with fin. saponis.  When the  scrofulous  character predominates, he uses
the cod-liver oil.  Of all the remedies advised to be used in the chronic
state, Mr. Harvey thinks colchicum is the best.  He was led to this con-
clusion from investigating the  history of this affection, and the contents of
the tonsils, resembling very much those concretions found in the joints of
gouty and rheumatic patients.                          Part xxti.,^. 2i5.
  Angina  Tonsillaris.—Dr. Flange states  that  the  employment of the
zincum  aceticum  in this disease, and especially in thirty cases occurring
during an epidemic  of scarlatina, where it Avas exhibited in very different
degrees of the  affection, has been  followed by almost immediate  relief.
He prescribes from  Bj. to 3j. in from §vj. to §viij. of water, giving a table-
spoonful in some mucilage every two hours, in severe cases, and frequently
gargling the throat  also  with the same.                Part xxii., p. 365.
                       TOOTHACHE.
   Oil of Ergot.—Suggested to relieve the pain; applied on a small piece
of cotton, within the cavity of the tooth.                  Part ii., p. 42.
   Oil of Valerian.—Suggested in cases of pain arising from carious teeth,
unaccompanied by inflammation of the fang.              Part ii., p. 56.
   Creasote,  generally gives  relief from pain; applied directly within the
cavity, but is thought to hasten the destruction of the teeth.
                                                       Part vl, p. 13.
   Gregorian Paste.—Currie powder, made  into a  paste  with  brandy, is
an excellent remedy for toothache, and  forms the celebrated Gregorian
paste.
  Augustura Bark.—When purely nervous, fifteen grains of Augustura
bark every four hours has often cured it in a few hours.
   Odontalgic Pill.—Dr.  Handel, of  Mentz,  strongly recommends the
following:
  R Opium, half a drachm;  extract of hyoscyamus, camphor, of  each six
grains ;  oil of hyoscyamus, one drachm ;  cajeput oil, tincture of lytta, of
each eight minims.  Mix.  Insert a little into the tooth as a pill, or on lint.
                                                     Part viii., p. 29.
  Aqua, or  Liquor Ammonias.—Recommended in  odontalgia, in  doses
of 20 to 40 drops,  thoroughly blended with a cupful of thick gruel, and
taken whenever the paroxysm of pain supervenes.        Part ix., p. 33.
  Chloride of Zinc in Toothache.—According  to  Dr. Stanelli, the chlo-
ride of zinc, liquefied by exposure to  the air  possesses the property of 
688
TOOTHACHE.
calming  dental  pains.   His mode of application  is most simple.   By
means of a small hair pencil, a small quantity of it is applied to the cavity
of the painful tooth,  and in the  space of a few minutes it appeases the
most acute sufferings, Avithout causing any irritation.   Before proceeding
to the application, it is indispensable  carefully to surround the tooth Avith
cotton wadding, and, when the chloride has been applied, to well fill the
cavity with this same cotton.  The mouth is finally washed Avith a  little
warm water.  The author  affirms  that he has obtained uniform success
from  this means in more than fifty cases, and that be has never observed
the progress of the caries rendered  more active by it.     Part ix., p. 178.
   Use of Pure  Tannin.—Prof. Druitt considers tannin the best remedy
for toothache:
   " It Avill often be found that the gum around a carious tooth is in  a
spongy, flabby condition; a little piece of it, perhaps,  growing into the
cavity.   The ache, too, is often quite as much  in the gum as in the tooth
itself.  But, be this as it may, when the tooth  aches, let the patient wash
out the mouth thoroughly with a solution of carbonate of soda in Avarm
water ; let the gum around the tooth, or betAveen it and its neighbors, be
scarified  with a  fine  lancet; then let a little bit of cotton wrool, imbued
with  a solution of a scruple of tannin, and five grains of mastic, in two
drachms of ether, be  put into the cavity, and if the ache is to be cured at
all, this plan wdll put an end to it in nine cases  out of ten.  I think that
practitioners are to blame  in not  paying more  attention to the cure of
toothache ; I am convinced that in most cases it  is  as curable as a colic or
a pleurisy; the  chief point being to  open the  boAvels, and put the secre-
tions of  the mouth in a healthy state, and to apply some gentle astringent
and defensative to the  diseased tooth till it is capable of being stopped
by some  metallic  substance.    I  say emphatically a fine  lancet, be-
cause the coarse, round, blunted tools  that are  generally sold under the
name of gum-lancets, only bruise the gum, and cause horrible pain.  The
lancet which I  use  is sickle-shaped, cutting  on both edges,  and finely
ground ; and if  guarded with the middle finger of the right hand, it may
be used  in the  case of the most unruly children Avithout any possible ill
result."                                                Part x., p. 139.
   New Remedy for  Toothache.—Sulphuric ether, saturated  in the cold
with camphor, and then a few drops of liq. ammonise added.  It acts as a
cautery.    M. Cottereau, who has  employed it for four  years, says it  is
always attended wdth success.  The rapid evaporation of the ether causes
a slight  deposit of camphor in the dental  cavity, and this protects the
nerve from the air.   The ammonia  cauterizes.            Part xiv., p. 324.

   Toothache—Morphine Locally to the Gum.—Three hours after the last
meal in the evening, rub a quarter of a grain of muriate of morphia gently
upon  the  gum,  for  about  three minutes; then incline the head  to the
affected  side, and keep in that position for ten minutes, taking care neither
to spit out nor SAvallow the saliva.  Repeat it in  tAvo hours if relief is not
obtained, except there is headache  or sleepiness.         Part xvi, p. 89.
   Carvacrol, a  New Remedy for Toothache.—Carvacrol,  according  to
Professor  Schweitzer,  is formed  by the action  of potassa, iodine,  or
hydrated phosphoric  acid,  upon oleum carui, ol. thymi: and according to
Ciaus, by the action of iodine upon camphor. 
TOOTHACHE.
689
  Carvacrol is an oily liquid, very similar to creasote, wdth a very unplea-
sant smell and strong taste.   Applied on a piece of cotton to a decayed
and painful tooth, it gives immediate relief.
  [The following has also been used with success:]
  A mixture of two  parts of liquid ammonia  of commerce with one of
some simple tincture is recommended as  a remedy for toothache, so often
uncontrollable.   A piece of lint is dipped  into  this mixture, and then
introduced into the carious'tooth, when  the  nerve is immediately cauter-
ized, and pain stopped.   It  is stated  to be eminently successful, and  in
some cases is supposed to act by neutralizing an acid product in the de-
caying tooth.                                          Part xvii., p. 58.
  Toothache.—Having dissolved soine gum copal in  chloroform, clean out
the hole, moisten a little cotton with the  solution, and introduce it into the
decayed part.                                        Part xviii., p. 105.
  Toothache.—Dissolve a little gum mastic in chloroform, so as to thicken
the fluid, and then apply it to the tooth on a little cotton wrool.
                                                      Part  xix., p. 67.
  Toothache.—Apply a minute portion of arsenic, not exceeding the tAven-
tieth part of a grain, in combination Avith creasote and muriate of morphia,
on a little cotton avooI,  to the sensitive  portion  of the tooth, and retain it
in situ for tAventy-four  hours, by softened Avax.   Then clear away the dead
dentine, lay  open the pulp cavity, and  remove  the pulp ; if the operation
gives any pain, desist from it, and reneAV the  arsenical application until the
following day.  When  the pulp and carious  dentine  have  been removed,
plug the tooth in the usual Avay.  If there is a discharge  from  the  pulp
cavity, after subduing the tenderness by the  arsenical application, and be-
fore proceeding to plug the  tooth, get the condition of  the pulp cavity
which gives rise to this secretion, relieved by the daily injection of a solu-
tion of alum or of nitrate of silver.  In the still more advanced stages of
toothache, hardly anything but extraction will do good.
                                                      Part xix., p. 32S.
  Toothache.—Let the mouth be first  cleansed with Avarm water contain-
ing a little  carbonate  of soda; then remove any foreign  body from the
cavity, dry  it, and drop into  it from a point,  collodion  in which morphia
has been dissolved, fill  the cavity with  asbestos, and  saturate this with col-
lodion ; lastly, place over it a pledget of  bibulous  paper.  By occasionally
reneAving this application, a more durable stopping ivith gold  may at last
be effected.                                           Part xix., p. 324.
  Toothache.—Apply a  bit of cotton saturated Avith a drop  or two of
strong tincture of capsicum (capsic. bacc, §iv.; sp. vin. rect., ixij).
                                                     Part xxi, p. 262.
  Toothache.—The most intense toothache connected with decayed teeth,
is relieved in a moment by the magic touch of the membrana tympani with
a blunt probe.  Agonizing neuralgia of the  face  is relieved in the same
way.  These effects are  supposed  to be obtained by the influence of the
chorda tympani nerve.                                Part xxiv., p. 336.
  Emetics in Toothache.—Sometimes this is  OAving to the stomach, and is
not relieved by any remedy, not even by the extraction of the tooth.   In
this case  try an emetic  of ipecacuanha.                  Part xxx., p. 137.
    vol. n.—41 
690
TOURNIQUET.
  Toothache.—A Asav drops of chloroform on a bit of cotton, applied to the
commencement of the meatus auditorius, often gives great relief.  The
chloroform must not be dropped directly into the ear.  Part xxxv., p. 32.

  Toothache.—For the last thirty years, Mr. Hoarder, of Plymouth, lias
been in the habit of using galvanism for the relief of toothache ; those cases
yield most easily in Avhich the pain  originates in the tooth itself.  A metal
disc covered Avith moistened cloth and connected with the positive pole, is
placed on the back of the neck, a similar disc connected with the negative
pole being placed either on the tooth itself  or gum; the degree of poAver
necessary is very feeble.   Most cases are relieved  permanently, many for
a considerable period, and very feAv not at all.  Of course, in cases  of ab-
scess at the root of the tooth, the symptoms, as might be  expected, are
aggravated.                                       Part xxxviii.,/). 253.

                              :---•-•-•---


                      TOURNIQUET.    *
  Proper Mode  of Applying the Tourniquet.—When you first put on the
tourniquet, says  Prof. Listen, no pressure must he made on the vessels ; the
surgeon must be ready to make his incision before it is screAved up ; for if
you allow it to remain on a minute or two, the ivhole limb is gorged with
blood.  If you are  desirous that the patient should not lose blood, it is of
the utmost moment to attend to this point.   Put on the tourniquet; you
may even allow  the surgeon to transfix the limb with his knife; the instant
the principal vessel is about to be divided, screAV it up quickly, and  again,
as soon as the larger arteries are secured, take it off.  If you go on  screw-
ing it up, look at the end of the vessels, then unscrew it; if you see some-
thing bleeding, try to catch the vessels, and then screw again ; there is an
immense quantity of blood lost, the veins pour it out as fast as the arteries,
you do not knoAV lvhat you are tying, and you are almost certain to tie a
great many vessels unnecessarily.                        Part xl,p. 185.

  Arch-Tourniquet.—[Dr. Oke,  of Southampton,  has  caused to be con-
structed an arch-tourniquet on a someAvhat novel.plan.]
  It consists of an arch, a pad, and screw.   The flanks of the arch are per-
forated with holes for the action of the external screw, wdiich is worked
by a short handle, as in the common  tourniquet.  The pad is  of the ordi-
nary size, flat on one side and convex on the other.  Upon its flat surface
there is a smooth cavity for the  reception and AVorking of the point  of the
screAV.  Mode of application : Let the arch  embrace the limb, so that one
of the perforations  of the flank may be exactly opposite the cavity  on the
flat side of the pad, previously applied over the trunk of the artery to be
compressed.   Then fit the external into the internal screw, and Avork it
upon the pad till sufficient pressure be made to stop the circulation of the
artery.                                                 Part ix., p. 174.
  Military Tourniquet.—This consists of an ordinary straight stay husk,
of sufficient length to embrace the largest limb, and by a series of notches
at both extremities, may be so reduced  as  to fit the smallest.  The limb
being surrounded by this, all that remains is to direct the pressure upon
the artery, by means of a screw.  The pads are made of box-ivood, and the 
TRACHEA.                          691
busk is covered Avith a sheathing of india-rubber, so as not to absorb mois-
ture.                                                Part xxxv., p. 87.
  Vide Mr. Guthrie's remarks on, Art. "Amputation."
                         TRACHEA.
  Removal of Foreign Bodies from  the Trachea.—The case of Mr. Bru-
nei, in Avhose windpipe a half-sovereign Avas accidentally lodged, has given
rise to one or two practical suggestions Avhich on future occasions will be
found valuable.   Although the symptoms in  such case may not be imme-
diately dangerous, disease of the lungs  would  very probably take  place
sooner or later, and, therefore, it would be ahvays wise to take the neces-
sary steps for the removal of such a foreign body without loss of time.
The opening of the trachea in Mr. Brunei's case  ansAvered one important
end, viz., it enabled the patient  to be inverted Avithout giving  rise to vio-
lent symptoms of suffocation, Avhich took place on this change  of position
before this orifice Avas made.  From this circumstance Sir B. Brodie comes
to the conclusion that in all similar cases Avhere it is necessary to invert
the body for the sake of dislodging a foreign  substance from the lower part
of the windpipe, or its bifurcations, tracheotomy ought always to be pre-
viously performed.  This will always act like a safety-valve to prevent suf-
focation, and will also enable the practitioner to manipulate Avith the forceps
or any other instrument that he may wdsh  to use.  At the same time it
will be seen from the experience of Mr. Erichsen that such an  opening in
the trachea does  not materially diminish  the irritability and contractility
of the glottis; and for this reason he has suggested an instrument Avhich
will answer the  double purpose of intercepting any foreign body ivhich
might fall downward toward the larynx during the inverted position of the
body, and of a scoop, so as to extract the substance when it is caught in its
net.   " It consists of a pair of cross-action forceps, the blades of which ter-
minate in branches 2\ inches in length, and slightly bowed at the extremi-
ties ; within the boAved part is inserted a piece of delicate but  strong net;
the forceps open to the extent of three quarters of  an inch, ivhich wdll be
sufficient to obstruct all passage through the windpipe in the ordinary situ-
ations for tracheotomy."   When the patient is inverted it is evident that
any foreign body would be very likely to  fall into this net, and  might theu
be removed at once, or by a pair of common  forceps.   Part viii.,/?. 124.
   Cases  of Spontaneous Expmlsion of  Foreign Bodies from  the Air-
Passages.—A case of spontaneous expulsion and subsequent  recovery is
given  by Mr. Plant, in the Dublin Hospital Reports.  A piece of wood
had  been passed into the trachea, and at first had lodged in the right
bronchus.  At the end of four Aveeks, during which  time  the boy had  suf-
fered much from troublesome cough, it was thrown  up from  the bronchus
mto the trachea,  wdiere it could  be detected moving up  and  down.  As
there appeared to be no particular danger, Mr. Plant, trusting that, as it
had been thrown up from its first situation, it might also be ejected from
the trachea, deferred operating.   At the end of the fifth week it was so,
and the boy recovered.  Another case of-this nature is given by Stalpart
Vahder Wiel.  A small piece of bone passed into the trachea  of a girl 
692                           TRACHEA.
while she was engaged in supping bouillon. The symptoms were constant
cough, fever, and ultimately hemoptysis, Avith  purulent  expectoration.
At  the end of four months the bone ivas coughed up, and the  girl re-
covered.  Mr. Howship relates a case in which a nail had passed into the
trachea of a man aged 65.  The accident occurred on the 15th of August;
severe pulmonary symptoms followed, and tne man Avas giA-en up by the
faculty, but the nail Avas discharged on the 12th November, the patient
recovered,  and was alive twelve years afterAvard, though subject to fre-
quent pulmonary affections.  In a case given by  Dr. Lettesom, the cover-
ing of a button remained  in the  air-passages for eight months, when  it
was coughed up, and  the pulmonary symptoms subsided.  The admission
of an ear of grass into the air-passages appears not to he an  uncommon
accident, and almost  invariably gives rise to very distressing  symptoms.
Dr. Donaldson, of Ayr, relates one of this description, in which the grass
remained in  the  right bronchus for seven weeks, giving rise to intense
bronchitis; it was then expectorated, and the patient recovered.
                                                     Part xii, p.  186.
  Case in which the Larynx of a  Goose was Impacted in the  Trachea of
a Child.—The children in Dr. Buroiv's vicinity are very fond  of blowing
through  the  larynx of a recently-killed goose, in order  to produce some
imitation of the sound emitted by this animal.   When given to them for
that purpose, it has usually ten or twelve rings  of the trachea connected
with it.  ,
  A boy, aged 12, while so engaged (Nov.  1,  1848), was seized wdth a
cough, and SAvallowred the instrument; a sense of suffocation immediately
ensued, which was, after a  while, replaced by great dyspnoea.   Dr. Burow
found him laboring under this eighteen  hours  after, his  face swollen, of a
bluish-red color, and covered with perspiration.  At every inspiration, the
muscles of the neqk contracted spasmodically,"and a clear Avhistling sound
was heard ; and at each inspiration, a hoarse sound, not very unlike that of
a goose, was emitted.  As, on passing the finger down to the rima glottidis,
it Avas found closed, Dr. Burow felt convinced (improbable as, from the
relative  size  of the two bodies, it seemed) that the larynx of the goose had
passed through it. Tracheotomy ivas at once performed ; but owing  to
the homogeneousness of structures of the foreign body and of the part it
ivas in contact Avith, the greatest difficulty existed in distinguishing it by
the forceps.   Moreover, so  sensitive ivas the mucous membrane, that the
instant an instrument touched it, violent efforts at vomiting were pro-
duced, and the entire larynx Avas draAvn up behind the root of the tongue.
At last,  after repeated  attempts, Dr. BuroAV having fixed the larynx in
the neck by his forefinger, so that it could no longer be drawn  up on these
occasions, he contrived to reniOA'e the entire larynx of the animal.  The
child Avas quite well by the ninth day.                  Part  xxi, p. 203.

  Improved Mode of Applying Nitrate of Silver to the Interior of the
Larynx and Trachea.—To apply nitrate of silver to the trachea, use an
instrument having a small grindstone, five  or six  inches in diameter,
ivhich, being caused  to be  rapidly revolved by means of a  pulley and
strap, and the salt being placed  upon  it, a fine dust is thrown  from it,
ivhich, by the mouth  being  opened and the breath drawn in, is  placed in
direct contact with the  diseased-surface of the trachea or larynx.
                                                    Part xxii., p. 150. 
TRACHEOTOMY.
693
                   TRACHEOTOMx.

  Tracheotomy.—[The larynx occasionally requires to be opened during
the existence of ulceration on some of its upper portions.   When this has
been accomplished, Mr. Listen recommends that the surgeon should touch
the parts with a solution of nitrate of silver, by means of a piece of sponge
at the end of a bent probe, carried upward through the wound in the throat.
It may happen that it is not necessary to open the trachea, but only to
make an orifice in the crico-thyroid membrane.]
  In cases Avhere  there is obstruction  at  the rima glottidis, as where
swelling has followed a  scald  of  the glottis, the  high  operation might
answer, and in cases where  a foreign body, not of large size, is lodged in
the ventricle of the larynx, an  opening in  the  crico-thyroid membrane
misht suffice,  and it is much simpler than tracheotomy.   It can be done
at once with  any pointed instrument that comes readiest to  hand, as a
penknife, and  Avithout any great incision.  You feel for the space between-
the cricoid and thyroid cartilages, and there make a longitudinal incision,
right into the  tube.  This might be resorted to where a person  is  suffering
from the lodgment of a foreign body in the oesophagus, and in  such cases
it has been done successfully too.  A patient may labor under serious and
alarming obstruction of breathing  in consequence of some large body
pressing on the back of the trachea, and you may have nothing at hand to
displace or extract it, but you  may save the patient, in the meantime, by
performing laryngotomy, and allowing him to breathe until you can examine
what the foreign body is, and take proper  means for its removal. In the
majority of cases the operation of  tracheotomy is to  be preferred, -as for
the extraction of loose foreign bodies, or of those lodged in the lower part
of the  canal.   In all diseases of the larynx  and  glottis you will also act
more wisely by opening the windpipe.   You thus get a large opening, and
in apart of the canal wdiich you are certain is quite pervious and clear; you
thus insure the free breathing of the patient.
  This operation, as I said before, is one not  attended with great  difficulty
or danger.  The Avound can be  made  down upon the windpipe Avithout
involving any vessel of importance.  There are sometimes  arterial branches
running across the windpipe ; but this is very rare.
  There is no  muscular substance to divide; but there  are a feAv veins,
lying over the windpipe and the thyroid body, to be avoided.   The wound
heals immediately;  everything is in favor of it, and  it is, therefore,  very
different from a wound across the Avindpipe.
  If you make an opening to extract a foreign  body, and succeed, the
wound will heal as far as you Avish it to do ;  you must, in fact, try to keep
it open for some time ; you must not dream of sewing it up, because blood,
even in a small quantity, might  insinuate  itself into the  windpipe, or be-
come infiltrated in the cellular tissue, or collect in the cavity of the Ayound,
and  cause  injurious or  fatal  pressure: you put a bit of lint betAvixt its
edges,  and cover the surface of the Avound Avith a pledget dipped in cold
water, which is to be frequently  renewed.  After the incision  has  been
made six or eight hours, you  may then bring it  together, or apply  some
strips  of plaster:  it will generally heal Avith  great rapidity.   You find
in cases where a  foreign body has been lodged in  the Avound for many
days or for many weeks, or even  months, that, upon its withdrawal, the 
694
TRACHEOTOMY.
parts contract so  much  that, in  twenty-four hours, if it were necessary
to introduce  an  instrument again, you Avill find it very difficult to accom-
plish.
   There is no difficulty in  getting doAvn to the lvindpipe in an adult pa-
tient, if he is  at all steady, and av tiling, as most patients Avho have suffered
from difficulty of breathing are,  to submit to the operation.  You place
the  patient on a chair (this is better than the recumbent  position), turn
his head back, and have an assistant to support it.  You make an incision
from the top of the sternum upward, toward the cricoid  cartilage, fully an
inch in length, through the skin and the subjacent tissue.   You expose, at
once, the  sternohyoid muscles, and cut betAveen them, push the veins out
of their place  doAvnward, clear  the windpipe  upward, by pushing the
isthmus of the thyroid body out of the lvay, if it is there, and then you are
quite prepared to cut into the passage.  You desire the patient to swalloAV
his saliva, and, taking advantage  of the windpipe being pulled doAvmvard,
you push  the knife into it at once, with the back toward  the top of the
sternum, and, by a little savving motion, divide three or four of the rings.
There is generally no difficulty in doing this, and no bleeding; but if any
vessel be Avounded you may tie  it,  or  Avait  a little before you  open the
windpipe.  If you operate for the extraction of a foreign body, the proba-
bility is that  it Avill slip out of itself at once ; by the relief of the respiration,
and the cessation of struggling and exertion on the part of the patient, the
bleeding,   principally  venous,  ivill cease immediately.   If there is  any
arterial bleeding, you will take care to arrest it; you then dress the Avound,
and allow it to come together in due  time.  If you operate for  an ob-
struction at the top of the windpipe, you  must  keep the opening in the
tube pervious ; and  for this purpose  you introduce a properly-formed
canula.  Veterinary surgeons do  not hesitate to cut a large square hole in
the trachea, and some surgeons, practising on the human body, have pro-
posed to cut out an oval piece of the  rings and their connecting mem-
brane ; but that is, at least, quite unnecessary, and, indeed, it may be
hurtful, by leading to an after contraction of the windpipe.
   In children you may sometimes find  difficulty in performing the opera-
tion.  The neck is short, and often very fat.   The space in which you cut
is very limited; the windpipe also is exceedingly small, and in  all cases
where the operation is  required, the  breathing is embarrassed, and the
parts are in constant  motion.   You  must have the patient avcII secured ;
you cut down  upon  the fore  part  of the neck, right in the median line,
expose the sternohyoid muscles, separate the  connecting cellular tissue,
and clear  the trachea.  You  cannot make a young subject elevate the
windpipe well or certainly, by SAvallowing  his  saliva; you must therefore
Stretch and fix the tube before cutting  into it; you do this by putting a
sharp hook in it.  You then pull the larynx upivard, push in your knife, and
make a sufficient opening.
   In some individuals, when the operation is  performed  for disease at
the  rima   glottidis, the canula  may soon  be  removed safely, and the
wound permitted to heal; but  sometimes it  must  be  wrorn for several
weeks.
   The same  precautions are to  be  observed here as in wounds after the
patient has  attempted  suicide;   the  Avound  must  have  a covering of
loose texture to prevent cold air getting into the  passages.
                                                      Part xi.,p. 171. 
TRACHEOTOMY.
695
  Trac/ieotomy.—When the operation of tracheotomy is to be performed,
says Professor Oolles, you will find  things in  a different condition from
what you might suppose from performing it on the dead subject.  It is all
very ivell to say, throw the head back, and give yourself room, but you
cannot put your patient into the position  you wrould wish, on account of
the difficulty of breathing; it is so great that he cannot bear such a positiou
an instant, and that in Avhich you find him is generally a bad one, for he is
leaning forward; aud you must put  up Avith the inconvenience.
                                                     Part xii., p. 186.
  Tracheotomy in Acute Diseases of the Larynx or Trachea.—M. Trous-
geau nas recorded the results of his experience in 121 cases of croup, in
which tracheotomy was performed.   He advocates  the rather  early per-
formance of the operation.
  If you cannot avoid the thyroid veins, cut straight through them;  the
hemorrhage ceases on the introduction of the canula.   If the case be not
very urgent, keep the edges of the wound apart by some instrument, for
a short time before introducing the canula, in order to alloAv of false  mem-
branes being expelled.  You may expedite this by dropping water into
the bronchi, and sponging the trachea.  If the canula become obstructed,
remove  it  immediately and empty it, and when the canula is withdrawn
introduce the dilator.  After the fourth or fifth day, diminish the size of
the canula, and by the thirtieth day,  it maybe dispensed Avith.  Drop into
the air-passages, fifteen or twenty drops of a solution of nitrate of  silver
(gr. v. to |j.), and cleanse the trachea Avith a sponge dipped in the same
solution.                                             Pari xiii., p. 237.
   Tracheotomy.—Dr. Marshall  Hall observes as follows: In every case
the first thing  to be  done is  to make  an  incision  of appropriate length
through the  integuments  merely.  All  the  other tissues down to  the
trachea are  to be pushed aside without further incision, which may be done
without the slightest hemorrhage.  For this purpose either an eye-probe
may be used, or the  double-acting forceps closed.   Either of these  being
introduced, and gently moved  in different directions, the trachea is at
length laid  bare, and this part is kept exposed by applying and expanding
the forceps.
  At  this  moment, either an incision may be made into the trachea, by
means of a minute scalpel, such as is used in  operations on the eye, and
this incision may be kept open, by means of the  double-acting forceps,
whilst a silver  tube is introduced; or the tenaculum canula maybe applied,
and a  portion of the trachea removed, and the tube may be inserted, or not,
according to the views of the operator.                Part xix., p. 151.

  Indication for  the Performance of Tracheotomy.—Dr. G.  H.  Rees
eays:  Do not  operate  for croup or laryngitis in  children if the ribs are
motionless during inspiration, as this indicates that effusion has taken place
into the pulmonary  tissues.  If the lungs Avere free,  the  ribs Avould be
pressed inward or backward by the external  atmospheric pressure, when
attempts were made at inspiration while there was some serious obstruction
to the air-passages.
  If the altered  movement be considerable,  the lungs are yet  free, and
incision may afford relief.                               Part xx.,  p. 83.
  Tracheotomy.—[If there is a necessity for  enlarging the Avound  in the 
696
TRACHEOTOMY.
  tracheotomy to introduce the canula, the knife should be carried upward,
  and not below.   The reason of this, says Prof. Fergusson, is, that]
    There is always much less danger in carrying your incisions upward, in
  this operation, than in cutting at the loAver part of the wound; for, if yon
  happen  to get very low doAvn, you might come in contact with important
  blood-vessels; the arteria innominate, in some  cases, rises very hi<>h, and
  that might be wounded; but more especially might the vena innominata
  be in  the way.   At the  upper  part of the wound  you may cut without
  much  fear; it is  true, there is the isthmus of the thyroid body in the way;
  but this does not  matter  much, so that you  keep exactly in the median
  line.  You must not misunderstand me, and fancy that I would wish you
  to cut through the isthmus.  You ought, if possible, in opening the trachea,
  to get below this process on all occasions ; but it is not easy or judicious
  to do  so in many instances.  In  the case under notice, the neck Avas very
  short, and I was obliged to divide the isthmus of the thyroid body.  It is
  most important to recollect these tAvo points  in performing the operation
  of tracheotomy : in  the first place, not to use your knife freely at the loAver
  part of the wound; and  to take especial care not to deviate from the mid-
  dle line.                                            Part xxv., p. 197.
     Tracheotomy.—Dr. Gerson, of  Hamburg, has invented  an  instrument
  wdiich  is  similar to  a   three branched  speculum  in principle, for the
  purpose of opening the trachea without risk of hemorrhage.
                                                      Part xxvi., p. 336.
     Tracheotomy.—Recommended by Dr. Marshall Hall, in cases of hydro-
  phobia. -                                            Part xxvii., p. 59.
     Impromptu Tracheotomy.—If you are called suddenly to a case requir-
  ing tracheotomy, without  proper instruments, take  a pair  of pointed
  scissors, and, the integuments having been divided with a lancet or sharp
  penknife, pierce the trachea ivith the scissors, and separate the blades. You
*  may then insert the handle  of  a teaspoon and turn it one  quarter or half
  way round.                                         Part xxx., p. 132.
     Tracheotomy.—When the trachea has to be  opened to extract a foreign
  body, don't be  satisfied with making a mere  slit, but make a  sufficiently
  large valve-like aperture, larger than the size of the body ivhich has passed.
                                                       Part xxx., p. 133.
     Dr. Marshall Hall's Tracheotomy Scissors.—To facilitate this operation
  both  in epilepsy, hydrophobia, and other cases, Dr. H. invented a  pair of
  scissors, made so as first  to divide the  skin over the trachea, and then beinq;
  pushed into the tube and  the  blade  opened, as large an aperture maybe
  made as required.  An  instrument called a cage is then introduced so as
  to keep the orifice open.                              Part xxx., p. 271.
     Tracheotomy.—Before opening the ivindpipe, always introduce a hook
  into one side, so as to keep the part  steady.   The opening is  then made
  much more  easily, and the  orifice  kept  open and prominent for the intro-
  duction of the canula.                               Part xxxi, p. 226.
     Tracheotomy.—Mr. T. S. Wells, of Samaritan hospital,  recommends to
  fix the trachea  by passing a tenaculum, grooved on  its  convex  surface,
  beneath the lower edge  of the cricoid cartilage ; by this the trachea must
   be draAvn upAvard and forward; then pass a knife  along the groove, and 
TRACHEOTOMY.
697
divide three or four of the tracheal rings:  nothing can be easier, simpler,
or safer, if the hook be used to fix the trachea.        Part xxxv., p. 93.

  Tracheotomy.—[We must admit that tracheotomy is a heroic  remedy,
and only appropriate  to  Herculean forms of disease.  But Dr. Marshall
Hall says :]
  I am persuaded that life may be saved, Avhere imminently  threatened,
by a simple  pair of pointed  scissors.  The integument, being taken  up
horizontally by the thumb and finger of the left hand, should, be divided
longitudinally by the scissors; these should then be promptly  forced into
the trachea, to the proper depth, and opened  horizontally to the  just ex-
tent ; the scissors must be then  turned, being kept  in their place, and
opened in the direction longitudinally; the operator has thus made, in a
tittle more than a moment of time, an  opening through which the patient
may breathe until  further appliances can be obtained.
  The scissors would be better if they were notched on the external edge,
so as to prevent them passing too  deeply.  The opening  made  must be
kept patent: a tracheotome made of silver wire, capable of being intro-
duced readily and expanding within  the edges of the opening,  is undoubt-
edly the best of any.                                Part xxxv., p. 94.

  Foreign Bodies in the Air Passages.—Tracheotomy.—An ingenious
and advantageous plan of operating in these cases,  is to lift up a piece of
the trachea like a  flap, Avith a common tenaculum, after the tube has been
laid bare, and then, havdng allowed the foreign body to be expelled, to drop
the flap down again into its original position.         Part xxxvi., p. 170.

  Foreign Bodies in the  Trachea—Tracheotomy.—In performing trache-
otomy for a foreign body in the air tube, says Mr. J. Adams, if the offend-
ing substance does not escape  at the time of operation, or cannot be dis-
covered, the tracheal tube is not  adapted  to maintain the patency of the
opening  made, as a foreign body could not readily escape through it.   A
strong metallic Avire speculum, something like those used in operations on
the eye, as invented by M. Luer, of Paris, could be easily modified so as to
maintain the patency of  the opening, and at the same time alloAv of the
exit of any offending body.   If  such an instrument Avere used in case of
croup, any false membrane making its appearance at the  opening could be
extracted.   The complete arre>t of all  hemorrhage would be  necessary
before an opening Avas made into the trachea, as the passage of blood into
that tube would not be prevented by the speculum.  Part xxxviii., p. 147.

  Foreign Bodies in the  Trachea.— Tracheotomy.—The opening required,
says Mr. F. C. Skey, is large, in fact, sometimes as large as it can  be made,
if in a child of four or five years of age.  There is no increase of danger or
difficulty in  making a large opening instead of a small one.  It is little or
no  use employing forceps of any kind for the purpose  of  extracting  the
offeiuling body, it is preferable to await  the return  of cough, which in the
act of expiration, will inevitably carry the foreign body with the current
of  air through the larger and nearer orifice, in preference to the smaller
and more remote one.                                 Part lx., p. 275. 
698
TRANSFUSION.
                      TRANSFUSION.
  Transfusion of Blood.—Dr. Pilchard mentions the case of a gentleman
who had  been reduced  to  an exhausted  and exsanguineous state by a
long continued draining of the system through the kidneys.
  " His early complaints had  been of dyspeptic  symptoms.   These Avere
folloAved by emaciation and loss of strength.  His actual state was that of
extreme inanition ; his pulse Avas feeble, jerking, very compressible, the cali-
bre of the artery apparently not filled ;  he had palpitation of the heart, in-
creased by the slightest exertion, while any effort brought on an approach to
syncope.  No disease ivas discoverable by the sounds of the  heart or res-
piratory organs, though some suspicion Avas entertained of slight dilatation.
  " The state of the urine alone threw some light on the nature of the disease.
It had long deposited a very copious sediment, of a whitish color, slightly
tinged Avith purple, which Avas redissolved by dilution, Avith  the addition
of an alkali.  It appeared to consist of lithates,  Avith  some chyle;  it Avas
thought probable by the medical gentleman Avho  had previously attended
the patient,  and by myself at our first meeting, that an exhausted and  ex-
sanguineous state, brought on by a long continued draining of the system,
constituted the principal disease, or at least that which  first required atten-
tion.  Under these  circumstances, it Avas determined to try a restorative
and repletive plan.   A nourishing diet was ordered, with malt liquor and
some other stimulants. His stomach would receive but little, and at length
rejected food.  His  exhaustion increased to  that degree that immediate
fatal syncope Avas threatened.  We determined, the patient being obviously
in extremis, to try the effect of transfusion, and as patients under cholera
had borne the injection of large quantities  of fluid,  there seemed to be no
danger in injecting a considerable quantity  of blood. Sixteen ounces Avere
taken  from the veins of a hale  young  man,  a servant of the patient, and
were injected most  skillfully by Mr. Clark.   The patient Avas immediately
revived and roused.  On the following day he appeared  much stronger,
but complained of some  sense of fullness about his head, and a few drops
of blood escaped several times from the nostrils.  This subsided; his  ap-
petite became good, and he ate plentiful meals of meat, and drank porter,
etc.  He gradually recovered his  strength.  The urine improved  under  the
use of alkalies with lime-water, and these were nearly all the remedies used
except a feAv bottles of an effervescing  solution of citrate of iron.  After
tAvo or three months he  left his  chamber, and then his house, and is now
travelling on commercial business."                     Part viii., p. 78.

   Case of Tranfusion.—[Mr. Brown  relates a case of transfusion Avhich
he performed in November, 1837.  His patient, wdio had been  subject to
epilepsy, Avas suddenly attacked, during labor, ivith most alarming prostra-
tion.   The child's head was opened and delivery  speedily effected, but she
did not rally ;  the lochial discharge was not more than usual.  Stimulants
were given, and friction along  the spine  made  use of, with other means
tikelv to restore her, but ivithout effect.   Mr. Brown then recommended
transfusion, although he  very much doubted  its efficacy.  He describes the
operation and its effects as follows :]
   Maw's  instrument was the one employed; the central cup, designed to
hold the blood, was surrounded by hot water, intentionally made two de-
crees  above the temperature of the fluid.   I took from the  woman about 
TRANSFUSION.
699
 giv., Avhich were  received in the prepared vessel, and in the quickest man-
 ner I could, Avhilemy assistant was engaged in receiving the blood into the
 apparatus, I punctured the right  basilic  vein  of the patient, and  most
 readily (after sending a stream of blood through the instrument, to expel
 the atmospheric air Avhich it contained) passed the extremity of the tube
 into the vein.   The piston ivas sloivly Avorked : after its second movement
 the  patient expressed that  she could feel  the  tranfused blood " go along
 her arm into the heart, and quite  warm it."  Before I had injected the
 remainder of the  blood, she  gradually improved both in  color and in
 warmth, and avowed her delight that I Avas  no longer of a "green  color,
 but quite right."   Her  subsequent  recovery took place without any unto-
 ward symptoms.                                      Part xiii., p. 341.

   Operation of Transfusion of Blood.—Dr. Routh has collected together
 all the recorded cases in Avhich transfusion  was performed, and from these
 data has come to  conclusions very favorable to the performance of the ope-
 ration.  According to him it should be employed—
   Firstly. In all cases of collapse induced by hemorrhage, whether primary
 or secondary.
   Secondly. In that state  of extreme exhaustion from  dyspepsia, where
 collapse is imminent, it might be  advantageously employed.  There are
 many cases in Avhich dyspepsia has  persisted for a long time, and perhaps
 been neglected, and where,  notAvithstanding, no organic disease can be de-
 tected ; in Avhich no food can be retained on the stomach, and the remedies
 employed are  poAverless.   He e  the  patient  will  sink from inanition, if
 something is not done.  In these cases it is highly probable, that Avere the
 operation more frequently  resorted  to, life  might often  be saved.   Dr.
 Blundell kept a dog alive  three weeks, by consecutively transfusing the
 blood of another dog in his veins.
   Thirdly. In  some cases of stricture of oesophagus, where no food can be
 taken, to give the patient time to rally, so as  to admit  the introduction of
 bougies subsequently.
   Fourthly. In the collapse which folloAvs long-continued fevers, more espe-
 cially those  of a  typhoid,  character,  produced frequently  by supervening
 diarrhoea, or by the  crisis  of the  disorder.  It is exceedingly probable,
 transfusion here might be  most advantageous.
   Fifthly. In the  collapse, or great  exhaustion following diarrhoea, dysen-
 tery, and  cholera.
   As a rule, the quantity transfused should  not be less  than 6 oz., nor more
 than 16 oz.
   The operation may be executed in three Avays: 1. By receiving the blood
 in a vessel, and alloAving if to enter  the body by gravitation.  2. By inter-
 posing a tube betAveen the blood-vessels of the emittent and recipient per-
 sons,  and trusting  to the force  of the  circulation for the  transmission.
 Both  these  methods  have  given place to the third or injecting  process,
 which is effected by the  stop-cock stomach pump;  but, instead of the tube
 through Avhich  the pump Avould be  filled, there is a funnel-shaped basin to
 receive the blood.   Much nicety is required in its make.
   " So little is the theory of transfusion understood by instrument makers
in general, that instruments are  made  and sold for the purpose that are
wholly inapplicable.   The basin should be cased like a plate, that it might
contain hot water.  The piston should fit accurate1;.-, and at the same time 
700
TUBERCLES.
work freely.   I think that an interruption by some elastic  material in the
tube that is to convey the blood, is advisable, for then the pipe that is in-
serted into the vein is less likely to be disturbed by any motions which may
arise in  the working of the syringe Or movements  of the patient.   At least
three persons  are required for the safe and efficient performance of the ope-
ration, and their attention should be wholly given to it.  Supposing every-
thing ready, the instrument quite clean, air-tight, and thoroughly warmed,
the basin filled ivith hot water, a vein in the patient's arm  should be punc-
tured, and  the finger applied to the orifice till the tube is ready to be in-
sert  d.   It is quite unnecessary to  dissect out a vein, and place a probe
under it before making the puncture, as has been  recommended.   A vein
in the arm from which the .blood is to be taken, is next to be opened by a
fine cut, and  the stream directed  into  the centre of the basin,  the arm
being held close to it.  When sufficient has entered, the syringe should be
filled, and  the piston pushed in a little till blood Aoavs at the end of the
pipe, Avhich is then  to  be  introduced into the vein.  The injector now
works the syringe  till the desired quantity has  been throAvn in.  There
should be no cessation to the  stream of blood  entering the basin till the
operation is ended, so that after each occasion of the  syringe  being filled,
there may  be at least an ounce of blood at the bottom of the basin, or else
air Avould  probably be sucked  in.  The accident to  guard against is the
transmission of air.  The greater facility wdth ivhich this is likely to occur
when transfusion is performed through the jugular vein, points out the im-
propriety of selecting this vein for the operation.   It would be worse than
useless  to attempt  to transfuse  unless an expert bleeder be procured.
Much of the  success of the  operation depends on the dispatch, as ivell  as
the  steady and uninterrupted course that is pursued ; for, Avith the disad-
vantage of the blood travelling over dead surfaces, very little exposure of
it to air must be apt to destroy vitality.                 Part xx.,p. 130.


                               —'" *

                        TUBERCLES.
   M. Lombard's  Conclusions regarding Tubercles.—1. Tubercle is a se-
creted substance, deposited under the form of yelloAvish opaque grains.  It
grows by superposition.  2. There are two species of tubercles, the simple
and the multiple ;  the latter forms by the  aggregation  of several simple
tubercles.  It contains organized parts within.  3. Granulations are a form
of chronic pneumonia; they do not pass into tubercles.  4. The  softening
of a tubercle depends  on the action of  the surrounding  living  parts.
5. Simple  tubercle  never softens  from the centre to the circumference.
6. The multiple  tubercle  often  softens from the centre to the. circumfer-
ence.   1. The most frequent  seat of tubercle is the cellular tissue.  Tuber-
cle is sometimes to be seen in the lymphatic Aessels.  Tubercle  does  not
occur  on  the free  surface of mucous membrane so long  as it  is entire.
8. Tubercles are often hereditary.  9. The lymphatic and sanguineo-ner-
vous temperaments are predisposed to tubercles.   10. Infants and females
are most subject to  tubercular diseases.  11. Inflammation  is an  exciting
cause of tubercles.   12. The  same is to be said of passive congestions, of
over-activity  or deficient  activity of an organ, and probably also  of the
alterations of the fluids.  13. No certain  sign of the rise of tubercles is 
TUMORS.
701
known.   14. The hectic fever which occurs in tubercular  diseases results
from the act of elimination.  15. To prevent the tendency to tubercles, Ave
must counteract  the  influence of hereditary disposition, of temperament,
of age, of sex.   16. In persons with predisposition to tubercles, inflamma-
tions should be  guarded  against AAdth the greatest care, or arrested as
promptly as possible.  17. The  same rules apply to passive  congestions.
18. The absorption of tubercles is very probable.   19. To obtain  the cure
of tuberculous ulcerations Ave must prevent the formation of neAV tuber-
cles, and confine  the work of elimination Avithin certain limits'.   20. Tuber-
cles may remain long in the organs in a latent  state ; to obtain  this result
Ave must seek to arrest the process of elimination by antiphlogistic means,
and above all by revulsives.                              Part xl, p. 52<
                          TUMORS.
  Erectile Tumor Cured by Vaccination.—A child  thirteen months old
(not vaccinated), had a small erectile tumor over  the  left  eyebroAv.  M.
Pigeaux  inserted nine  points  of Aaccine matter  over its whole  surface.
The vaccine eruption Avas confluent on the  tumor,  but  folloAved its usual
course; on the 25th day the scabs fell off, and nine-tenths of the tumor
had disappeared.  The surfiice of the'tumor was noAV poAvdered Avith alum,
and the scab Avas removed every four or five days, to permit a fresh appli-
cation of  the poAvder.   At the end  of three Aveeks  the  wdiole of the erec-
tile tissue Avas destroyed;  the  bottom of the Avound  threw up  healthy
granulations, and in seven weeks it Avas completely healed.  For the suc-
cess of an operation of this kind, it is necessary that the points of insertion
be sufficiently  numerous to produce a confluent  pock;  and should any
portion of erectile tissue remain after the  remoAral of the scabs, it must be
destroyed by some caustic like the poAvdered alum.       Part vii., p. 168.
  Mode of Taking out a.Fatty or Steatomatous Tumor from the Breast.—
On this  subject Sir B. Brodie  says: We know  of no  internal medicine,
nor of any local application that will disperse these tumors, and the only
thing to be done is to remove them by the knife. This may be done when
the tumor is quite small.  I do not, however, generally recommend the
operation at this period; first, because the tumor may never increase, and
as long as it is small  it is  of no consequence; and secondly, because the
operation is really more easy Avhen the tumor has  attained a certain size.
Still, it is better not to let the tumor go to any very large size;  and for
this reason, lest the pressure of the  skin should cause it to contract ad-
hesions to the neighboring parts.  Where such adhesions have taken place
the operation is rendered difficult, and you cannot be Certain that  you do
not leave some small portion of it, which may be the nucleus of a future
growth.  As soon, then, as  the tumor becomes large enough to be trouble-
some from its bulk, you may dissect it out; and this is  a  simple operation
if you knoAV how to do it, and  very difficult otherwise.  Make a  free in-
cision of  the skin, not upon the tumor, but into it, cutting fairly into its
substance.  Do not spare the incision  through the skin,  but let it extend
from one end to the other.   Then lay aside your knife, and you wdll find
that with the fingers  you can   easily separate  the  cyst that contains the
adipose matter from the neighboring textures, pulling  out one lobe after 
702
TUMORS.
another, till at last the tumor remains attached only at one corner, that  is,
at the point at which the vessels run in and out.  You have no bleeding in
any other part of the operation, but in this last part of it you Avill generally
find one or tAvo arteries which you must secure by ligature.  AVhen the
tumor is situated under a muscle, the operation is'to be performed in the
same Avay, with this exception, that besides laying open the skin, you must
freely divide the muscle, cutting across the fibres.
   [Sir Benjamin gives a curious case, ivdiieh illustrates  the value of liquor
potassas in some of these fatty deposits.  It is as follows :]
   A man came to this hospital some seventeen or eighteen years ago, Avith
a very odd  appearance—an enormous double chin, hanging nearly doAvn
to the sternum, and an immense swelling at the back  part of the neck—
tAvo great tumors  as  big as  oranges sticking out, one behind each ear.
The patient stated that these tumors had begun to form three or four years
before, and had been gradually increasing in size.  They gave  him no
pain, but they made him miserable, and in fact had ruined him.  The  poor
telloAV Avas a gentleman's servant, and having such a  strange, grotesque
appearance, nobody would hire him.  I gave  him half a drachm of liquor
potassas three times a day, and gradually increased the dose to a drachm.
This was taken in small beer.  About a month after he began to  take it,
the  tumors were  sensibly diminished  in size.   He Avent on  taking the
alkali  a considerable  time, and the tumors continued decreasing.  It was
just then that iodine began to  have  a sort  of reputation, much beyond
Avhat it deserved, for tile cure of morbid growths, and I gave him the
tincture of iodine. It Avas curious that Avhile he took the tincture of iodine
he lost flesh generally, but the tumors began  to groAV again.  Finding this
to be the case, I left off the iodine, and  gave him the liquor potassas a
second  time.  He took an  immense quantity altogether, and left the hos-
pital \-ery much  improved, being directed to continue to take the medicine
for some time longer,  off and on.   I had lost sight of  him for some time,
Avhen I happened to be requested to visit a patient  in Mortimer street.  I
did  not observe the servant that opened  the door, but as I came dowm he
stopped me in the hall, and said that  he wished to thank me for what I
had  done for him.   To  my surprise it Avas this very man.  He had  gone
on taking the caustic alkali for a considerable time, and you  may suppose
how much he Avas  improved by his being able to get  a  situation as  foot-
man.  There were some remains still of the tumors, but  nothing that any
one Avould have observed.                              Part ix., p. 117.

  Sanguineous Tumors on the Heads  of Newborn Infants.—[Mr. Adams
has met wdth several cases of a rare form of infantile pathology, wdiich  is
scarcely  mentioned by British authors.  All obstetric practitioners are
acquainted with  the caput  succedaneum, as  it is  usually termed—a soft
tumor formed by effusion of the serum of the  blood at the presenting part
of the child's head, and  which, though  usually requiring none but the
simplest treatment, sometimes, though rarely, inflames  and gives rise to
abscess.  There is, however, another class of tumors found under the same
circumstances, which, on  account  of  their rarity, have  either attracted
little attention, or have been mistaken for  a totally different pathological
state.  For our knowledge  of these we  are  indebted  entirely to French
and German writers.  They applied various  names to these  tumors, for
which Naegele has substituted Cephalhajmatomata.] 
TUMORS.
703
  Cephallucmatomata may exist in three forms, viz., under the aponeurosis,
under the  pericranium, and  under the bone.  The  first kind,  viz., that
wherein the blood is effused under the aponeurosis formed by the expan-
sion of the occipito-frontalis  muscle,  is generally considered to be of a
simply contusive  character, as evidenced by its mode of production as
well as  by its external and internal anatomical characters.   This  is the
simplest, but at the same time the rarest form of the cephalhematoma.  In
general it disappears rapidly,  and requires only mild  discutient treatment.
The third  variety  in the  above list, the subcranial  cephalhematoma,
which has its seat betAveen the  dura  mater  and  the bone, has  been but
rarely observed, and very little of a satisfactory nature is knoAvn regarding
it.  The  symptoms are those  of cerebral compression, but it is impossible
to diagnose its existence during life, and it can only be guessed at when it
coexists with an external cephalhematoma, which, according to M. Baron,
frequently  happens.   The  second variety,  or that in  which the tumor
exists beneath  the  periosteum, although much more  frequent than  either
of the two preceding, is on  the Avhole  a rare affection.  I place it last, be-
cause it  is  to it I mainly ivish to direct attention, as being the most  in-
teresting in a practical point of view.
   Mr. Adams then relates two of the best  marked cases of the second
variety.  He \vas sent for  to examine the  head of a healthy male child,
Avhich he had delivered eight days before ;  the  presentation was in the
second position of natural labor, and  the duration of labor six  hours, of
which the first stage occupied five. The mother and friends were alarmed
at what they called " a hole in  the child's  skull."  There Avas a soft fluc-
tuating tumor over the left parietal protuberance, which felt as if circum-
scribed by a ridge of bone that seemed to mark the boundary of an open-
ing into the skull.  But, on more careful examination, the  bone could be
felt in the centre of the apparent hole, Avhich, together with the absence
of pulsation, etc.,  satisfied him  that  it Avas  a  case  of cephalhematoma.
Evaporating lotions and slight pressure with  a  bandage were accordingly
used, and in three wreeks the  tumor had entirely disappeared.
   Another  case of exactly the same nature  occurred in the practice of Dr.
Menzies, Avhich was left  to the  efforts of  nature, and recovered without
any treatment.  The presence of a bony ridge,  circumscribing the tumor,
Avhich gives the impression  of an opening in the cranium, is the most strik-
ing peculiarity, and of the greatest practical importance.   The bone Avithin
the circle can generally be felt uninjured on pressing the finger firmly from
the edge to the centre.  The  time the tumor takes to become fully deve-
loped varies from a few hours to  as many days, and  it  seldom disappears
entirely Avithin  four  or five weeks.   Various are the opinions  as  to its
causes, some holding that it is a consequence  of severe labor or the use of
instruments, Avhile others say that Avhen it occurs it is almost always after
very easy labors.
  But the most important researches on this point have been made  by M.
Valleix.  He considers that  cephalhematomata  do  not exist before the
occurrence  of labor, and that  they are the consequence of force or pressure
employed upon the child's head during delivery.  For a right understand-
ing of his vieAvs it is necessary  to advert to  the  anatomy of the parietal
bones in the infant.  At birth the pericranium adheres but slightly to the
bone, with the exception  of a feAv lines at the sutures and fontanelles, and
consequently a  slight force is  sufficient to strip it  off.  In doing so, nu- 
704
TUMORS.
merous vessels are seen to enter the fissures of the bone.  The bone itself
ossifies from one point in the centre, i. e., the parietal protuberance, and
bony radii shoot from the centre to the circumference.  These radii  are
best seen on a dried preparation.   Haller noticed, that on compressing the
head of an  infant even slightly, after removing the pericranium, he saw
springing from between these radiated fibres innumerable drops  of blood,
which, collecting together, formed a thin layer over the bone.   M. P. Du-
bois, after corroborating Haller's experiment, suggested that  the fact fur-
nished a  probable  explanation of  the formation of the bloody tumors of
the  head.   M. Yalleix, after numerous  observations, confirms the theory
of Dubois, and concludes that if pressure, and above all, if circular pressure,
is made upon a jioint of the  cranium, blood ivill spring from the surface of
the bone, and by its upward pressure strip off the pericranium, wdiich is
easily detached ; that as the liquid blood accumulates under this membrane,
new outlets will be opened up for the escape  of more blood, and thus at
length a tumor ivill arise.   Assuming this as a settled point, he considers
that the pressure of the child's head against the mouth of the uterus causes,
according to the  degree  of pressure, either the simple  sero-sanguineous
tumor, an ecchymosis, or  a sub-pericranial cephalhematoma.
   The contents of the tumor may vary in quantity from  a scruple to
nearly eight ounces.   Dr. W. Campbell, in  one case ivhich he punctured,
obtained  a large teaspoonful, and in another half a teaspoonful of slimy
sanguineous matter.
   There are but few diseased appearances occurring on the heads of new-
born infants likely to confuse the diagnosis ;  and it  requires  little more
than a knowledge of the  existence of such  affections, and of their distin-
guishing characters to prevent our falling into error.   A favorable prog-
nosis may in general  be  given.  If, hoAve\-er, the cephalhematoma be of
great size, or remain undiminished for  several weeks, the bone is apt to
become  affected, Avhen, from the excessive discharge, and  the constitu-
tional disturbance attendant upon the extension of the disease to the brain,
death will almost inevitably result.
   Regarding the treatment of cephalhematoma there needs not much be
said.  In many cases—I might  almost  say in  most cases—no treatment is
required, or at least the treatment adopted may be of the simplest descrip-
tion, and used  principally with the view  of preventing the parents or
friends from becoming anxious.   When the tumor is  small, causing no um
easiness, and not threatening to inflame, there may be used  a simple  eva-
porating lotion, such as a  solution of muriate of ammonia  wdth alcohol,
and this treatment may be  conjoined w ith slight pressure.   But wdien the
tumor is large, and does not diminish at the end of a fortnight or three
weeks, these  means  are  likely to fail, and  it may be necessary to adopt
more active measures  to procure absorption or evacuation of its contents.
   [Dr. Zorer, of the Foundling Hospital of Vienna,  employs cold appli-
cations of  calomel Avhen cerebral congestion is  supposed  to  exist,  and
.almost invariably opens the tumor, a most injudicious practice Avhen has-
tily adopted.]
   Lowehhardt recommends puncture Avith a trocar, and strapping; and to
 this plan I am inclined to  give preference, using, however, the ordinary
 kn'fe for subcutaneous puncture instead of the trocar.  Where the  con-
 tents of  the tumor are fluid, it ivill  be equally efficacious, and  the wound
 wi 1 be more  readily disposed to heal by the first intention.   The wound 
TUMORS.
705
must afterward be treated on the ordinary principles, and the simpler tho
dressing the better.   In making  the incision, care must be taken to avoid
the arterial vessels; for, in a case operated on  by M. Valleix, death fol-
lowed the division of a small branch, and Smellie records  a similar unfor-
tunate case which happened in the hands of one of his pupils.
                                                     Part xl, p. 207.
  Encysted Tumors— Cure for Encysted  Tumors, or Wens of the Head,
or  otlier  Parts of the  Body, without Cutting them Out.—First make a
longitudinal cut along  the scalp.  This is performed with little loss of
blood.  Next, press out the contents of the cyst, and apply freely, alcohol
in the cavity, aa ith a camel's-hair brush.   Then  place in the cavity, also,
from tAvo to six grains of nitrate of silver, and bring the  edges together
Avith strappings, wdien inflammation takes place.   Should it inflame too
much, apply cold water dressings, and give a few doses of active purgative
medicine.   This plan, says Dr. Harvey, has ever been found to complete
the cure in a few days.                                 Part xi.,p. 156.

  Pulsating Tumors of Bone.—[Mr. Stanley remarks that there are three
distinct sources of pulsation in the tumors of bone:  1. The proximity of
the tumor to a large artery ;  2. The development of blood-vessels and
blood-cells, constituting a sort of erectile tissue within the  tumor; 3. The
enlargement of the  arteries of the bone in  Avhich the tumor  has arisen.
Of these, the first is by far the most common.  The tumor generally con-
sists of soft, fibrous,  and dense osseous tissue. Such cases have frequently
been mistaken for aneurism, and the principal artery supplying  the part
has in consequence been tied.  On the  subject of pulsation in the tumors
of the bone dependent on the development of blood-vessels and blood-
cells, forming a sort of erectile  tissue Avithin the tumor,  Mr.  Stanley re-
marks, that assuming these  cells to be continuous  Avith the surrounding
arteries, the rush of blood into this structure might give to the whole mass
a pulsation resembling that of aneurism.  Several cases of the third variety
are referred to.  The  density and  resistance of the investments  of the
tumor are specially noticed by the author as appearing to  have a material
influence  in causing pulsation in them, for it may be doubted whether any
of these tumors Avould  pulsate without  the resistance derived from the
bone or its coverings.]
  After some observations tending to sIioav the little value to be attached
to the presence of belloAvs-sound  in the diagnosis between aneurism and
the pulsating tumor  of bone, Mr. S. proceeds to relate the case of pulsating
tumor of the ilium which occurred in St.  Bartholomew's Hospital, in which
a ligature Avas  placed around the common iliac artery.   The patient,  a
man, aged 42, had on the inner side of the right upper arm, a tumor about
the size of a small orange, very loosely connected with the surrounding
structures, free from pain, and Avithout  pulsation.   This tumor was first
observed  about ten years ago, and during the last three years it had ceased
to grow.   The pulsating tumor  of the pelvis had its chief attachment to
the left ilium, and projected from both surfaces of the bone.   It reached
downward to Poupart's ligament, and to the extent of about three inches
iuto the abdomen.  It felt moderately firm, and a little below the crista,
near the  anterior  superior spine, a small movable  piece of bone was dis-
covered apparently involved in the tumor.   Everywhere Avithin reach of
the fingers the tumor pulsated, not with  a thrill of vibration, but with the
  vol. n.—45 
706
TTJMOR8.
deep heavy beat of aneurism.   By the ear resting against the abdominal
parietes, a bellows-sound Avas plainly recognized.  After a minute descrip-
tion of the local features and constitutional phenomena of the disease, the
author observes, that in deciding on the nature and treatment of the case,
the following points Ave re involved—was this pulsating tumor an aneurism ?
and if so, from  what artery had it arisen ; or was it one of the pulsating
tumors of bone ?  He then states the argument which, in consultation, led
to a preponderance of opinion in favor of this tumor being an  aneurism.
In the uncertainty respecting the origin of the supposed aneurism from the
external or internal iliac artery, the decision would  obviously be that the
common iliac should be tied, and the man having decidedly expressed his
feeling in favor of submitting to the operation, the author considered it hia
duty  to undertake it.
   The case proceeded favorably to  the middle  of  the second day, when
symptoms of peritonitis  ensued, and he sunk on the morning of the third
day from the operation.  On examining the body, the effects of peritonitis
were observed in the deeper parts and left side of  the abdomen.  In the
wall of the left ventricle of the heart there was a medullary tumor about
the size of a  filbert.  Medullary matter was found in the bronchial glands,
and a few deposits  of the same kind in the lungs.  A minute description
is given of the tumor in the pelvis, Avhich was connected \vith the ilium,
and composed of a spongy tissue  with cells  and  convoluted vessels dis-
tributed through it.   The tumor  in the arm, which had all the marks of
an innocent structure, was found to the surprise of the author, identical
in structure  with the tumor in the pelvis.
   NotAvithstanding its density, says M. Roux, the osseous structure may
 become the  seat of a transformation similar to that ivhich, in the soft
parts, constitutes  sanguineous  (erectile) tumors.   The capillary vessels,
 more especially those Avhich depend on the arterial system, become extra-
 ordinarily developed.   Perhaps Avhen they are thus amplified, the network
 which they form naturally may assume a different  arrangement; perhaps
 the capillaries are differently interlaced, anastomosed.   However this may
 be, as  these  capillaries become dilated and filled  wdth  blood, the bone
 softens, swells, and probably there is destruction of the proper fibres of the
 thin  lamelle which  constitute its substance.   At  last,  the disease pro-
 gresses to such an  extent that the external lamelle of the bone, even those
formed by the compact  tissue, are reduced to  a kind of thin, flexible  en-
 velope, through which the pulsations of the tumor  may be felt, and Avhich
rupturing divides into little fragments, or disappears entirely.  This state
 of the osseous substance may be compared to  aneurism; it is indeed, an
aneurismal state of the capillary system of the bone.  The  flat  bones,
 which have a well-marked diploic structure, such as those of the skull and
 pelvis, and the spongy portion  of the long bones, are the most liable to  the
 disease.  The immediate cause is  nearly always a blow.   As is the case in
the soft tissues, sanguineous fungus tumors of the bone are not always be-
nignant ; they may be endowed Avith a force of expansion and a rapidity
of growth, Avhich alone Avould render them extremely formidable, and pre-
sent, on anatomical inspection, the most heterogeneous structure; or  the
cancerous element  may manifestly be superadded.   When this is the case,
these tumors approximate very closely to the degenerescenoes of the osse-
 ous structure, knoAvn under  the name of spina ventosa or osteosarcoma.
 These latter appear to he merely  different forms of cancer of bone, a dis- 
TUMORS.                           707  ,
ease Avhich has been but imperfectly described hitherto, and which it will,
perhaps, be ever impossible to  delineate Avith  precision, so great  are the
anomalies Avhich it is susceptible of presenting.  These tumors are so rare,
that M. Roux has only seen a few well-marked cases during his long sur-
gical career.   The only methods of treatment Avhich can be adopted with
any chance of success are—the ablation of the  tumor along with the part
of the bone Avhich is diseased: the amputation of the entire part or organ
affected; and lastly, the ligature of the principal artery of the diseased
region.
  M.. Lallemand, of Montpellier, describes a sensation of crackling to be
perceptible to the finger Avhen pressure  is made upon the tumor.  This is
due to the breaking down of minute osseous septa which exist in the sub-
stance of the morbid mass.  The noise produced has been compared to the
u crumpling " of parchment.  The above phenomenon also presented inself
in a case treated by M.  Roux.                          Part xl, p. 180.

  Adipose Tumor in the Spermatic Cordr-— Unique  Case.—The patient,
43 years of age, in the autumn of 1842, discovered an enlargement in the
left side of the scrotum.  This was at first supposed to be  hernial, but by
careful examination av ith an exploratory needle, the disease was considered
to be confined to the spermatic cord.  As the tumor  increased in size,
Mr. Edwards Avas consulted.
  He considered the tumor to be irreducible  epiplocele, but advised the
patient to consult  Mr. Lawrence.   By  him endeaA^ors were made, but
without success, to reduce the supposed hernia, and a suspensory bandage
was directed to  be Avorn.   In the spring of 1844 slight enlargement had
taken place,  and a change in form  Avas perceptible.  No effect resulted
from  the administration  of iodine,  an hich  Avas used both  internally and
externally.   At  midsummer, 1844, there Avas a manifest increase  in size,
though slight, and the tumor had assumed a lobulated form.   The lobules
were very hard, not unlike scirrhus, and insensible.   In April, 1845, the
tumor had enlarged  to  the size of a melon; the left testicle  lay in front,
and both spermatic cords could be felt in a sound condition.   Mr. Travers
was now consulted, and he convinced himself that  the mass Avas  uncon-
nected with either abdomen or testicle, and advised  operation.   Sir  B.
Brodie and Mr.  Lawrence, on examination with a candle, Avere  convinced
that it Avas not hernia,  and agreed  in recommending excision  of  the
tumor.
  Mr. Lawrence thus describes the symptoms : " Upon first vieAV it would
be pronounced a scrotal rupture.  It Avas a pyriform enlargement occupy-
ing the whole left side  of  the scrotum,  extending  to the abdominal ring.
The integuments and cellular tissue were perfectly natural.  But a  cir-
cumstance was immediately perceived at variance Avith the supposition of
a rupture; the  left testicle lay on the front of the SAvelling; it Avas loose
and movable on the mass ; the cord could be traced a little above  it,  and
was then lost in the tumor.  When  firmly grasped, the mass was found to
be of an unequal consistence ; portions Avere solid and firm, but the greater
part was soft, so that I examined  it Avith a  candle, supposing it might
contain fluid ; there was no transmission of light.  Judging from the mere
manual  examination,  it might  have  been a  large  scrotal" rupture, wdth
various contents, principally omentum; or it might have been a tumor not
cf uniform  consistence.   It had the  doughy feel belonging to omental 
708
TUMORS.
rupture ; and the omentum, when long out of the abdomen, becomes some-
times much enlarged by the deposit of fat in its texture, especially  in
corpulent persons, but this gentleman was thin.  Although the SAvelling
was continued upward, careful examination showed that it had no  con-
nection with the cavity of the abdomen ; the cord could be felt free above,
close to the abdomen.  The conclusion  was obvious; the swelling could
not be a  rupture, but I could not make up my mind as to its real com-
position.   Although the nature of the disease was doubtful, there were no
evidences of dangerous character, nothing to contra-indicate the operation
of removal, which had become urgently  necessary from the great bulk  of
the tumor, and its rapid rate of increase during the last few months."
  Mr.  LaAvrence, assisted  by Mr. Travers, removed the diseased mass.
The first step was an incision into  the SAvelling.  Twro elliptical incisions
were now made, including a considerable portion of the skin of the scrotum.
An attempt was made to save the testicle, but the different constituents  of
the spermatic cord  were so entangled \vith the substance of  the tumor,
that after some loss of time, the entire contents of the left scrotal sac were
turned out. Mr. Lawrence thus describes the tumor after excision: " This
mass, measuring  about eight inches in  length, by six in ividth, Avas taken
from the scrotum.  It presents the ordinary appearance of adipose swelling,
the component masses of fat  being larger, and the  surface being partly
lobulated.  On  a superficial view of its exterior, and of the  cut surface
after it had been divided, it might have been taken for a mass of beef suet.
Swellings of the scrotum, in the great majority of instances, are ruptures
or  morbid conditions of,  the  testis, its coats,  or  the  spermatic cord.
Diseases of the cellular structure, excepting inflammations and effusions of
blood, serum, pus, or urine, are very uncommon.   I  do not remember to
have met with a tumor in this situation  ; and the fatty growths so common
in the adipose  tissue, are Avhat Ave should have least  expected in a part
which naturally does not contain  a  particle of fat.   I have never seen in
the scrotum, the cellular tumor which is sometimes met with in the external
organs of the female."  The  ligatures came  away kindly, and in three
Weeks the patient Avalked about his  house.  He now walks from Islington
to the city without inconvenience.                      Part xii., p. 225.

   Removal of Tumors by a Flap Operation.—[Every practical surgeon
must have noticed the facility wdth which a tumor loosely connected Avith
the parts  on  Avhich it rests can  be raised,  and also that this facility is
diminished when the skin is  dissected., off it.  By the  ordinary mode  of
incising, the operation becomes converted into a digging ; this is proposed
to  be remedied by using a flap.   The mode in Avhich Mr. Chippendale
operated in a  case of this sort, is  best described  in his own Avords, as
follows :]
   Raising the  tumor as far as I  could from  the body  with  one hand, I
passed a long narroAV knife under the skin  near the border of it, in the
direction of its long diameter; having cut through  the  connections at its
base, and the edge  of the  knife having arrived at the opposite border, it
was turned toward the surface  of the  body, and  the skin  severed.  The
whole was noAV turned out, and the tumor dissected from the flap thus
formed,  Avith the greatest facility.  The few  vessels wdiich bled had liga-
tures applied, which in  a quarter of an hour, were  again  removed;  the
flap was laid down on the wound wdth two points of suture in the long side, 
TUMOR8.
709
and the edges secured Avith adhesive plaster;  the whole Avas healed in a
few days, leaving a scar representing three sides of a rectangular parallelo-
gram as thus [.
  The skin Avhen thus divided,  so  soon shrinks, that it can seldorit be ne-
cessary to take any portion of it away ;  but should a case occur where such
a proceeding became  necessary, a portion could  be taken from the free
border of the flap, so as to  make it fit the exposed surface, as parts are
brought to  coincide in autoplastic operations.            Part xii., p.  251.

  Pulsating Tumors of Bone.—[These tumors so nearly resemble aneu-
risms that they are liable  to be  mistaken, even by the most eminent sur-
geons ; they have, indeed, been named  osseous aneurisms.   M. Dupuytren
regards them as accidental development of erectile tissue, generally impli-
cated with  the cancerous element.   He has recorded many of these cases.
Mr. Teaks observes:]
  A case of pulsating tumor of the ilium, supposed to be aneurism, recently
occurred at St. Bartholomew's Hospital.  Mr. Stanley describes the tumor
as pulsating throughout  its  whole  extent; not with a thrill or vibration,
but Avith a  deep  heavy beat of aneurism; and a  belloAVS  sound was dis-
tinctly audible.   A ligature was applied to the common iliac artery.   The
patient died on the third day, from  peritonitis.  The tumor on dissection,
Avas found to be composed of a spongy tissue,  Avith cells  and convoluted
vessels distributed through it.   In the wall of the  left ventricle there was
a medullary tumor, of the  size of a filbert.  After relating the case to the
Medico-Chirurgical Society, Mr. Stanley alluded to  several others, in Avhich
tumors originating in the bones had  been  mistaken for aneurism.  Tavo
such had occurred at St. BartholomeAv's Hospital:  one was an encephaloid
tumor of the humerus: the other a morbid groAvth, consisting of a  soft
fibrous and dense osseous structure, originating  in the femur, and supposed
to be  popliteal aneurism.  Mr. Stanley also referred to a  case of great
interest, Avhich had occurred to Mr. Guthrie.   In this instance, a medullary
tumor, situated in the gluteal region, presented so decidedly the characters
of aneurism, that it was regarded as such by Sir Astley Cooper and other
surgeons, and accordingly Mr. Guthrie applied a  ligature to the common
iliac artery.                                          Part xiii., p. 235.
   Treatment of Pendulous Tumors.—[These tumors after remaining sta-
tionary  for years, often  become the   seat of morbid action :  hence  the
general rule of practice  is to  remoA'e them Avhen  first presented.   The
chief point  of importance  in their removal is a consideration of the proper
part of the  pedicle  at which the division is to be effected.  Dr. O'Ferrall
observes :]
  If the section be  made too near the bulb, an unsightly projection will
remain after the operation ; if it be done too near the other extremity of
the pedicle, the integument, on retracting, will  leave a wound, and conse-
quently a scar, much larger than could have been anticipated.  Allowance,
then, must  be made for the elongation  of the pedicle by the weight of the
bulb, and for the contraction of the stalk, which always folloAvs its division
—the  same process  Avhich renders it unnecessary  to tie the  neck  of a
uterine polypus close to the mucous surface from which it has grown.  The
best mode of proceeding is, to poise the tumor  on  the hand, and allow the
surrounding skin to retract and recoA-er its pristine position, and then to
make the section of the pedicle a little beloAV its origin.  Should the nutri 
710                            TUMORS.
tibus artery be large enough to deserve attention, the jet of blood may be
prevented  by previously including the neck of the tumor in a provisional
ligature, and, when the section  is accomplished, tying the  divided artery.
The provisional ligature may then be removed altogether.  A slight touch
of the nitrate of silver, just sufficient to produce a delicate white coating,
will not only shorten the duration of the subsequent smarting, but lessen
the probability of any reaction, especially of an unhealthy  kind.  Simple
water dressing will then  complete the local treatment.
  In operating on the adipose pendulous tumor, the  extent of interference
with the pedicle will be regulated by the presence or absence of tatty mat-
ter in its substance.  If the growth  extend through  the neck into the sub-
cutaneous  cellular membrane beyond it, such an incision must be made as
will allow of its complete extraction.  In such a case, the small cavity then
left should be filled with lint dipped in olive oil, and the integument brought
gently over it, to prevent an unnecessarily large cicatrix.  The lint is with-
drawn  when suppuration  is  established, and the  integuments brought
together by  adhesive plaster.
   The  proceeding in  the  case of pendulous nevus  is someAvhat  different,
and must be adapted to the peculiar circumstances  of the case.  It is not
usual for the pedicle, in  such instances, to be entirely free from  all traces
of erectile tissue.   Should the pedicle be implicated, or should the vessels
of the  cellular  or dermoid  tissues  beyond it be hypertrophied, a simple
section Avould be inadequate to  the cure ; hemorrhage of a troublesome
nature  would be the immediate result, and reproduction of the disease the
more remote consequence  of such an imperfect procedure.  The diseased
part  must be included  in an  elliptical incision, and thus  freely  and com-
pletely removed.  It may happen that the erectile  formation may extend
irregularly, for  a considerable  distance, beyond the origin of the pedicle.
In such cases, the amputation of the pedicle alone Avould entail the conse-
 quences already alluded to, while the excision of the whole of the morbid
 structure  might be forbidden by its extent, or by the importance of the
 parts in which it is found.  The folloAving is the mode I Avould  recommend
 under such ciroumstances, and wdien the removal of the pendulous tumor
 is desired on account of the inconvenience it occasions.  The tumor being
 held horizontally and on the stretch, the point of the style or nail cautery,
 described by Dr. Wilmot, should be passed through the cervix  in several
 places, so as to  insure  the  obliteration  of the vessels contained in  that
 place.  The wdiole cervix may be traversed by these punctures at one or
 several successful operations, according to its breadth.  When the vascular
 character of the  cervix is thus  changed, its  section may be performed,
 ivithout risk of hemorrhage.
   When a pendulous tumor is knoAvn, or suspected  to be malignant, great
 care  must be taken to remove  the entire of the  morbid parts.  If the
 heterologous structure be confined to the bulb of the tumor, and the pedi-
 cle or surrounding skin be healthy,  there can be no reason for doing more
 than simple  section of the former;  but the section should not, for obvious
 reasons, be made too near the bulb.   But should the neck of the tumor he
thickened, hardened, or irregular, a fi-ee eUiptical incision  should be made
 in the integument beyond it, and all suspicious parts satisfactorily removed.
                                                      Part  xvi, p. 313.

    Tumors of the Neck connected with Blood-vessels.—[Some years ago Mr. 
TUMORS.
711
Listen punctured a tumor in the neck, from which considerable hemorr-
hage occurred, and w hich the operator  then supposed to be an abscess in
communication with an artery.  Professor Syme has published the account
of a similar case in Avhich he tied the  artery, but after death the tumor
w as found not to communicate.  Mr. Syme says :]
  About a month ago a young man  called upon me to get my opinion of a
swelling  in his neck.  It Avas seated on  the right  side, and  occupied the
upper triangular  space.  It Avas of an oval form,  quite circumscribed, and
obviously consisted of a bag  containing fluid. • Upon more particular ex-
amination, I found a distinct pulsation of the kind which I had been accus-
tomed to regard  as characteristic of aneurism, being an expansive impulse,
not limited to a portion of the tumor, but felt equally at  every accessible
point,  even from the mouth, and more especially in a  lateral direction.
The patient stated that  the  SAvelling had commenced about nine  months
ago^and had progressively enlarged Avithout any cause that had  been as-
certained,  lie also stated, that when he worked hard, or walked fast, the
tumor increased  in  size,  and  had a strong beating in it.   I felt satisfied
that there Avas an aneurism of the  carotid artery, but expressed no opinioi
at the time, and desired the patient to call again for further  examination.
When he did so,  I varied the process by placing him in different positions
—by trying the effect of pressure on the tumor and artery—and by listen-
ing to the sounds of the tumor.  There wTas no distinct aneurismnl " bruit,"
but a very strong loud pulsation, that implied  the action of the  heart upon
an extensive surface.   Finding my impression thus confirmed, I informed
the patient of my apprehension ; but before giving a decided opinion, re-
quested that he Avould  call once  more.  He did  so a feAv days afterward,
and I then felt fully warranted in  informing him  that an operation would
be requisite for his relief.  Next day he placed himself in my hands for this
purpose.  After he had been confined to bed for a few days, I tied the ar-
tery beloAv the crossing of the omo-hyoideus,  as the tumor prevented this
from being  done higher  up.   The  textures of the neck were more than
usually adherent, and the vessel was not exposed to view wdth nearly the
6ame facility as upon the former occasions Avhich have required me to per-
form  the operation.   I nevertheless  succeeded  without any  tearing, or
undue disturbance of the  parts, in passing and tying the ligature, so as to
relieve me from the slightest apprehension of any bad consequences.  The
tumor immediately sustained a very  distinct diminution of bulk, which was
remarked not only' by the gentlemen present, but by the  patient.  He
went  on most favorably after the operation until the fifth  day,  when
hemorrhage took place  from the wound, and notAvithstanding every effort
to effect prevention, recurred  from time  to time  until the evening of the
twelfth day, until it proved fatal.
  The, parts concerned  were examined next day in  the presence  of
Drs. Scott,  Duncan,  Mackenzie,  Peddie,  Brown,  Gillespie, and  Ballin-
gall.
  We found a tumor, extending from the ear  to the extremity  of the omo-
hyoideus, and completely  occupying the upper triangular space of the neck.
At  the lower  part  it seemed to terminate  in the sheath of  the vessels,
which  looked like a prolongation of it doAvmvard, but Avas found to be
merely enveloped by  the bag, wdiich  I  dissected out entire from the
coats of the vessels to which  it had intimately adhered.  The cyst, when
opened, was found to  possess a tough  consistence, and  to contain a fluid 
712
TUMORS.
like thin  gruel.  At the posterior part, when viewed internally, it dis»
played a sacculated or honeycomb-looking structure.
   [Another case has been reported in which a large abscess in the neck
(treated by a quack) had not been opened, but allowed to go  on  till it
burst by several openings.  When the discharge had gone on for about a
month, alarming and repeated hemorrhages took place from the openings.
After death,]
   The blood-vessels were injected, and it was found  that ulceration had
occurred in the  subclavian artery, as it lies upon the first rib.   The rib
was in a carious state, as well as the bodies of the contiguous vertebrae.
The situation  of the ulcerated  opening in the artery was  toward the
bone, and occupied about one-fourth   of the calibre of  the vessel; the
opening was of oval shape, and well defined.  There was no  enlargement
of the capacity of the vessel at the point.              Part xvii., p. 141.
   Treatment of Erectile Tumors.—M. Behrend, of  Berlin,  treats  these
tumors by the  application of the concentrated  acetic  acid, followed by
lint dipped in  distilled vinegar.  Under this treatment the tissue becomes
pale and. hard, diminishes in  bulk, and is at length completely thrown off.
He also, in some cases, enjoins the repeated division of the dilated vessels,
by puncturing them with a needle with double-cutting edges.
                                                    Part xviii., p. 230.
   Tumors—Encysted.—In cases  of small sebaceous tumors, instead of dis-
secting out the  cyst, puncture  the tumor, squeeze out  the contents, and
apply nitrate of silver all over the internal surface of  the cyst.  The most
convenient way of applying the nitrate, is, to have a probe coated with  it.
                                                     Part xix., p. 211.
   Neuroma, or  Tumor of Nerve.—No measure is successful except that
of excision.  The tumor may either be dissected out of the mass of nerve-
fibres among which it has grown, or it  may be cut away together with the
piece of nerve to which it is attached. The latter measure  is generally
quite safe and practicable.  Lastly, amputation may be resorted to [if the
disease is situated in an extremity], when other means fail, and the symp-
toms are urgent.                                      Part xx.,]). 59.
   Extirpation of Erectile Tumors by  the Cautery.—Dr. Douglas Macla-
gan makes the following remarks : "These erectile  tumors, which consist
essentially of a congeries of enlarged blood-vessels,  are commonly treated
by ligature; but this causes a good deal of suffering, and often much con-
stitutional irritation, before the strangulated mass finally separates.   The
method of applying the  cautery is to pass a large red-hot  surgical needle,
which may he readily heated  by a gas-flame, once or twice through the
base of the tumor;  and the object is to cause effusion of lymph, and thus
to alter the structure of the tumor, and to arrest its  growth.
                                                   Part xxiii.,/). 154.
  Fibrous Tumors.—[According to Dr. G. M. Humphrey,  with the excep-
tion of the fatty, the fibrous are perhaps the most common of the simple
growths.  They resemble the natural  fibrous tissue  as found in areolar
membrane, in  ligaments, tendons, etc.  Their miscroscopical  examination
is  also distinctive. .  In some instances, the fibres are disposed more or less
concentrically.   These tumors generally do not attain  to a very large size.
la other instances, the component fibres interlace in a complicated irregib 
TUMORS.
713
lar manner.   These kinds may attain to a very large size; they are com-
monly round.   In a third, but more rare class, the tumor consists of an
aflroregation of small nodules, or masses closely compressed together,  hav-
ing an uneven, knotty outline, and looks like a conglomerate gland.]
   When you examine fibrous tumors Avith the naked eye you may observe
that many or most of them consist of tAvo structures,  viz., dense opaque
fibres, or bands, coursing about and interlacing in the midst of a more clear,
hyaline, softer substance; the latter being contained iu the meshes formed
by the interweaving of the former, much in the same Avay that the fatty is
related to the  fibrous element of an adipose tumor.   The actual difference
between these two components of fibrous  tumors seems to depend upon
the larger quantity of fluid—serous or aqueous fluid—which exists in the
softer substance;  and the proportion Avhich this substance  bears  to  the
rest of the mass varies  exceedingly.  In some instances it is scarcely  per-
ceptible, the tumor appearing  to  consist almost entirely of the tough,
opaque, fibrous element; in others the latter structure forms but an insigni-
cant part, or may not even  be distinguished at all in the soft, succulent,
cellular mass of Avhich  the tumor consists.   When a tumor of this latter
kind is opened, and the  fluid allowed to drain aAvay, the mass shrinks, and
soon loses a half  or tAVO-thirds of its Aveight.  Now and then the fluid is
contained in  distinct cysts Avith  smooth  walls, lying  in  the interstices
between the interlacing fibres ; thus constituting  one of the forms of
"sero-cystic  sarcoma," and consist of  a thickened  condition of   the
cellular tissue excited, perhaps, by chronic  inflammation, or some long-
continued irritation,  or  they may take  place without any  obvious
cause.
   Fibrous tumors vary so much in the' compactness of their structure, and
the mode of  arrangement of their fibres,  that  in the  classifications of
tumors made by Abernethy and succeeding pathologists, the several mem-
bers of this class were arranged in separate divisions.  The name "cellular
sarcoma," or u vascular  sarcoma,"  Avas given to those in Avhich the struc-
ture A\"as soft  and succulent, resembling the common cellular tissue, the
chief bulk and Aveight of the mass being dependent on the larger quantity
of fluid contained in the spaces betAveen  its solid  elements.  Tumors of
this kind groAV, as Ave might expect from their structure, more quickly than
the other varieties of the class; they are  found generally in parts wdiere
the cellular  tissue is naturally lax  and  abundant -in  the scrotum  for
instance, and in the labia pudendi,  occasionally in the  ovary, or  in  the
cellular tissue surrounding the loAver part  of the  uterus and the vagina.
They are generally invested Avith a thin capsule, which separates them
from the surrounding parts ; their connections are loose, and though they
may attain very large size, they are easily dissected out.  The capsule is
not, however,  always present:  on the contrary, the tumor may be blended
Avith the surrounding cellular  tissue, so that it is not easy to define its
limits very clearly.  Those enormous tumors of the scrotum which  are
occasionally  met  Avith  in  this  country, and  are  more  common  in warm
climates, appear to be of this nature.
   The testicles and penis are  commonly buried in these masses.  Some-
times the skin is affected iu a similar manner, becoming greatly thickened
and tuberculated, so as to present  the usual appearance and characters of
elephantiasis.  When an incision  is made into a scrotum thus diseased, a
large  quantity of serous fluid drains aAvay, and the size of the mass soon 
714:                            TUMORS.
 diminishes.  I have occasionally met wdth ill-defined  tumors under the
 skin of the face and in other parts of the body, which I could account for
 only on the supposition that they depended upon a hypertrophic condition
 of a small portion of the subcutaneous cellular  tissue.  You will perceive
 that there is a near relation between tumors of this kind and that thickened
 condition of the areolar and fibrous tissues which occurs in warts, polypus,
 Pterygium, and the like; indeed, we cannot draw any clear line of distinc-
 tion betAveen them.
   Another specks of fibrous tumors  has been called the " mammary sar-
 coma," from  the resemblance  of the  tumors to udder ; their fibres being
 interwoven  so as to form  a toughish, doughy, pale mass, intermediate  in
 consistence between the cellular sarcoma and the tumors next to be des-
 cribed.  The specimens  of mammary sarcoma' are  generally  found  in tht
 neighborhood of the breast; they have been knoAV to  attain a very larg«
 size, and are usually capsulated.
   The third  species of fibrous  tumors, ivbich is by far the most common,
 and in Avhich the characters of the class are most strongly marked, was
 not distinguished by Mr. Abernethy with a particular name.  These tumors
 are remarkable for their great hardness, and on this account are very often
-described under the name " scirrhus," a word which has been so indiscrimi-
 nately used in former times as to have retained hardly any definite meaning
 at all, but which is now  by all  accurate  pathologists applied exclusively  to
 one of the varieties of cancer; they are more frequently found in the uterus
 than in  any other part  of the body,  and were described by Dr. Baillie
 under the name of the afleshy tubercle of the  uterus;" the term "fibro-
 calcareous " has also been applied to them, because of their liability to un-
 dergo calcareous degeneration, a peculiarity which I believe is not shared
 by either'of the other varieties of fibrous tumors.
   In each of these species there is a general correspondence to be remarked
 betAveen the characters of the tumors and those of the tissues  in which
 they groAv.   Thus the soft, succulent, " cellular " tumors are found in the
 loose cellular tissue of  the scrotum;  the "mammary " tumors are found
 in or near the breast; and the last variety, the "fibrous" tumors—strictly
 so-called—are found in the uterus, among tendinous structures, in the
 periosteum, and in the dura mater.
   The characters of these three species of fibrous tumors are  so far distinct
 that I have thought it worth while to direct your attention to them ;  at
 the same  time you should know that the intervals betAveen them  are filled
 up by  intermediate gradations, jnst  as it is in natural  structures wdth
 regard  to the areolar and fibrous tissues.  Here, for instance, is a round
 tumor groAving in the tough cellular  tissue ivhich forms  the  soft, strong
 padding at* the extremity of a finger: it is scarcely bard enough to belong
 properly  to  the  third species  just  mentioned, yet it is too  firm to  be
 classed with either of the other tAvo ;  and you will find many specimens
 not strictly included in either of these species, but serving to connect them
 more closely together.
   A fibrous  polypus consists of a fibrous tumor,  which, projecting into
 the interior  of the uterus,  has  become pedunculated.   It corresponds in
 structure  with the fibrous tumors groAving in other parts of the  uterus,
 though I think its structure is not generally quite so dense.  It is covered
 by the mucous membrane of the uterus reflected over it, together perhaps
 with a thin layer of uterine tissue ;  these converging at the upper part  of 
TUMORS.
715
the polypus, pass from it to the uterus, and constitute the pedicle, which
is  generally narroAvest at the middle, expanding beloAv over the polypus,
and again expanding above where it is connected wdth the uterus.  The
pedicle thus  consists entirly of stretched uterine  structure, forming, in
reality, no part of the polypus, which explains the fact of its not being
necessary to remove  the  entire  pedicle in order to prevent a return of the
disease after  operation.  The mucous membrane covering  the polypus is
sometimes very vascular, so as  to bleed profusely when it  is lacerated or
superficially ulcerated.  This was  the case with a patient lately in the
hospital,  who had been  greatly reduced by  repeated  hemorrhages and
continual oozing  of  blood from the vagina; on examination I  found a
fibrous polypus presenting at the os uteri, and  the loAver end of the tumor
rough from superficial ulceration.  The os Avas sufficiently dilated to permit
the introduction of the finger and Gooch's canula, ivith the assistance  of
wdiich the tumor was  tied  at its upper end, and the patient quickly recovered.
   When the  tumor is situated  near the exterior of the uterus it  projects
into the  abdominal  cavity,  carrying before it the  peritoneum, together
perhaps with a thin layer of uterine tissue.  In process of time the tumor,
gradually projecting  more and more,  may become pedunculated ; as in this
instance, wdiere a large fibrous tumor hangs from the left cornu of the uterus
by a pedicle  thinner than one's little finger.  Under such  circumstances
the tumor is  likely  to contract adhesions to  the adjacent viscera, and in
some instances it has been knoAvn to be quite detached from the parent
organ  and transplanted as it were  to a neAV soil.   When  this has taken
place, I believe the tumor ahvays ceases to grow and becomes calcified.
   In like manner, wdien  the tumor is situated near the internal surface of
the uterus it  projects into the cavity of the organ, carrying before it the  •
mucous  membrane,  with perhaps  a thin layer of uterine  tissue.   As it
increases it projects more  and more into the  uterine cavity, where the
resistance is least, its basis of attachment to the uterus gradually narrows
and at last forms a  mere pedicle.   In this manner is formed the fibrous
polypus  which differs from the mucous and  uterine  varieties of polypus
described on a former occasion, inasmuch as it  is the result  of a fibrous
tumor forcing its Avay into the cavity of the uterus.
   Under ordinary circumstances  fibrous  tumors occur  in considerable
numbers in the same uterus; in some of these specimens there are five, six,
or even more, indeed they are rarely single, except when they project into
the cavity of the uterus, and distend its walls;  there is then commonly
only one tumor.  This exception is a matter of some practical importance,
inasmuch as it gives  us greater confidence that AAre may be able to effect a
permanent cure by our operations upon  polypi, and that the patient will
not be troubled ivith relapses  from  the  presence of other tumors.  I do
not mean to say that such is invariably the case, for you will every noAv
and then meet wdth an instance of fibrous polypus, associated wdth fibrous
tumors in  other  parts of the  uterus, and such a coincidence  may be
adduced as an argument in favor of the view Avhich  regards the polypus
to be  of the  same nature  with the tumors,  but it is certainly not the
general rule.
   In the greater number of cases the fibrous tumor in the  uterus consists,
as I have said, of a  firm globular  mass groAving from one centre Avithout
any peripheral processes or lobes;  this, ho av ever, is not their  constant
character.  Sometimes there are several nuclei, forming distinct masses, 
716
TUMORS
   closely packed together.  Here is a specimen of an uneven, granulated, or
   finely lobulated tumor in the fundus of the uterus, which appears to consist
   of a number of separate masses  less closely packed; it looks something
   like a salivary gland, but is of firmer structure.
     Again,  fibrous tumors  are generally distinct from the  surrounding'
   uterine substance, and separated from it in their Avhole circumference by a
   well-marked capsule.  Exceptional cases, hoAvever, do occur, in which the
   line  of  demarcation betiveen the tumor and the  uterine  tissue is  less
   marked.
     In this specimen the tumor consists of a thickened, coarse, hypertrophied
   state of one  side of the fundus uteri.   Rarely is the os uteri the seat of
   fibrous tumor at all, but when it is so the tumor, so far as I have been able to
   ascertain by the examination of specimens  in different museums, consists
   of an enlargement of one or  both lips  of  the os uteri, the posterior  lip
   being most frequently affected.   The tumor thus formed partakes of the
   usual characters of fibrous tumors, except in the continuity of its structure
   Avith  the  uterine tissue ; it  may  attain  to  a very large  size, filling the
   vagina, or even projecting externally.
     All the changes to Avhich  fibrous tumors  are  liable may be observed in
   those affecting the uterus.  They are : calcareous degeneration, softening,
   and the various effects of inflammation.
     Calcareous degeneration commences with the appearance in the substance
   of the tumor of one or more small grains of hard, straw-colored substance,
   consisting of carbonate, with some phosphate of lime.  They are generally
   near the centre of the mass  at first,  and gradually extend toward the cir-
   cumference ; they increase at the  expense of the fibrous structure, and are
*  evidently the result of a transformation  of it—a  conversion of the fibrous
   into earthy matter.  In course of time the  earthy grains enlarge and coa-
   lesce, forming very hard, branching, knotty masses, like  coral, of straw-
   color.  They are closely connected wdth the  remaining substance of the
   tumor; indeed they are continuous Avith it, so that they cannot be cleaned
   wdthout great difficulty, or the help of maceration.  Such masses may attain
   to considerable size,  involving the greater part of the tumor, but they ge-
   nerally contain enough of the fibrous structure in their interstices to dis-
   close their real nature.  In a feAv  instances  the calcareous degeneration has
   commenced upon the surface of the tumor, and I have seen one case in wdiich
   it had converted the outermost layers of the tumor into a hard shell,  in-
   closing the central  part like a kernel.  It may take place  in the tumors
   which project into the peritoneal cavity, or in those which hang polypose
   into the uterus ; but I have not met with an instance in which it affected a
   tumor formed by the hypertrophy of an  appreciable portion of the uterus,
   such as those originating in the os uteri  just  mentioned.  Neither have I
   knoAvn it to occur in the cellular  tumors, in the mammary sarcoma, or in
   any of the softer varieties of fibrous tumors.
     Softening appears to take  place in  two Avays: first, as a chronic process,
   affecting some circumscribed portion of the tumor, ivhich is  usually at or
   near the centre. The change is observed to commence ivith a slight disco-
   loration—a yellowish or dark tinge—which is folloAved by a loosening or
   incipient disintegration of the structure; at  the same time a line of demar-
   cation is formed round the altered portion,  Avhich becomes separated hke
   a. sequestrum from the surrounding mass.  Both  the detached portion and
   the cavity are at first rough  and shreddy on their  opposed  surfaces; the 
TUMORS.
717
former undergoes still further disintegration and solution,becoming broken
up into a number of small fragments, which float  about in  a dark, dirty,
turbid fluid, and Avhich may, ultimately, quite disappear.
  The process of destruction may go on in the adjacent portion of the
tumor, enlarging the central cavity, till the whole is reduced to a fluid or
semifluid mass,  walled in by the cellular  capsule of the tumor, which now
Btands in the relation of a cyst-wall to the disorganized contents.  Uterine
tumors, ivhich have undergone this change in a greater or less degree, have
more than once been  mistaken for ovarian cysts, and  tapped accordingly.
There is a specimen in the museum of the College  of Surgeons, wdth a his-
tory appended,  to the effect that an encysted tumor formed in the uterus,
and the patient  Avas tAvice tapped and the cyst emptied, the disease having
been supposed to be ovarian dropsy during life; it was, probably, a  case
of the kind I am hoav  describing, if we may judge from the appearance of
the sac, and from the knoAvledge that cysts are very rarely produced in the
Avails of the uterus.  In some instances the softening process is completed
at one spot Avithout extending to the circumference; the ragged  processes
hanging into the interior of the cavity are  removed, the latter acquires a
smooth lining, and looks like a simple cyst lying in the substance of the
tumor.  You  must not mistake for cavities thus formed, the vacancies oc-
casioned hy enucleation of portions of the tumor after  death.  It is neces-
sary to give you this hint, because I have known such an error to have been
made.
  The second mode in wdiich softening takes place is more rapid and more
diffused ; the  wdiole or greater portion of the tumor being  affected at once.
The change commences with the infiltration into the mass  of a serous fluid.
whereby its texture is loosened, and its components separated ; at the same
time the tissue of the tumor is softened, and interstitial absorption is set up
in it.  As the result of these processes combined, the tumor is soon broken
up into detached fragments, and reduced to a diffluent pulp, or it may be,
completely liquefied.   It may even burst into the  cavity of the  uterus or
the abdomen, and its contents be discharged.  These changes are probably
occasioned by some altered  state of nutrition  analogous to inflammation ;
they may be induced by an  accidental cause, an  injury, or pregnancy, and
purulent fluids are sometimes found mixed up with the softened substance
of the tumor.   Nevertheless, they are not necessarily attended  with  any
constitutional disturbance at all corresponding witti the extensive destruc-
tion Avhich is  in progress.
  Suppuration has been now and then  knoivn to take place in a fibrous
tumor, and ulceration sometimes extends into it after penetrating its cover-
ings, as in the case of polypus.  Here is a specimen of large fibrous tumor
of the uterus, projecting into the peritoneal cavity, and  covered with a
coating of cancer, which was diffused over nearly the ivhole interior of the
abdomen.   At one part you may see that the cancerous disease has pene-
trated the tumor, and destroyed its substance for about an  inch. Dr. Lever,
in bis  work on disease of the uterus, relates a case where  melanosis was
deposited in the structure of a fibrous tumor.
  We cannot  say that these tumors are attended with  any particular train
of symptoms,  they have hardly any nervous link connecting them wdth the
rest of the body.  The drain upon the vascular system, occasioned by them
is scarcely appreciable, neither do they return to it any noxious element, or
communicate  an evil influence in any other Avay.  The symptoms to Avhich 
71S
TUMORS.
they do give rise are almost entirely dependent on their  effects upon the
neighboring organs  and tissues, and  therefore vary wdth their position.
Thus, if they be placed near the lining membrane of the uterus, they occa-
sion the several symptoms of chronic inflammation of that membrane, such
as uneasiness, discharges of mucus  or blood, wdth, perhaps, the pains of
forced uterine contractions, sensations of iveight, bearing doAvn, etc. When
situated more in the middle of the uterine wall, or nearer to its external
surface, they may exist for a long time, and attain  considerable  size, with-
out giving any  indication of their presence.  In some cases, by their pres-
sure upon the  rectum  or bladder, they occasion an irritable disordered
state of these organs, or difficulty in A'oiding the urine  and feces.  These
and  other symptoms of  the like  kind are rather casual results  of the
tumor's relation to certain external parts, than of any intrinsic  quality of
its own.
   The fibrous tumors of the uterus  become the subject of treatment only
Avhen they grow' from the os uteri, or  when they project into the cavity of
the uterus and  the  vagina,  assuming the polypose form.  In either case
they may be removed by ligature, or if their pedicles be narrow, may be
excised, as recommended  and extensively practised by Dupuytren.  In  a
few cases an incision has been carried through the coverings of a fibrous
tumor, projecting into the cavity of the uterus or  vagina, but not become
polypose, and attempts  have been made to turn the mass out of its bed by
dissection, and by tearing the fine filaments ivhich unite it to its capsule.
This proceeding, though  successful in a few instances, is for obvious rea-
sons, seldom to be  attempted.  The application of iodine externally, and
its internal administration, has been recommended wdth the view of pro-
moting the  absorption of these tumors, and is  said to have been attended
with success.   I have seen it tried in a feAv instances, but  the  result has
not been  encouraging.
   Fibrous  tumors  affecting the bones are usually found upon those of a
spongy nature, upon the ends of the long bones, the phalanges,  pelvis, and
lower jaw7.  So far as I have seen, they are confined to the exterior of the
bones, growing from the periosteum,  and creeping along the surface of the
bone in such a manner as to prove almost to a certainty that they originate
in some morbid condition of the periosteal fibres.  The bones underneath
these tumors  may  suffer  absorption,  in  consequence of the pressure pro-
duced, but  do not seem  to  be  affected in any other way.  They appear
upon the maxillary bones more frequently than upon any other part of the
skeleton.   On  the  lower jaw they spread along  the  ramus, encircling it
beneath and on the sides; so that the bone is  almost concealed by the
tumor.  In  some instances they form  within the substance of the jaw, pro-
bably from  periosteum lining the sockets of the teeth,  and as they increase
the walls of the bone become spread out over them.  They grow up around
the teeth, and where they project into the mouth, may be soft and fungous.
In the upper jaiv they  form uoav  and then in the antrum, and gradually
distend the walls  of the  cavity; more frequently they commence on the
outside, and groAV along the surface of the bone, projecting into  the mouth,
nose, orbit, and toAvard  the cheek, so that the natural outline of the
maxilla can scarcely be  recognized.
   In some instances these fibrous tumors of the jaws have exhibited a semi-
 cartilaginous structure  ; and noAV  and then fibres, or  plates of bone,  are
 formed in  various  narts  of them.   The progress of  the  disease is wrell 
TUMORS.
719
 illustrated by the series of tumors of the jaivs in the College of Surgeons,
 from  the museum of the late  Mr. Liston.  These  preparations  furnish
 ample proof, if proof Avere needed, of the skill of that illustrious operator;
 they show also how necessary it  is to bear in mind the mode of growth of
 these periosteal fibrous tumors of the jaw; because fiom their disposition
 to creep along the surface of the bones, they are liable to return  after
 removal, unless the immediately adjacent as  ivell  as the  affected part bo
 excised.  The histories attached,  to the specimens teach us that very large
 fibrous tumors, both of the upper and lower jaiv, together with the bones
 on Avhich they grow, may be removed successfully.
  Xearly allied to tbese tumors of the periosteum,  and forming a  close
 connecting link in pathology between  them and the common warts  and
 polypi, are the tumors of the gum called " epulis."  They are of tivo kinds;
 one consisting of a red granulated or nodulated growth springing from the
 sockets of the teeth,  originating apparently in a morbid  condition of the
 membrane lining the sockets,  and caused  in many  instances by a diseased
 state  of the teeth.  Such a growth requires to be extirpated, and it is not
 enough simply to slice off the tumor, for it is deeply  rooted and will most
 likely reappear unless the alveolus from which it springs, be removed wdth
 it, which may easily be done by cutting a notch in  the jaAv wdth the bone
 forceps or a small saAV.  The second kind of epulis is exemplified by this
 specimen of tumor of the gum on the outside of the upper jaw; it is a red,
 soft, pulpy growth, as large ns a  walnut, in appearance resembling swollen
 gum; indeed it consists evidently of a  groAvth of the gum.  It is slightly
 lobulated on the surface, and tolerably defined at the circumference, where
 it is  continuous ivith  the surrounding gum.   The patient was a healthy
 young Avoman, and the disease had been observed to  folloiv the extraction
 of a tooth six  months  before she came to  the hospital.   The tumor Avas
 closely connected ivith the bone,  so I removed the  portion of the maxilla
 on which it rested, including the  sockets of the canine and first molar
 teeth.  Seven  years have noiv elapsed  since the operation was performed,
 and  the  patient is still quite well.  The tumor was very vascular, bled
 frequently and might have been mistaken for a malignant affection.
  Fibrous tumors are not  uncommonly found in  nerves.  In some cases
 they form distinct round masses within the neurilemma.   In others they
 appear to consist of an increase  of that  fibro-cellular tissue ivhich unites
 the nervous filaments together.   These  tumors are  in some cases attended
 wdth a good deal of pain, felt in the course of the nerves and easily excited
 by pressure, a slight blew, or a  quick  movement.   Excision is  the  only
 remedy, and it must in each case be uncertain hoiv  far it will be possible
 to effect that Avithout injuring the structure of the nerve.  Not long ago
 I removed from  Avithin  the sheath  of the medium nerve near the wrist,
 from a woman aged forty-eight, this  spherical tumor ;  it is as large as an
 orange, presents a semi-opaque glistening  appearance, not unlike brawn,
 with more opaque yelloiv spots interspersed here and there.  It resembled
some  of the varieties of encephaloid disease so closely that I should have
been apprehensive as to the result had it not been gradually forming many
year.s, during AA'hich time the ivoman enjoyed good health.   It ivas attended
ivith a good deal of pain and a shrivelled  state  of the fore and  middle
fingers.   Some filaments of the nerve were removed with the tumor, never-
theless, the patient  recovered completely, regaining the use of the hand ;
the fingers were also in course of time restored to their natural condition. 
720
TUMORS.
  It has already been intimated that fibrous tumors occur in several other
parts  of the body besides the uterus, the periosteum, and  the nerves.
Here  is one as large as a walnut and of spherical  shape, groiving from the
inside of the dura mater, and  causing an indentation in the  surface of the
brain.  Sometimes they form in the  substance of the  testicle, the prostate
gland, the ovary, and even the walls of the alimentary canal. Very rarely
are they to be met with in any other of the internal organs.
  One point more requires to  be specially mentioned in relation to these
growths; viz., their occasional liability to return  after they have  been to
all  appearance completely extirpated.  Where this  has taken  place the
tumor has, I believe, generally grown  quickly in the  first instance, has
been  composed of several detached  portions, of  ivhich one or more  may
have  been left behind in the first  operation, or has consisted  in a thickened
morbid condition of the tissue in ivhich the growth occurs, affecting a con-
siderable area and probably not having such definite limits as these growths
usually present.   To the latter circumstance I have already directed your
attention  in speaking of fibrous  tumors of  the periosteum, and have said
that the same feature is to be observed in  some of  the adipose tumors,
more  particularly those under the skin.                Part xxiii., p. 236.

  Diagnosis of Tumors  in  the  Neck.— [This ahvays presents great dif-
culties when the tumors  are of  large  size, only  slightly  painful and
fluctuate  indistinctly.  If a  complete and accurate history of the case
cannot be obtained, more than a general diagnosis may be impossible ; but
when the precise position of the tumor at its commencement can be made
out, when its relations to the larynx and trachea, and its mobility in regard
to them and the surrounding parts when it was of small size, can be ascer-
tained, together  ivith the rapidity and manner of its growth, Dr. Redfern
thinks there will be  little  difficulty in arriving at a satisfactory conclusion.]
  A  tumor developed in the substance of the thyroid body presents itself
in the front of the neck, is usually larger on one side than the other, is firmly
-connected Avith the  larynx and trachea, moves freely with the  larynx in
deglutition, and wdien it is displaced laterally by manipulation.   The other
features vary ivith the nature of the tumor.
  In  ordinary  bronchocele (hypertrophy) the SAvelling is soft, projecting,
elastic; without  fluctuation, pain or tenderness on pressure;  it occurs
usually in early life, in the female  sex, and in particular districts of country ;
it is simple in its nature throughout, and presents no tendency to degene-
ration or change of  structure: it in no way interferes with respiration or
deglutition, nor does it affect the patient's health or comfort until it becomes
of very large size, when  difficulty of respiration and  deglutition, with fre-
quent headaches, occasion the greatest  distress, and may end with the
death of the sufferer.
  In  cystic disease of the thyroid the nature  of the tumor becomes mani-
fest, sooner or later  by the presence of fluctuation  in one or more cysts,
by a  glairy,  serous, or soro-sanguineous fluid escaping readily along  a
grooved needle when introduced,  the fluid containing no cellular formations
when  examined microscopically,  or having  such  a structure as  is consis-
tent with the idea of the existence of cancer—by the formation of the
tumor taking place at or after the middle of tife—by  its sIoav and painless
growth, and by the  slight inconvenience  it occasions as long  as its size is
not very great. 
TUMORS.
721
  In cancerous disease of the thyroid (usually scirrhus) the  tumor ap-
pears betAveen forty-five and sixty-five years of age, is of great and uniform
density, and generally painful;  it is  developed rapidly, and may attain a
large size in the course of a few months; it accompanies the larynx in its
movements, but shortly limits their extent  by attaching the organ  to the
surrounding parts; it occasions great difficulty of deglutition and  respiration
from an early period ; hoarseness, cough, and spasmodic action of the mus-
cles of the larynx and pharynx come on and increase in their intensity—the
distress and anxiety of the patient, his sallow complexion and emaciation,
marking him out as  the subject of" a steadily advancing and  destructive
malady.
  In medullary  cancer of the thyroid the  surface of the tumor may
be even and tense, or indistinct fluctuation may be perceived, the other
characters depending on the steady infiltration of the surrounding textures,
distinguishing the disease from  other tumors of the same part.
  Enchondromatous tumors are to be recognized by their great density,
the sloAvness of their growth, and the absence of any signs of the extension
of the affection to the surrounding parts, and of general evidence  of the
existence of malignant disease.
  The diagnosis of tumors of the neck not connected with the thyroid body,
is to be established by reference to the general characters which  distin-
guish them in other situations, every particular of their history and mode
of growth being carefully ascertained as  essential points,  and sufficient
care being exercised lest the presence of a  quantity of coagulable fluid, in
the interior of a cancerous tumor, lead to  the belief that it is  of a cystic
character.                                           Part xxiii., p. 279.
  Tumors, Encysted.—Evacuate the contents  by making a small oblique
opening on the cyst.   Inject  then  an alcoholic solution of iodine, closing
the aperture with  diachylon or charpie.  As soon as the inflammation hap
subsided, the cyst becomes detached, and  may be extracted by means of
the forceps.  Usually, however, M. Borelli  has found that tivo or three in
jectipns are necessary to promote  a complete separation.
                                                    Part xxiii., p. 295.
  The Cold Douche in Promoting Absorption.—Dr. Sloan submitted to
its action,  cases of an encysted tumor—a goitre and a scirrhous mamma—
and in all there has been decided improvement.   The water with ivhich he
has practised is supplied to the town from a basin 100 feet above the  loivest
street.   He applies it by means  of the gutta percha tubing fixed to one of
the pipes, allovving the stream  to strike the object at from six inches to
two  feet from the end of the tube ; at all events, before the  column of
\vater is broken.  A pressure of less even than forty feet  of water produces
excellent effects.   The  application  should  be continued until a decided
sense of pain is induced, or for something less than five minutes.
                                                    Part xxiii., p. 306.
  Sanguineous Pelvic  Tumor in Females.—M. Nelaton calls attention to
a peculiar  form of tumor, hitherto  much  neglected by authors.   These
tumors are usually preceded by some general  symptoms, as malaise, dis-
turbed menstruation, pains in  the hypogastrium, and a feeling as if a heavy
body were about to escape from the vagina.   The abdomen is sometimes
enlarged, and a hard, xevy painful tumor is felt  by the patients in  the hy-
pogastric region;  in  other cases they are not aivare of its existence, and,
    VOL. II.—10 
722
TUM0R8.
when it is pointed out to them, they cannot say how long they have had it.
On examination, the abdomen is found to be  inflated, tense, convex, and
painful.  The decubitus is dorsal, w ith the thighs flexed on the pelvis.  By
palpation  in the hypogastrium, a tumor  is felt in the  cavity of the pelvis
[petit bassin).   This is sometimes confined within its inner border, and
sometimes extends as high as the  umbilicus;  it is  commonly inclined to-
ward the  right iliac fossa.  The tumor is  small, rounded, ivithout knotty
projections, and becomes gradually lost  in the pelvic cavity ; it is scarcely
movable, and is of  pretty firm consistence, sometimes  presenting fluctua-
tion. On  vaginal examination, there is found, betAveen the uterus, a tumor,
advancing toward the orifice of the vulva in proportion to its size.  It is
smooth, rounded, and fluctuating, varying from the size of a large goose-
egg to that of a thumb, Avithout  pulsation  or expansive movement; it may
narroAv the vaginal canal so as only to permit of the passage of the index
finger. The uterus may be  raised by the tumor,  so  that its  body is felt
above the pubes ; and its neck may be so  much elevated, that the forefin-
ger can only with great difficulty reach  it.
   The treatment of these tumors consists in  evacuating the liquid ivhich
they contain.   M. Nelaton proposes  to employ a large trocar, and then a
simple lithotome to enlarge the opening.  The patient is  placed on her
back, on a tolerably high bed, ivith her legs  and  thighs  bent, as in  the
 position for lithotomy.  By introducing a speculum into the vagina, the
 tumor is discovered toAvard  its base,  at the posterior wall.  The point
 where fluctuation is most apparent having been discovered, a long trocar
 is introduced, with a canula sufficiently long to allow the  escape of the
 matter, which  is liquid, black, and viscid, like treacle. The incision ought
 generally to be three centimetres in extent; it should be made in the axis
 of the vagina, so  as to avoid wounding  the  uterine  arteries.  It should
 also be carefully ascertained that there are no arteries on that part of the
 wall in which  the  incision is  made.  The incision should be neither too
 wide nor too deep, so that the rectum may be avoided. When some days
 after the operation, the liquid which escapes has become purulent and fetid,
 disinfectant injections should be employed.  The  strength of the patient
 should at the same time be supported  by quinine and other tonics.   The
 walls of the tumor should also be explored with a  scoop (curette), so as to
 remove any adherent clots,  which may be in a state of commencing putre-
faction.                                             Part xxiv., p. 297.
   Calcification of Fibrous Tumor of  the Uterus.—Mr. I. B.  Brown ex-
hibited a specimen  of fibrous tumor, which had been transformed by  calci-
fication into a solid, heavy body,Aveigbing eight ounces. It Avas situated at
the fundus of the uterus. The sides of the uterus were not adherent to this
body, but were distended so as to form a sort of close-fitting bag to the
tumor ; the neck of the uterus was drawn up and lost in the body, and the
 os was elongated and thin. This interesting specimen was found in a patient
aged seventy.
   The calcareous crust of this tumor consists of semi-transparent plates,
overlaying each other, having a glassy fracture ; these dissolved in dilute
muriatic acid allowed an abundant escape of carbonic acid, leaving a resi-
due of an imperfect fibrous basic substance.            Part xxv., p. 292.

   Fibrous Tumor of the Womb removed by Incision and Enucleation.—
 Mr. Teale recently  removed a large fibrous groivth from the interior of the 
TUMORS.
723
aterus.   The tumor  had protruded through the mouth of the womb and
filled the vagina.   It was  so large  that  the fingers could not be passed
above it to determine its mode of attachment.  The treatment adopted in
this case, which Mr. Teale also recommends in similar ones, is, to jiull down
the tumor beyond the external parts, if necessary, by midwifery forceps or
other means, and partially or completely invert the womb.  The  operator
can then ascertain Avhether the tumor be  pedunculated  or imbedded in the
wall of the womb.  Should the latter mode of attachment be found, he re-
commends the investing membrane of the tumor, a little below its attach-
ment, to be carefully cut through in a transverse direction, by long curved
probe-pointed scissors, to such an extent as to allow of the tips of tivo  or
three fingers to be insinuated betAireen the  investing membrane  and the
tumor,  and  the  process of  enucleation to be  completed by detaching the
upper part of the tumor  from the wall of the uterus,  after which the re-
maining attachment of the investing membrane may be divided by the
scissors, and the tumor removed.  If the  uterus should remain inverted, it
must be immediately replaced by gentle but firm pressure, ivhich may gene-
rally be done wdthout difficulty, as the os uteri has been so long subject  to
distention that it will offer but little resistance.      Part xxviii., p. 289.

  Nerves—Excision of Tumors of (Neuroma).—When a tumor pressing
upon, or in  any  way implicating  a nerve, has to be excised or dissected
out, make a clean incision of the  nerve  either  above or below the tumor
before the operation, as this will not only considerably lessen the pain, but
also the subsequent inflammation.  The consecpient paralysis lasts only a short
time, as the divided nervous extremities  soon reunite.   Part xxx., p. 309.
   Tumors of the Upper Jaw.—It is a common opinion that these tumors
originate within  the antrum of Highmore.  Mr. Hancock does not agree
with this opinion. Mr. Ormerod, of St. BartholomeAv's, has taken pains to
classify these tumors, which he does as follows:
  1. Epulis.
  2. Cystic  tumors, consisting of the Avails of the bone  expanded on  or
into a sac, wdth more or less of solid groivth ; the walls  in some parts being
quite membranous and transparent, and the sac filled with glairy fluid, or
a firm substance  contained in  cells,  or accompanied with a granular fatty
substance,  partitioned by fibro-cellular  substance; also  consisting of  a
single bony cyst lined by a membrane, with a second canine tooth adherent
U> it, and having its  cavity filled by a glairy fluid.
  3.  Cartilaginous and osseous tumors from the upper jaiv-bones,  as round
tumors growing on their outer surface here and there, but chiefly as a mass
growing from their inner surface, so as to fill  up the maxillary sinuses, the
septum  nasi and spongy bones  being also  affected.  The  thickening is
dense, hard, and  ivory-like.
  4.  Fibrous tumors from  the upper and loiver jaw-bones, consisting of
white or pale yellow, firm, and nearly homogeneous, with or without specks
of bone, or of dense, more  or less fibrous,  or even obscurely fibrous, sub-
stance,  containing at times one or more small cavities filled with pus, with
a glairy fluid, or  ivith blood ;  growing cm a healthy bone  and periosteum,
or from the alveolar and outer surface of the  bone, or originating in the
cancelli, and being  accompanied with a perfectly  healthy condition, with
absorption or consolidation of the surrounding bone.
  5. Medullary tumors from the upper or  loAver jaw,  consisting  of round 
724
TUM0R8.
lobed, or nodulated masses, with a smooth membraneous covering, or with
a rough fungous  or ulcerated shreddy surface;  invested by a thick cap-
sule, by a dense periosteum, or by partial thin lamine of bone; composed
of round  lobes, connected together by cellular tissue, or formed  of an
almost homogeneous mass ; made up  of a  structure of a soft  medullary,
brain-like, spleen-like, or firm fatty nature, wdth cells  and bony spicule,
sometimes commencing in the neighboring glands, and extending to the
jaivs secondarily.
  In addition to these, Mr. Stanley enumerates fatty and erectile tumors of
the jaiv ;  whilst Mr. Paget adds what he terms myeloid tumors of the
part; but whilst  the examples he  quotes  resemble so much, on the  one
hand, the fibrous, on the  other medullary tumors, their true character,
whether innocent or malignant, is so very doubtful, that I should hesitate
in admitting them as a distinct class.
   I have  never met with a fatty growth so invading the  upper jaw as to
require the removal of any portion of that bone, and therefore I do  not
presume to  offer any opinion upon that form of disease.
   Mr. Stanley states that the erectile tumor is a very rare form of disease ;
but  that  it  occurred  to M. Gensoul  in one of his successful cases.   The
tumor was  soft and vascular, and  quicksilver, impelled into the morbid
structure, readily pervaded it throughout.  I have not seen a similar case,
nor  have  I been able to meet with any recorded elsewhere.  It is occasion-
ally very difficult to form a correct opinion of the exact point of origin of
a fibrous  tumor of the upper jaw.  It will sometimes commence by a  con-
tracted pedicle, enlarge, and spread out, and not only fill the antrum, hut
extend into the nares ;  by its peculiar and  irregular appearance giving rise
to the  supposition of its being a  polypus of the  nostril, and leading to
abortive  attempts for its removal  by the  polypus  forceps. Mr. Stanley,
although not mentioning the disease,  has the following observations bear-
ing  upon this point: " A tumor gradually increasing within the antrum
may occasion yielding of the Avails equally in all directions; but in some cases,
disease extends chiefly in one direction, and causes difficulty of  diagnosis.
In a case I  saAV, a morbid growth originating in the antrum had extended
only in the direction  of the nostril,  and portions  had been extracted by
polypus forceps."
   [Osseous  tumors are the most frequently met Avith amongst the non-malig-
nant groivths of the upper jaw.  Mr. Hancock has two specimens of this
disease:]
   The first  case is that of a young  man, aged 22, a farmer, residing in Lin-
colnshire, who Avas sent up to me on the 1st October,  1848, by Mr. Young,
of Gosberton, whose patient he Avas.  This case Avas a striking example  of
what has  been affirmed elsewhere,  that "osseous growths are in some in-
stances combined with  hypertrophy of the surrounding  bones, producing
general enlargement."  The whole  of the bones on the right side of the
head and face Avere very much enlarged  and thickened, the bone  at the
fronto-malar suture presenting a surface of more than a square  inch, and
this, I believe, is the usual origin of the tumors in question.  I believe that
they should not be regarded as originating within the  antrum, or from
causes connected with the teeth, but from excessive development or hyper-
trophy of the bone itself, Avhich, in its growth, extends in various direc-
tions, invading the antrum of Highmore,  and in some instances entirely
obliterating  that cavity.  M. Paget, in his Lectures on Surgical Pathology, 
TUMORS.                            725
 in allusion to these tumors, says : " More commonly, it is almost limited to
 the antrum;"  but he  singularly disproves his assertion, and confirms  my
 views, by his  illustrative  example.  He says : " In this case, it may exist
 with little deformity.   In  the museum of St. Bartholomew's Hospital is a
 specimen, in wdiich both the  antra appear nearly filled  by the thickening
 and in-groA\dng of their Avails ;  only small cavities remain at their centres.
 The neAV hone is  hard, heavy, and nearly solid, yet it is  porous or finely
 cancellous, and is neither  so compact  nor so  smooth on its cut surface as
 that of ' ivory exostosis.'   The same  disease is manifest  in a less degree
 upon the outer surfaces of the maxillary bones, and on the septum and side
 Avails of the nose."
   I have operated upon three cases of this form of disease.  One of thtise
 I have just related, and in the other tAvo the antrum remained; in one of
 these there Avas general hypertrophy of the bone, causing  great disfigure-
 ment, and  necessitating its entire removal.  The swelling did not  arise
 from, and Avas not confined within, the cavity, but Avas, in truth, a portion
 of the general thickening  and enlargement  of the bone.  I  have a prepara-
 tion, Avhich was taken from a child of six years of age, upon ivhom I ope-
 rated in April, 1852, and is a well-marked  example of the fallacy  of Mr.
 Stanley's position, that " morbid groAvths  mostly arise from either of the
 lateral parts, not from the front of the jaw—a fact ivhich might be explained
 by the consideration that  irritation more frequently originates in a molar
 than in an incisor tooth,"  as does the folloAving case:
   A child was admitted, under  my care, into  the Charing  Cross Hospital,
 in August, 1852, with tumor of the left upper maxilla.   It  appears that in
 December, 1851, she fell and bruised  her  face.  Soon afterAvard a tumor
 ivas observed on the left side, just beloAv the orbit.   This Avas unattended
 ivith pain, but it gradually increased in size until, at the time  of admission,
 it was about the size of a  walnut.  Upon careful examination, I found the
 hard palate and gums perfectly healthy;  the tumor was smooth and solid.
 Upon  carrying my finger behind  the soft palate, I could  not detect any-
 thing wrong in that situation ; but as  I otherwise could not detect the ex-
 tent of the mischief, or ivhat was the extent of operation required, I intro-
 duced a small exploring trocar into the tumor, and felt it enter a solid mass,
 which prevented my giving the instrument any lateral motion.  I next per-
 forated the upper jaw above the  alveolar process corresponding  to the
 molar  tooth, and found the instrument  enter a cavity, in which I could
 freely move its point, and  from  ivhich I decided the case  was hypertrophy
 of the anterior portion of the  maxillary bone, and I acted accordingly,
 confining the operation to  the simple removal of the part affected, without
 interfering either ivith the  floor  of the orbit or the roof of the mouth.
  The last form of abnormal growth is the encephaloid or  medullary sar-
 coma ;  and it is here that  a correct idea of the  origin  of these  groivths
 becomes of so  much importance.  I have throughout  this  paper been  at
great  pains to disprove the opinion so universally maintained, and so de-
 cidedly advocated by Mr.  Stanley, that morbid  groivths commonly origi-
nated Avithin the antrum, not only because I felt, from what I had observed,
that such opinion was wrong, or rather open to very many exceptions, but
because the statement,  backed by such an authority, gives rise to the sup-
position that  medullary sarcoma usually commences within  the  antrum;
and that, if attacked sufficiently early, it may be  eradicated by operation.
At the risk of  appearing tedious, I feel that the importance of* the subject 
726
TUMORS.
fully justifies my again quoting Mr. Stanley.  He says: "But even wdth
the help of the most  careful examination, whenever the disease fills the
antrum and nostril, it will be uncertain  whether or not it  extends pos-
teriorly beyond the front  surface of the pterygoid processes of the sphe-
noid bone.  Whilst Mr. Listen has observed: 'If anything is to be done,
it ought  to be undertaken with a thorough determination to go beyond
the limits of the morbid growth, to remove the cavity ivhich  holds  it, and
thus get quit, if possible,  of all the tissues implicated, or which  may have
becoihe disposed to assume a similar action.'  I know from experience, that
this step,  if adopted in time, may prove successful."  It may appear pre-
sumption in me to differ  from such authorities as these, and men of such
experience, but my own experience leads me to an opposite conclusion.
   I entirely differ from the opinion that medullary sarcoma commences in
the antrum of Highmore, and extends backward to the  pterygoid pro-
cesses ; but, on the  contrary, from ivbat I have observed,  I firmly believe
that the disease commences in the cancellated structure  of the body of the
sphenoid  bone  and bones  at  the base of the cranium;  and that, hoAvever
early we may perform the operation, we never succeed  in  eradicating the
mischief, which is sure to  return at a longer or shorter period, according to
circumstances.
   I have  performed, and  assisted at many operations for the removal of
the upper maxilla for  this disease;  and where the mischief, as  far as ex-
ternal examination and the introduction of the finger behind the soft palate
went, appeared to hold out every reasonable prospect of its complete re-
moval, but in no one instance was  this satisfactorily accomplished,  and in
no one instance did the disease fail to reappear, whilst post-mortem ex-
amination demonstrated its growth from the body of the  sphenoid bone,
the basilar  process of the  occipital bone, etc.  This disease will sometimes
extend into the orbit,  in some instances causing the eyeball to protrude,
in others presenting us a firm tumor on  one side of the eyeball.   But it
should be borne  in mind that, notwithstanding the absence of external
swelling of the cheek, these growths rarely, if ever, originate in the orbit,
or are confined to that cavity, but that the swelling in  the orbit is  almost
invariably an extension of the disease in that direction, its origin being in
the cancellated structure of the bones at the base of the cranium, and that
it mostly, at the same  time, invades the spheno-maxillary fossa and antrum
of Highmore, so that it can never be entirely removed  by  dissection from
the orbit.
   I have  a lady at present under my care,  who consulted me for protru-
sion of the  left eyeball, with apparent  commencing chemosis of the con-
junctiva  and indistinctness  of vision.   The protrusion  is not very  great;
but pressing the base of the eyelids near the margins of the orbit, gives
the sensation of an elastic body between the orbit and the eyeball.   There
is no swelling  of the cheek; but, upon examining the  mouth, I find the
gum is beginning to separate from the  molar teeth, and the dental margin
to become everted, whilst separation is also commencing between the hard
palate and  its covering,  the bone appearing softer than natural when
pressed upon.  Carrying my finger behind the soft palate into the spheno-
maxillary fossa, I can distinctly feel an  irregular  growth in that situa-
tion.
   This case shows the  impropriety of operating upon orbital growths of
this description, the tumor in that situation  being commonly but a local 
TUMORS.
727
manifestation of disease extending into the upper jaw  and elseivhere,
where the knife cannot penetrate.  In some instances the tumor will be
more isolated  or partial, and equally, if not more malignant, if we may
judge from the rapidity  of its growth.   It will not present the same
elasticity to the touch, feeling more like an enchondroma, and when cut
into, it has very much the appearance of a fibrous  groivth.
  A Avoman brought  her child, aged tAvo years, to me at the Ophthalmic
Hospital with a conical tumor of the orbit, at the inner and upper part;  it
was very firm to the touch, and the mother said it caused  the child great
uneasiness.   She had perceived the  swelling about  a month before.  I
entertained some doubts as to the nature or the  swelling, and  expressed
them to the mother,  at the same time telling her that I could not recom-
mend any operation.   At this time  the disease was apparently confined to
the orbit, as by careful examination I could not  detect any manifestations
elseAvhere.   She pressed me to do something, and therefore I endeavored
to remove it, and found it to consist of dense fibrous structure, invested by
yelloAv, firm substance; it penetrated  so deeply, hoAvever, that I could not
get the  whole aAvay, and  the SAvelling  rapidly reappeared,  the disease
seeming to be lighted up  with fearful  intensity.  The child lived  tAvo
months  afterward, but had  become a most frightful object.   The  tumor
protruded from the orbit, extending upward toivard the forehead, out-
ward, invading the temple, and downward through the upper maxilla and
mouth to the neck.
  These cases justify the opinion that fungoid or medullary growths of
the orbit rarely exist as independent disease, but that they almost always
coexist with the same disease in the  antrum and  spheno-maxillary fossa;
at all events I do not recollect  an  instance where this Avas not  the case,
and I have seen many of them.
  Having endeavored to point out the inadvisability of performing opera-
tions in  cases of medullary sarcoma of the upper jaw, I will now advert to
some of the most prominent  means of diagnosis  between this disease and
other abnormal growths of that  part.  The diagnosis between fibrous
tumors  and medullary sarcoma  is  very obscure;  some idea may  be
obtained from puncturing the tumor, and from the degree of resistance  to
the lateral motions of the instrument presented  in the former disease,  as
well as from the absence of spicule of bone discernible in some forms of
the latter ; but the principal  diagnostic signs ivhich Ave posses are, the con-
dition of the teeth, gums, and bones of the part.   It is true that the bones,
in certain conditions  of health—as in the case to-which I have  alluded—
may, from pressure, become carious,  or  even destroyed by necrosis; but
they are never converted into that soft  degeneration so characteristic of
medullary sarcoma, or the  malignant disease. Pressure on the hard palate
is met Avith  firm, hard resistance ;  whereas in medullary sarcoma—in all
cases wdiere the tumor projects from the cheek, and in very many of those
wherein  the  disease  manifests itself in the orbit—the palate upon the
affected  side is elastic to pressure, usually more congested  than natural,
Avhilst the gums are congested and thickened, the dental margin is thick-
ened and everted  from the  teeth,  Avhich become  irregular, loosened, and
projecting.  When seen for the first  time, this condition of the gums and
teeth may be mistaken for abscess or disease  connected Avith  the teeth,
with wdiich, however, it has nothing to do,  and  from ivhich it may be dis-
tinguished  by the  comparative slight pain which accompanies it, by  its 
72S
TUMORS.
gradual progress, by the absence of inflammatory swelling of the cheek,
and by the character of the enlargement of the gums.
  In this affection  the gums  are  spongy and elastic, and, when pressed
up»n, are found, in a great degree, to have lost the support of the alveolar
process, which becomes softened by the disease :  whereas in  inflammation
and abscess resulting from disease  of the teeth,  or alveolar  sockets, of a
simple character,  the pain is very great, the sivelling of the cheek  is evi-
dently of an inflammatory character, whilst the  enlargement of the gums
is smooth and firm, and the  firm resistance of bone beneath may almost
always be detected.  In medullary sarcoma this  state of the gums should
be regarded as the result, not the cause, of the disease; and for the
reasons which I  have already given in the early part of the paper, the
teeth, though loose and comparatively useless to the patient, had  better
not be meddled with.
  Bony tumors, though more easily distinguished from medullary sarcoma
than fibrous groivths, may, upon superficial examination, create doubts in
the minds even of well-informed surgeons.   As I  was going down into the
operating-theatre, to remove the upper jaw from a child aged six years, a
surgeon of some standing, who had examined the child in the ward, said,
" Surely, Mr. Hancock, you  will  not meddle with that; it is malignant."
He was misled by a certain degree  of elasticity presented at one point of
the tumor, and ivhich I have observed in all the cases which have  fallen
under my observation. They have not  been  of that form denominated
ivory exostosis, but have all presented a certain  degree of yielding  to the
touch; but they have this  marked distinction from the medullary sarcoma:
in this latter disease the surface of the tumor is uneven and elastic, but the
elasticity is superficial; whereas in osseous tumors the elasticity is deeper
seated, and the yielding or elastic substance is evidently covered by a thin
shell, ivhich recedes when  pressed upon, but appears to recover itself when
the finger is removed.  We  have not the crepitation in these cases as in
osseous cysts, but the  elasticity is  covered by a  thin, smooth investment,
and  is  not so immediately upon the surface  as  in  osteo  or medullary
sarcoma.  Puncturing these tumors with an exploring needle, or what I
prefer, a small trocar, will also assist  us in our  diagnosis.   In medullary
sarcoma, the instrument appears to enter  a soft  mass, and with but little
force a considerable degree  of lateral  motion may be given to the  instru-
ment ; but not so in osseous tumors.  Here, though it may be introduced
with difficulty, still it will  appear to  be clung  to by the structure into
which it penetrates, and  lateral motion cannot be obtained except with
that  degree of violence Avhich we  should be unwilling  to employ; and,
again, as in fibrous growths,  the  condition of  the gums and  teeth will
pretty surely mark the non-existence of malignant disease.  The teeth will,
in many instances, be perfectly sound ; and though, in others, the patient
may have lost some of those organs, the gums may have healed, and will
not shoAV any of that spongy appearance, or tendency to eversion, so cha-
racteristic of the malignant  disease.  I  never  saw a tumor of  the upper
jaw  of a malignant character unaccompanied by mischief about the palate
and gums ; but an osseous tumor may have attained great size, and cause
considerable deformity, Avithout projecting into the mouth, or complicating
the palate or gums at all;  and  this is  an additional reason for employing
an exploring needle or trocar, this  instrument, in some cases, affording us
the only  means of ascertaining the extent of operation to be performed-^ 
TUMORS.
729
whether the whole, or  a portion  only, of the upper  maxilla  is  to  be
removed.  Mr.  Fergusson  has  laid doivn  that rapidity of growth is a
diagnostic sign  of malignant tumor; this, however, is not entirely to  be
depended upon, as the growth of bony tumors will sometimes be extremely
rapid, as in oue  case wherein the tumor attained a great size in less than
five months.                                         Part xxxi., p. 136.

  Tumors of the Jaws.—[In a  clinical lecture on this subject, Mr. Syme
makes the following important general remarks which will apply to tumors
affecting both upper and loAver jaw*.]
  There are some anatomical differences between  them, ivhich lead to
pathological differences.   In the upper jaw, the hollow of the maxillary
antrum exposes  to a condition ivhich cannot exist  in the lower jaw—viz.,
inflammation and suppuration of the cavity.  The  antrum also serves as a
receptacle for polypus growths, which, however, are mere intruders from
the nasal cavity, and not diseases of the jaiv itself.  In both jaAvs the bone
is apt to die from  the effects of inflammation.  In the upper no reproduc-
tion of bone takes place after removal of the exfoliation  ; in the lower the
bone is denser, and the  periosteum  more  capable  of  reproduction, and
there is no instance in the body of  a more complete  restoration of bone.
I have repeatedly seen almost the whole lower jaw, including the condyle,
throAvn off as an exfoliation, yet complete reproduction has  taken place.
These are  all the differences which  it is necessary for me to notice now.
There has  been  a notion  prevalent, that tumors of the upper jaw originate
in the antrum.   This is  erroneous; their origin is in all cases similar to
tumors of the lower jaw.
  Tumors  of the jaws are chiefly of five different kinds—three solid and
two fluid.  Of the solid, you have one growing from  the surface, and tivo
in the interior of the bone.  The one on the surface is denominated " epulis,"
or "epulotic tumor;" it appears on the gum, and increases in size without
ltinit to its growth, and at last becomes inconvenient from its bulk ; it is also
liable to bleed, and may become as serious, in this  respect, as if  it were
malignant.  Epulis grows from the surface of the bone, and requires for
its remedy the  removal  of the part to which  it is  attached.  The knife
never cures the  disease completely, and it is ahvays requisite to take away
more or less of  the alveolar process, in order to do ivhich you must extract
oue or more teeth.
  The other two forms of solid  tumor originate in the  osseous substance,
and are divided into simple or local, and malignant, or  those where there
is  some constitutional derangement  connected ivith the local condition,
which produces  a tendency to a return of the disease  after its removal.
The first kind  are  generally of firm consistence, and sIoav groivth, and
accompanied by a healthy state of the constitution;  the second are of soft
consistence, and rapid growth,  and the patient's  constitution commonly
unhealthy.  But these kinds pass, by various degrees, insensibly into each
other.  The slower the groivth, the firmer the consistence, and the more
healthy the constitution,  the greater will be the probability that the dis-
ease is entirely local,  and that the removal of the tumor ivill be followed
hy a permanent cure.  But tumors of  the most rapid groivth and softest
consistence have sometimes been taken away, without any return of the
disease ; and hence the  general rule is, that if such tumors are distinctly
limited to the  jaw, they should be removed.  You must bear in mind. 
730
TUMORS.
however, that a malignant  growth is apt to  extend its roots beyond the
bone from  which it originated, in this respect remarkably differing  from
the  simple, local, or fibrocartilaginous groivths, to ivhich your  attention
was lately directed.  The other day, a lady, said to be  laboring under
polypus  of the nose, consulted me.  I found,  however, that the soft  mass
which showed itself in the nostril was realiy a tumor proceeding from the
superior maxillary bone;  and further, a  swelling  at the  inner canthus,
shoAved that the disease was not  limited to that bone, but extended up to
the ethmoid, and  probably to the base of the skull.  I therefore advised
her  against any interference ; but had the disease appeared limited to the
superior maxilla,  I should  have  recommended excision of the bone.  I
could mention several cases, where the removal of soft tumors of the jaws
of rapid  growth has been  folloAved by permanent recovery.
  The fluid tumors of the jaivs are of tAvo sorts, being collections either of
serous or purulent fluid ; the serous or cystic are not unfrequently mistaken
for solid tumors ;  they grow in the  substance of the bone, and  are gene-
rally at  some parts of their extent  as hard and as unyielding as bone, so
that if their examination  be  limited to these parts, the  tumors will be
supposed to be solid.   Even so accomplished a surgeon as M. Gensoul, of
Lyons, had once made his incision and exposed a tumor of the jaAA', when
all at once the knife entered a cavity, from wdiich serous fluid escaped.  I
have myself met such cases, and seen them in the practice  of others.  It is
therefore necessary to examine a  tumor of the jaw over its whole surface;
then, if  it  be cystic, you  will be almost  sure to find some yielding point
where the hone gives way  like pasteboard, and is perhaps felt to crackle
under the  finger.
  These cysts frequently exist independently of any other morbid condition,
but  sometimes, and  especially in  the upper jaw, they are  connected  with
displaced teeth, one of the permanent set  having taken a wrong direction,
so that,  Avhen the  cyst is opened,  the tooth is found lying in its interior: I
have, in  this theatre, more than once found such a state of things present.
Whether this be the case or not the treatment is the same—viz., to  open
the cavity  freely and  stuff it with lint.  The  prognosis is, hoAvever, more
favorable if a tooth be found in the cyst; it is  then almost certain that the
cavity aa ill contract and  heal.  This may occur in other  cases, but it has
also  been noticed that cysts, after being opened, are  not unfrequently fol-
loAved by the formation of a solid tumor. I  could mention to you cases
where I have opened cysts  containing nothing but serum, in the place of
wdiich solid tumors have  afterAvard  been formed.  It is also possible that
the  cysts  may be complex, and  so  extensive as  to require  removal.  A
patient left the hospital only a feAv Aveeks since Avho applied  to me five
years ago  on account of a  large  cystic tumor of  the loAver  jaw, which ]
opened, and gave exit to a large quantity  of albuminous fluid, and  stuffed
the cavity  AAdth lint.  The swelling afterward contracted to a considerable
extent, but never  entirely disappeared, and she returned two years later
Avith the tumor as large as when I  first  saw her, and affecting the  jaw
more extensively.   I  again  opened  and  stuffed  it, and the  tumor again
contracted  to  a  certain extent.   It, however,  again increased,  and  I
repeated the process  for  the third  time, but Avith  the same result, the
patient returning last autumn with  the tumor larger than ever, and ex-
tending now from the symphysis to the coronoid process.  I removed half
the jaw  by disarticulation,  and on examination we found  that  the  cy*t, 
TUMORS.
731
instead of being simple, Avas complex, consisting of four chief cavities, the
walls of Avhich were studded with smaller cists of various sizes.  It was
clear that in this case nothing short of excision of the portion of the bone
affected could have  produced a cure.
  Tumors depending on  purulent collections are not  at all uncommon,
They are almost invariably in connection with  the stump of a tooth.  A
portion of a stump may remain after the extraction of a tooth and be for-
gotten, and the -tumor may be  supposed by  the surgeon  to be solid.
Generally, hoivever, the parietes, like those of  serous collections, will be
found to yield at one place, and you find an additional guide to  your diag-
nosis in the presence of the diseased tooth.  I  lately saw* a tumor of the
lower jaw, ivhich ivas removed under the supposition  that  it was solid
throughout; but on being saivn  through, it  proved to  be an abscess, the
osseous Avail of which  had undergone immense thickening, except at one
small point in  immediate  connection with a diseased  tooth, which had
never caused any pain.  In that case, it may be doubted whether it would
have been possible to afford relief otherwise,  even if the real nature of the
disease could  have  been made out, from the difficulty of affording a free
outlet for the discharge.                               Part xxxi, p. 140.

   Fibrous Tumor of the  Womb.—Give the liq. calcis chlor. from 30 to 50
minims, twice a day for months,  or give the  Kreuznach-water  (artificially
prepared by Mr. Hooper) 3j. three times a day  in warm  water, at the same
time  using an injection  for the vagina of 3ij. to the  ^j. of water.  Dr.
Preiger, hoivever, chiefly depends on baths and fomentations composed of
the Kreuznach-water, and some extraordinary  effects have no doubt been
produced by him, as ive have seen.                     Part xxxi., p. 212.
   Iodine in Fibrous Tumors in the Uterus.—Dr. West almost invariably
 orders for those of his patients at St. Bartholomew's wdio are the subjects
 of fibrous tumors of the uterus, a long course of one or  other of the prepa-
rations of iodine.  The folloiving  is the prescription ivhich was ordered for
 a middle aged woman, who applied with that disease.
   Potassii iodidi, gr. j.;  sirup ferri iodidi, mxx.; aquse carui, gss.  Ter die
 sumend.                                             Part xxxi., p. 311.
   Atheromatous  Tumors of  the Scalp.—[These consist  essentially of a
diseased sebaceous follicle, lined inside by tessellated  epithelium,  and com-
bining a cheesy-looking matter ; if they contain a darkish-colored matter,
it is  a sign of disintegration, not unfrequently folloived by  ulceration,
which may readily be mistaken for a malignant growth. Mr. Erichson says :]
   The mode of  removal of these tumors before ulcerating is very simple.
A single incision is  made across the Aven or  cyst, and then, wdth a strong
drag of a forceps, a sort of evulsion is practised, the entire growth coming
out like an  almond from its husk  or  shell.  They are  found also under the
eyelids, and are  made ivorse  by any practice but one—namely passing a
small probe through them on the conjunctival surface, and stirring up the
contents with the probe dipped in nitric acid.        Part xxxii., p. 196.
   Vascular Tumors.—Elastic  ligatures  are much  superior  to inelastic
ones  in the removal  of vascular tumors, etc.  To  apply it  the elastic
thread  must be stretched to its  full extent, and tied in a single knot ; it
must then be slipped over the  tumor and tied, by a  double knot.  Stran-
gulation follows, and the tumor falls off in a  few days.  Part xxxv., p. 93. 
732
TUMORS.
  Sebaceous  Tumors.—Pass through the centre of the tumor a needle
carrying a thread, and tie the same as a seton; the tumor will inflame,
pus will form and be evacuated through the apertures.   The thread may
be removed in a fortnight.   This treatment is  only applicable to  those
tumors  Avhich are  more or  less in a fluid state.   The size of the thread
must depend upon the size of the tumor. (M. Marchand.) Part xxxv., p. 170.
   Uterine  Fibroid  Tumot—Enucleation  of.—In  making the opening
through the uterine wall, the French and American surgeons prefer the
use of the  knife.  In a case of Dr. Simpson's, caustic potash Avas applied
an inch behind the os uteri.   Our OAvn opinion is decidedly in favor of the
knife, and to make the opening through the uterine  structures from Avithin
the uterine cavity, rather than from the vagina.   Then comes the question,
ought we to enucleate at once by instruments, or  Aiait for the expulsive
action of the uterus ?  Before we can ansiver this, we ought to be able to
say whether the organ is, in such cases, always in a condition to exert it.
Is it hypertrophied ?   This is by no means invariable.   Hence how  hope-
less it would be in certain cases to  wait for any expulsive  uterine action,
for the uterus may be actually atrophied, although this is very rare.  We
may generally expect hypertrophy  if the fibroid groAvths project into the
cavity of the uterus and  irritate the mucous membrane;  or if the tumor
be vascular ; also if it be developed during or shortly after the period of
conceptivity.   On the other hand,  Ave should expect atrophy if the tumor
occurred  during the period of decrepitude.  If the uterus be hypertro-
phied, will it ahvays exert its expulsive action ?  In all the cases recorded
it has not failed to occur, so that after making an artificial os, the cellular
attachments of  the  tumor must  be  separated and expulsion Avaited for.
If the pains do not come on, the operation of separation must be repeated,
the uterus ivill he sure in time to expel the exposed  and  partially separated
tumor.  Ought  the tumor to be enucleated  at once,  or the uterus be
allowed to expel  it, either partially or  entirely ?  In favor of the  latter
method we may say that  it bears a more close relation to the natural pro-
cess of effecting the same object;  there is less risk of hemorrhage, and
lastly, the cavity left is much smaller, and the uterus is more likely to con-
tract on it.  In the removal of these tumors, we  should recommend, 1.
That the incision through  the  uterine  walls be made sufficiently large.
2. That the separation of the cellular attachments  be as extensive as pos-
sible.   3. That the cyst  of the tumor me not cut into.   4. That ergot be
given.  5. That the hand be introduced  as soon as  the dilatation of the os
will admit to remove the tumor.  (Dr. Grimsdale.)     Part xxxv., p. 234.

   " Phantom Tumors "  of the Abdomen.—Dr. Greenhow relates the fol-
lowdng among other remarkable cases:
   Mrs.----, aged forty-four, having borne a family, had suffered for seve-
ral years from menorrhagia, alternating w ith  profuse  leucorrhcea.   She
had also suffered from a variety of other ailments  referable to spinal irri-
tation,  itself due, I  do not doubt, to the  disarrangement of the uterine
system.  I  was consulted by her, somewhat more  than three years ago,
for a  tumor in the left bypochondrium, the appearance of which had been
long preceded by occasional attacks of pain iu  that situation, of such in-
tensity as  to make her writhe about in bed, and for the relief of ivhich
opiates, even in large  doses, were  of  little avail.   This pain w*as of par-
oxysmal character., often coming on very suddenly, and sometimes without 
TUMORS.
733
apparent cause,  although more frequently as  a consequence of over-ex-
ertion.  It sometimes lasted for many days Avithout intermission, but Avith
variable intensity.   The  employment of counter-irritation  to  the spine,
and of tonic treatment calculated to improve the general health and lessen
the uterine  flux, Avere of essential service; and  when, at  a subsequent
period, I sought for the tumor, it Avas not discoverable.  After an interval
of many months I Avas again consulted for the tumor, which, sure enough,
had very evidently returned, and is described in  my notes  of the case as
" an ovoid  movable tumor, free from tenderness, and  apparently floating
loose in the  left  hypochondriac region ; it is difficult  to estimate its size,
but it appears to be  somewhat reniform, and at  least tivice the  natural
size of a kidney."   It is further added that the  patient ivas in all other
respects  in  good health; that no fullness, tenderness, or pain  existed in
the posterior lumbar  region, and  that the urine  was  normal.  NotAvith-
standing that I believed the  tumor to be of the same character with those
already related, I thought it desirable that the patient should have the
benefit of a second opinion, particularly as I had been  unable to find it on
a previous occasion.   An eminent physician Avho ivas  called to my assist-
ance, devoted much  pains to its elucidation, but without arriving at any
more  satisfactory conclusion as to its nature  than  myself.  We  agreed
that it could not be ovarian, from its position; that it ivas too movable for
an  enlarged  kidney, which was also  discountenanced by the absence of
any unusual fullness,  resistance, or tenderness posteriorly ; and that it had
not the character, neither had the patient the aspect, of malignant disease.
Although in great  doubt on  the subject, ive treated it on the supposition
that it might eventually prove a hydatid groAvth.   Some time afterward
other symptoms of spinal irritation manifested themselves ; and although
I had never seen an avoAved case  of Dr. Addison's " phantom tumors,"  I
began to suspect that this would prove an example of  them, as it subse-
quently did.  The  patient very shortly after the  consultation, w*ent from
under my immediate observation,  although she continued to act under my
instructions.   In the course of a  few weeks she wrote me Avord  that the
tumor had  dispersed ; and a feAv months  ago, being again in toivn, she
afforded me several opportunities of satisfying myself that the tumor really
was gone.                                           Part xxxv., p. 247.

   Arterial  Tumors—Aneurisms.—Mr.  Cusack, of  Steevens' Hospital,
Dublin, applies compression  by means of conical weights, ivhich, suspended
to a frame arching over  the limb, may be  exactly applied to the artery ;
five and a half to seven and a half or eight pounds, are generally required
to arrest the pulse  of the femoral artery completely.   At first the circula-
tion must only be partially arrested, and the weight must be applied every
alternate hour.  After the lapse  of six or eight days the Aveight may be
uicreased till the circulation is completely arrested, the pressure not being
continued, however, more than an hour and a  half at  a  time.  This mode
of applying  pressure appears the  best hitherto suggested, as it approaches
the nearest to manual pressure.  It is easily applied, and has proved very
satisfactory in its results.                               Part xl., p. 307. 
734
TURPENTINE.
                       TURPENTINE.

  To Prevent Nausea, from Administration of Turpentine.—It is stated
that turpentine when made into an electuary with mucilage, honey, and a
little magnesia, may be given Avithout  exciting the disgust and nausea, so
frequently.caused as ordinarily prescribed.               Part xii., p. 301.

  Oil of Turpentine  as a  Styptic and Astringent.—As an astringent, in
doses varying from 20 minims  to  a drachm, according  to the urgency of
the  symptoms, and repeated ei*ery three or four hours, turpentine is one of
the most efficacious remedies which Ave  possess.  The best vehicle for its
administration, in the first place, is water, flavored with sirup of orange, or
any other agreeable aromatic.   It may afterward be advantageously com-
bined with any other therapeutic agents, which the special nature of the
case may require :  thus, in epistaxis depending upon the rupture of one or
more small vessels, and where much arterial blood has been lost, muriated
tincture of iron will form a valuable adjunct.  In hematemesis and other
sanguineous  discharges from the bow-els, it may be united wdth compound
infusion of roses, sulphate of magnesia, iced-water, and solutions of tannic
or gallic acid.   In some forms of hemoptysis, it may usefully be added to
infusions  of  matico ; in  hematuria, to the decoctions of uva  ursi, chima-
phila, pyrola, etc.; or to tincture of the sesquichloride of iron.  In purpura
hemorrhagica, the decoctions or infusions of the barks form wdth it an
excellent adjuvant.  In hemoptysis, it has  speedily and effectually arrested
the hemorrhage ; and is a much safer remedy than lead.
  Dr. Smith  states that in his experience, there is no single medicine in the
materia medica, that can be compared  Avith it as a styptic, either as to cer-
tainty of action, or to the safety of its effects.  It is compatible alike with
acids and alkalies.                                     Part xxi, p.  116.

  Baths containing Oil of Turpentine.—[Dr. Smith recommends the em-
ployment of alkaline camphene or turpentine baths, in chronic rheumatism,
lumbago, sciatica,  gout, and other affections.  He says :]
  I  have employed  camphene in the form  of a bath, mixed with common
,soda ; or two pounds of the latter ivith from a quarter of a pint to half a
"pint of camphene,  and half an ounce of oil of rosemary,  will form an excel-
lentN bath.   In  delicate skinned  patients, females and children,  gij. of
camphene wdll  be  sufficient. I may  remark, in limine, that  the  alkaline.
camphene bath possesses virtues peculiarly its own.  In the coldest day in
winter, as I have verified in more than one instance, it  may be  employed
ivith the most  perfect safety.  Whilst  the individual is  in  the bath, he
experiences, to my knoAvledge, no disagreeable annoyance from  the disen-
gaged vapor; on  the contrary, if we except the taste of the turpentine,
ivhich for some time remains in the mouth, a sense of  calmness and tran-
quillity very  often follows a previously disturbed, irregular, or excited con-
dition .of the respiratory or  sanguiferous systems. After five  minutes
recumbency in the bath, the pulse is found to become fuller, softer, and
slower;  I have seen it fall from 100 to 80.  The respiration also becomes
freer, deeper, and  less labored.   On coming out of the bath, the ivhole skin
has  a peculiar velvety, soft, and agreeable feeling; the breath is  strongly
tainted with the  terebinthinaceous odor.  If it  have not been too hot, a
pleasurable tingting ivarmth is experienced throughout the ivhole cutaneous 
ULCERS.
735
surface ; and this, wdth the preceding symptoms, may continue tAventy-four
hours.  One great adi*antage of this bath Aiill be found in the circumstance
that it may be employed  at a heat from 10° to 15° below the temperature
of the ordinary ivarm one, without including that sensation of chill to which
some delicate constitutions are so peculiarly obnoxious ; ten  or fifteen min-
utes is the length of time a patient ought to remain in a bath of this descrip-
tion.  In the  first instance, it  is ivell for  patients to commence  with a
smaller quantity of the turpentine and soda, say a pound of the latter, wdth
tAvo or three ounces of the former, and gradually increase its strength on
each repetition of the bath, to the first mentioned proportions.  This bath
may be taken every second or third day, according  to the urgency of the
symptoms and the nature of  the affection for wdiich it is prescribed.
                                                     Part xxi., p. 355.
                          ULCERS.
  Baynton's Method of Treating Ulcers.—[Mr. Joseph Bell,  brings  for-
Avard cases to. shoiv the efficacy of this mode of treatment, ivhich he justly
supposes has fallen  too much into disuse.  There is no doubt that  the
practice is excellent; but the troublesome attention which  it constantly
requires must always be an impediment to its general  and continued use,
especially amongst the  classes of poor people in whom  the most trouble-
some cases occur.  Mr. Bell says :]
  To explain at any length the method of this  celebrated surgeon, may
seem to some superfluous.  It is, however, my decided conviction that the
majority of practitioners  are  either ignorant  of it, or  do not put it into
practice.
  Baynton's  system consists of three  parts: First, straps of adhesive
plaster, from tAvo to three inches broad, and of sufficient length to surround
the limb, and to overlap a few inches.  These straps are to be applied by
placing the centre of the  strap  exactly opposite the ulcer, over ivhich the
free ends are to be crossed, pulling them as tight as the feelings of the patient
will permit.   The first strap is to be placed a little beloiv the low*er margin
of the  sore ; the  second  is to overlap it a little ; the  third to  overlap the
second a little ; and so on till the ulcer is completely covered ;  a soft piece
of cloth  is  then  to  be placed over the ulcer; but I frequently dispense
with this.  Secondly, a bandage is to be  applied, from the extremity of
the limb to the articulation above the  sore.   Thirdly, this bandage is to
be  kept  constantly ivet Avith cold ivater.  The  dressing to be changed
every day,  or every  second day, according to the quantity of discharge
and irritability of the ulcer.  Such then is the Bayntonian system, which
when properly applied, is competent to cure, speedily and effectually,  the
irritable or inflamed, and  the varicose,  as well  as the indolent or callous
ulcer ;  proper attention, of course, being paid to the improA*ement of the
general health—a sine qua non in every plan of treatment.
                                                      Part iii., p.  105.
  Ulceration of upper part of Rectum and Sigmoid Flexure—Case of—
Cured  by Lime Moxa.—Dr. Osborne of Dublin relates the case of a female
who labored under the symptoms of ulceration of the upper part of the
rectum and sigmoid flexure, for above a year,  and had constantly most
severe  pain  in those parts on  passing  her motions,  whichfpwere  accom- 
736
ULCERS.
panied by discharges of purulent and sanious matter.  On being examined,
the rectum and lower part of the colon were free from contractions, and
the fecal masses which occasionally passed, although productive of great
suffering,  yet showed that the passage was not considerably narrowed ; a
lime moxa, Avhich extended to about the size of a croivn, was applied over
the sigmoid  flexure, and  Avas immediately folloAved  by a diminution of
pain and an almost complete cessation  of the discharge ; and before the
ulcer produced  by the  moxa had tilled up by granulations, all  the symp-
toms of the internal ulceration had entirely disappeared.   Part v., p. 129.

   Treatment of Old Ulcers by the use of Corrosive Sublimate and Tinc-
ture of Iodine.—E. B., aged 43, ivas admitted into hospital with a large,
foul, and painful ulcer on  the lower part of the  left  leg ;  extending from
the instep nearly six inches  upward, across the whole front  of the limb.
Several useless attempts being made to effect a cure, Mr. Furgusson put
her on a course of mercury, in the following way.  "Twelve  grains of the
bichloride  of mercury Avere  made  up  into 240  pills; two of these were
taken for a dose immediately after dinner, the first day,  four on the third,
six on the fifth, and so on; increasing the dose by two  every second day,
until the patient should take thirty pills  at a time.  After this, if necessary,
the dose ivas to be gradually diminished every second day by two pills,
until the number decreased to two.  The patient proceeded till she took
eighteen pills for a  dose, Avhich affected the system, and she then desisted
taking any more.  Meantime, Mr. Partridge had recommended the sore to
be lightly touched with a  strong tincture of iodine, which had an excellent
effect; and it was  supposed, by the combination of the tAvo remedies, a
most obstinate case was cured.                           Part v., p. 144.
   Outward Applications to Ulcers—Chemically considered.—On examin-
ing the composition of the more common medicinal applications to indolent
ulcers, it  ivould appear that, 1st, their energy on the animal tissue, and
tlieir caustic properties, are in direct ratio to the rapidity ivith which they
part with their oxygen; and  2d, the bases of those compounds which ex-
perience  has taught us to prefer, are, when deprived of their oxygen,
perfectly inert,  and their affinity for  oxygen  is comparatively slight.
Three qualifications, therefore, appear necessary to constitute a good out-
ward application to an indolent ulcer.  1st.  A substance  containing a large
proportion  of oxygen, or  of  an  electro-negative body.  2d. A compound
that will part with its oxygen  to the  animal organism moderately slow.
3d. A compound w*hose elements, when its oxygen is abstracted, possesses
no chemical or solvent poivers on the tissues, nor poisonous effects on the
body generally.
  Guided by these view*s, Mr. Sankey is led to recommend the employment
of various  compounds to indolent ulcers, such  as the iodate  of the pro-
toxide of mercury in the strength of 3ss. to 3ss. to the ounce of lard; the
iodide of starch ; the oxide of silver; pectic acid  applied as a poultice; the
iodate of peroxide of mercury; the preparations  of periodic acid, the bro-
mates ; succonates ; the precipitate formed by tr. opii on  Goulard Avater ;
mucic acid ; alloxan ; hydrated peroxide of iron, etc.  In angry and in-
flammatory ulcers, on the  other hand, ivhich .are attended  with increase ol
circulation, and consequently, wdth  excessive supply of oxygen, the oxy-
genated compounds would be prejudicial.  Cold lotions or poultices, for
chemical reasons, would bo  indicated;  or, if ointments  are  used, those 
ULCERS.                            737
only containing a  preponderance  of electro-positive  elements,  as  ung.
cetacei, creasote, etc.;  perhaps, also, the application of turpentine, or the
non-oxygenated essential oils, as the ol. limon.           Part xii, p. 168.
  Simple  Ulcers  of the Cervix  Uteri—Caiderization of.—M.  Lisfranc,
greatly vaunts the  mode of treating ulcers of the neck of the uterus, by
the application of escharotics.  That ivhich he prefers greatly to all others,
is the solution of mercury in an excess of nitric acid.  The speculum uteri,
he says, is indispensable.  The escharotic is never to be applied otherwise
than very lightly ;  nor with a AdeAV  to destroy the ulcerated or altered sur-
faces, but to modify their vital state—to produce a new action in the parts.
A soft brush, or dossil of lint, is the  proper tool for making the application,
and the speculum is immediately afterward to be filled with tepid or cold
water—the abraded surfaces are to be washed clear of all remains of the
caustic,  which is only felt as peculiarly painful,  when it is  suffered to come
in contact with the sides of the vagina.                 Part viii., p. 155.
   Phagedenic Ulcer of the Septum Nasi—Chloride of Zinc.—Dr. Zwerina
gives the following case : A woman, aged 30, who had suffered from severe
pain and enlargement of the right tibia, which was judged to be syphilitic
in its nature, was at the same time affected with an  ulcerous disease of the
nose, which by and by perforated  the septum, and threatened to destroy
the whole member.  The disease  of the leg was arrested under the use of
mercurial inunction, that of the nose  resisted  all the  topical applications
that were made to it—sublimate,  arsenic, red precipitate, sulphuric acid,
nitric acid, etc., until the chloride of zinc was called into requisition.  One
grain and a half of the salt was dissolved  in one ounce of distilled water,
and the scabs being removed, the sore Avas pencilled over several times a
day wdth the solution.   At the end of a fortnight, a healthy granulating
surface ivas found underneath the thick crust Avhich iioav covered the sore,
and this being  removed from time  to time, and the solution  re-applied, at
the end of five weeks,  the cicatrix ivas perfect, and the patient well.
                                                      Part viii., p. 155.
   Use  of Turpentine.—Mr. Hancock  recommends  turpentine  iu  those
ulcers which are prevented healing by deficient action, where the ulcer  is
sluggish, surface smooth, without granulation, or of a greenish foul appear-
ance ; discharge serous, edges rounded, smooth, and callous, and  the  sur-
rounding skin is pink or blue. It should not be exhibited ivhere the patient
is plethoric,  the  ulcer inflammatory, and  the pulse  full  and frequent, or
where it produces nausea,  or other  unpleasant symptoms; in the last case
substitute cajeput oil, three drops three times a day, or give capsules, each
containing twenty to twenty-five drops of the turpentine.   Continue the
use of the turpentine until good healthy granulations appear, wdth the se-
cretion  of good pus.                                   Part xiv., p. 321.
   The treatment of Ulcers.—With  respect  to ulcers with exuberant granu-
lations, Bransby Cooper says:
   In such cases pressure is indicated,  which is best effected by the applica-
tion of bandages;  but, should such means  not succeed, escharotics may be
required to keep down the tendency to hypertrophy.  Sulphate of copper
I consider the best application for  this purpose'.  Nitrate of silver, ivhich
is very  frequently employed, tends, in my opinion, rather to increase their
growth ; for, although when first applied, it removes them, yet they appear
to return with increased vigor after its escharotic influence has ceased.
     vol. n.—17 
738
ULCERS.
  [Indolent ulcers will generally require both constitutional treatment, and
stimulating applications to the sore.  Mr. Cooper says:]
  Bark and acids are indicated, having taken care first that the boivels are
freely opened and the secretions generally natural.  Stimulants should be
applied to the ulcer, either the ung.  nitrici oxidi, or the ung. zinci; or.
should  lotions be preferred—and, indeed in some cases they seem more
suitable than greasy applications—nitric acid lotion, or zinc or lead in solu-
tion, may be substituted ; but at the same time, the patient should be kept
during  a large portion of the day in a recumbent posture, and much benefit
is sometimes derived from the elevation of the affected limb.  Porter and
generous diet wtill also expedite the cure, by exciting the reparative pro-
cess.  The pressure and support of a bandage is occasionally useful, but in
languid or indolent ulcers its utility is doubtful; for I have frequently
observed that a tendency to slough follows its application,  as if the granu-
lations  were too tender to sustain the  slightest pressure.
  When  these ulcers  prove very stubborn,  and resist  all the  consti-
tutional and topical  remedies,  I  have lately witnessed the best  results
from  stimulating their  surface by subjecting it to a stream of negative
electricity.
  At a  convenient distance from the indolent ulcer (not less than five or six
inches)  a portion of  the cuticle is raised from the cutis by the application
of a piece of emplast. lyttae of the size  of a half-crown.  The cuticle is de-
tached  by  a pair of scissors, and on the exposed cutis a piece of zinc foil is
 filaced,  of  the  same  size as the denuded spot.  A plate  of silver foil is
 aid on  the original ulcer, and the two plates connected by means of a thin
copper  wire.   The size of the silver plate is immaterial.  Both zinc and
stiver are now covered with pieces of moistened lint and oil-skin, and the
apparatus, as recommended by Dr.  Bird, is complete.  In a few hours the
surface  beneath the zinc becomes white, and a slough begins to form, which
in a short time is thrown off, leaving a healthy ulcer behind.  In the mean-
while a great change has taken place in the original ulcer; it has throAvn
aside its indolence ;  the granulations are sprouting and contracting; new
skin is  forming at the  margin, and the whole  surface looks healthy  and
animated.                                             Part xxi, p. 228

   Callous Ulcers of the Leg.—Prof. Syme's method of treating these tire-
gome cases ivas to apply a large  blister over the sore and  neighboring
swelled part of the limb, which has the effect of speedily dispersing the sub-
cutaneous  induration and thickening, so as to relax the integuments, and
thus remove the obstacle  opposed to healing action.   In the course of a
short time, seldom exceeding a few days after the blister has been applied,
the surface of the ulcer, however deep it may  have  been, is found to be
on a level  w ith that  of  the surrounding skin; not, of course, through any
process of reproduction  or filling up, but  merely from  the removal of
interstitial effusion, allowing the integuments to descend from the position
to Avhich they had been elevated, as  may be readily ascertained by mea-
suring the circumference of the limb, before and after it has undergone the
effect of blistering.   But, along Aitith this  change of form, the ulcer in
other respects no less speedily requires  the  characters of a healing sore,
assuming a florid color, affording a moderate discharge of purulent matter,
and presenting a granulating surface with surrounding margin of cicatris-
ing pellicle.  No subsequent treatment beyond  the attention requisite for 
ULCERS.
739
 insuring quiet and cleanliness is needed, and  recovery is completed, not
 only more quickly, but wdth  much less tendency to relapse, than when
 accomplished by other means.
   With regard to the varicose ulcer, the author states that his opinion  is
 not in favor of aiming at what is called the " radical cure," by obstruction
 of the vein or veins concerned.  He has frequently practised the method
 of Velpeau, Avho accomplishes the object of obliteration by passing a pin
 through the skin under the vessel, and then tying a thread lightly round
 the included part; and has never met Avith any bad consequences from
 doing so : but he is  nearly satisfied, from what has  fallen within his own
 observation, that the operation  is barren of good effects in permanently
 remedying the tendency to ulceration.  The black wash has long seemed
 to him the best  application for promoting cicatrization of the ulcer. If the
 sore comes  under treatment  in an inflamed or irritated state, poultices
 should be employed in the first instance ; and if the depressed surface and
 thick edges denote a complication of the callous condition, blistering will
 be proper instead of such relaxing means.              Part xvii., p. 188.
   Phagedenic Ulcers.—[Phagedenic ulcers may occur in other cases than
 syphilitic ones.  The disease is very rapid in its progress, and is attended
 with severe  pain preventing sleep, headache, fever, furred  tongue, and
 tenderness of epigastrium.]
   " In the local treatment," Professor Cooper  says, " bleeding ,can rarely
 be resorted to with advantage; venesection exposes the patient to the
 risks of hemorrhage, on account of the natural tendency of this  disease; and
 leech-bites assume a morbid action, as is just what we see in hospital gan-
 grene.   Mr. Welbank found  an application of strong nitric  acid to  the
 surface an excellent means of arresting  the ravages  of gangrenous  pha-
 gedena.  His  mode  of  applying it was, after protecting  the surrounding
 skin ivith a thick coating of cerate, to dip  lint  in the acid and apply it to
 the part, the surface of which Avas thus converted into a firm and dry
 mass.  Simple dressings were afterward employed,  and an  evaporating
 lotion.  In France a solution of chloride of sodium, consisting of one part
 of the concentrated solution in eight of Avater,  is  employed, either mixed
 in a poultice or used with lint.  The dressings most used are  bread or
 carrot poultices, a watery solution of hyoscyamus, the  liq. opii sed., with
 a pledget or poultice  over  the lint.  From a consideration of the  predis-
 posing cause you ivill infer the propriety of attending  to diet and regimen ;
 when great debility exists, you are to employ bark, quinine, and wine,
 with a light nourishing diet.   In St. Thomas's  Hospital it is customary to
 allow a mutton chop with eggs and milk."              Part xvii., p. 195.
   Treatment of, by Proteine.— Vide. Art. "Caries."
   Treatment of  Specific  Ulcers—Strumous.—A weak solution of iodine,
 or the black  wash, are  useful stimuli to strumous ulcers.  If there is a
 mass of strumous matter forming beneath the skin, paint it over with
 tincture of iodine, or solid nitrate of silver.
  Phagedenic.—In  cases of  phagedenic  ulcer wdth extensively under-
 mined elges, in which, if an escharotic were used, a large quantity of skin
 would have to be destroyed, take small strips of lint thoroughly saturated
 with black wash, and thrust them with a probe to the very bottom of the
sore, so as to bring the black  powder into contact wdth its entire surface.
AfterAvard apply strapping, sec. art. 
710
jTLCER9.
  A suitable course  of medicine and generous diet are accessories in the
treatment which must not be omitted.
  Menstrual.—Mr.  Critchett next  proceeds to speak  of  the menstrual
ulcer.  He says:
  There are  tAvo or  three modifications of this disease met Avith in prac-
tice ; thus  you have a class of cases, in which, the uterine  function being
entirely suspended, the system finds relief in  a constant discharge  from
the surface of a sore, which discharge is altered in quality and increased in
quantity at the usual monthly period.  In  other cases the uterine function
is performed, but  the sore becomes inflamed and painful, and increases its
amount of discharge at that period ;  thus giving evident signs of sympathy
and  co-operation with the. uterus.   There is,  again, a peculiar and very
formidable class of  sores, Avhich  occur either  at the period when, in the
natural course of things, the menstrual function is about to cease ; or Avhere,
from some organic change in the menstrual  organs, this discharge no
longer takes place.
  The first form  of this  disease to which I have alluded, and which may
be distinguished as  " the true menstrual ulcer," occurs generally in young
females, soon after the age of  puberty.  It is  often, in the first  instance,
of a strumous character;  or it may have arisen from some external injury.
The  uterne  function not being very fully and regularly  established, by
degrees it  ceases,  and its place is supplied by ttie ulcer.
  I  have invariably  found that the breaking out of the sore has preceded
the  suspension of the menstrual discharge, or has been first formed prior
to that period  of  life when the function of the uterus commences.   I note
this especially, because it is an important element in the consideration of
the  treatment  of these cases.   The appearance of  the ulcer is charac-
teristic of  its nature:  it is generally rather large, its edges are ragged, its
surface is irritable, dark-colored,  and  exhibits specks  of blood; the
surrounding parts are of a deep  red-color, but not  much swollen ; the
discharge  is thin, and often mixed with blood ; the pain and  soreness
are generally distressing  and  much aggravated at the period when the
uterine function is due.   When this vicarious discharge is fully established,
the  disease becomes most  intractable.  I have met with cases that have
existed above  three years,  having resisted all the ordinary methods of
treatment  adopted on these occasions.
  If we consult surgical authorities on this subject, we invariably find the
matter rather briefly dismissed, somewtiiat in the following Avay :  "Restore
the  healthy functions of the uterus, and then  the ulcer will heal."   This
sounds very rational and very proper, and no doubt answers exceedingly
well when it can be accomplished; but, according to my experience, it is
always difficult, and very frequently impossible.
  I  contend that  it  is scientifically more correct, and practically far more
efficacious, to adopt a method the very converse of the one I have above
stated—viz., "Heal the  ulcer, and the uterine function will  speedily be
restored to health and regularity."
  I  commence, then, at once to attack the ulcer. Some stimulus is often use-
ful in allaying the irritation ; a solution of the nitrate of stiver is generally the
best.  I then apply strapping rather tightly ; for I find in all those cases in
which I have,  as  it  were, to compel a cure in spite of the rebellion of the
constitution, rather  tight and very accurately applied support is necessary.
   As the  discharge is  copious, it should  be applied frequently,  either 
ULCERS.
741
 alternate days, or every day.  The wound ivill soon take on a healthy
 action, and  begin to heal, and you will naturally suppose the cure is at
 hand; but as the monthly period approaches, in spite of all your efforts,
 the  aspect  of the sore changes, the discharge again becomes  thin and
 copious,  and much of the  improvement that  has  taken  place  during  the
 previous month  is lost.  You must  not be discouraged  by this,  but must
 start again, and each month you will find you gain  more than  you had
 previously lost, until, at last, you  succeed in  entirely closing the wound,
 and  then you are safe ; the ulcer being healed, the uterus spontaneously
 resumes  its healthy  and regular function—at least,  such has  been my
 experience.   But even suppose such  a result should not  invariably occur,
 you  have then a  simple case of amenorrhasa to deal with, which is surely
 far more  easily controlled when uncomplicated Avith a vicarious discharge
 from an  ulcer in the leg.
   When  sores occur about the time of the cessation of the  catamenia,
 take care, before healing them, to get a freely-discharging issue made.
                                                     Part xix., p. 200.
   Treatment of Indolent  Ulcers.—Mr.  Chapman's  plan is as  follows :
 Dress the sore Avith a compress of lint dipped  in cold water, and folded
 once, tAitice,  or  three times,  according to the amount of  compression
 deemed  necessary; or, if the ulcer is very deep, cover  it first aa ith soft
 sponge torn up into very small shreds, and soaked, in water, and over this
 apply the Avetted lint in a single layer ; then take three or more moistened
 strips of linen or calico, about tivo and a half inches Aitide, and apply them
 round the leg in the same maimer as Baynton's  strapping.   Cover the
 ivhole by a calico bandage,  placing compresses of lint about the  malleoli,
 so as to insure the bandage being evenly applied.  Soak the bandage wdth
 cold Avater, and envelop the limb in oiled silk, reopening this from time to
 time, to reneAv the cold affusion.  At  first the ulcer may require  dressing
 every day, but after a time, an  interval of three, four, or even five days,
 may elapse between the dressings.                     Part xix., p. 203.
   Use of Chloride of Zinc.—Dr. Brookes states that  the chloride of zinc
 exerts a  good  effect in stubborn  ulcers, especially Avith  callous, hard,
 everted  edges, and  will rapidly set up  a  healthier  action  when other
 remedial  means have failed ; the surface will speedily granulate and heal.
  Take tAvo  parts of chloride of zinc, and three parts of gypsum; mix
 them, and spread the powder over the surface of the sore, protecting the
 edges of  the healthy  skin  Avith vinegar.  In about a quarter of  an hour
 apply a poultice.                                     Part xix., p. 205.
  Foul and Flabby Ulcers.—Bi-sulphate  of iron and alumina, is recom-
 mended as an excellent application.   Vide Art, " Iron."
   Chronic— Use  of Collodion.—Apply collodion, in  the following man-
 ner :  Dry the ulcer  Avith bibulous paper; wash it over Avith ether,  by
 means of a soft brush ; again dry Avith the paper; then apply the collodion
 Avith a brush in a circular manner, so as to cover the edges of the ulcer to
a greater or less extent, as may be deemed necessary,  and varnish over so
much of  the ulcer itself as to leave a  small central opening for the escape
of discharges. Any stimulus judged to be favorable to cicatrization may
be applied in the dry form before beginning to paint ivith the collodion.
                                                    Part xix., p. 318.
  Chronic Ulcers—Treatment.—Dr.  T. II. Burgess recommends, to env 
742
ULCERS.
 ploy fumigation in the following way.   R  Sulphuris, otij.; hydr. sulph.
 rubr. 9ij.; iodinii, gr. x.   M.  Ft.  pulv. sex.  Put one of these  poAvders
 upon a heated iron at the bottom of a large jar or tin case, the iron being
 covered by a grating.  Immediately put the limb into the jar. and close it
 up to prevent the escape of vapor; and continue the bath  for fifteen or
 twenty minutes. In a feiv days the proportion of iodine may be increased.
                                                      Part xx., p. 168.

   Treatment of Ulcers by means of Opium.—Mr.  Skey says :  Mr. P.,
 placed himself under my charge, Avith a large chronic ulcer on the calf of
 the right leg.  Its margin was irregular and jagged, and Avas elevated to
 at least one-third of an inch above the base of the ulcer, which base was
  ale and  bloodless.   This wound w*as about the size  of a man's extended
  and, including the fingers, or even larger.   It  had  existed for, I think,
 seventeen years.  All remedies  had failed, and the  cure  had long been
 abandoned as hopeless.  I gave  Mr. P. half a grain of opium night  and
 morning.  Jn three days he himself noticed  the singular red color of the
 entire margin of the ulcer, which in a week extended  over  the  base.  I
 rolled and strapped  the limb; the entire sore consequent on its depressed
 surface being placed beyond the influence of the pressure.  Within two
 months that sore Avas reduced to the size of half a crown, and  the only
 remedy employed was half a grain of opium night  and morning, ivhich,
 by the by, had a very beneficial influence on his health.   Part xx.,p. 111.
   Treatment of the " Warty Ulcers of Marjolin," by means of the  Chloride
 of Zinc.—[Dr. Fearnside proceeds to describe the case which fell under his
 care.  His patient was a large unwieldy man, having the aspect of a man
 accustomed to indulge in malt liquor.   About nine years previously he had
 6UStained a severe injury in the front of his right leg.   Inflammation and
 a swelling ensued, the size of a pullet's egg,  which underwent tittle change
 for some years.  But  10 or 12 months  prior to his coming under Dr. Fearn-
 side, pain ivas felt in  the tumor, wdiich acquired a dark red color, the skin
 covering it being indurated and uneven, and the discharge thin, fetid, and
 often bloody. Dr. Fearnside continues :]
   When I first saw him, the morbid growth presented the following cha-
 racters :   From the  centre of the front of the right leg,  occupying a space
 of about  three  inches in  diameter, there sprung a dark grey substance,
 which projected at least tivo-thirds  of an inch above the  surrounding skin.
 Its surface had a granular appearance—at first view not unlike the head of
 a cauliflower; on closer examination, it was  seen that this  was occasioned
 by the prominent extremities of coarse fibres ivhich arose from the base of
 the ulcer, and were collected into masses, separated  from each other by
 deep fissures.  The margin of the sore was  thickened, elevated, and pos-
 sessed little  or no connection with the fibrous structure  above described:
 the surrounding integument had undergone considerable  warty induration
 and  discoloration.  A thin ichorous discharge proceeded from the part;
the pain experienced was  not violent;  there was no enlargement of the
popliteal or inguinal  glands.   He  complained of being weakened by re-
peated loss of blood, but  his health ivas otherwise good.  He had been
previously under the care of one or two medical men, and had been advised
to submit to amputation of the leg, on  the supposition  that the disease Avas
fungus hematodes.  The case was considered a favorable one for the  em-
ployment of the chloride of zinc.
I 
ULCERS.
•743
  On its first application, the remedy was  mixed with flour.  (Canquoin's
formula.)  But little  pain was occasioned by it, and  the resulting slough
was not  deep.  When  it Avas next  employed, it w*as blended with pure
sulphate  of  lime, as  proposed by Mr. Ure.  The whole  of the morbid
growth was  covered to the  depth of a third  of an inch Avith a paste com-
posed of one part of chloride of zinc and two parts of sulphate of lime. The
application gave  rise to severe  pain, which  was only partially under the
control of opium.  At the  expiration of four days an extensive and deep
slough was produced, ivhich separated in  the course of the  ensuing week
or ten days.  The greater part of the sore was then covered with healthy-
looking  granulations ; but to  get rid  of two  or three small  masses of
whitish semi-cartilaginous substance,  as well as to overcome the indurated
condition of the margin of the ulcer, it Avas requisite again to have  recourse
to the caustic paste.  The subsequent progress of the  case was, upon the
whole, highly satisfactory. No hemorrhage ensued after the first complete
application of  the chloride of zinc.  In the course of a month small florid
granulations had arisen to the level of the  adjoining surface, and cicatriza-
tion commenced.                                      Part xxii., p. 249.

   Treatment of Varicose  Ulcer at  St.  Thomas's  Hospital.—After  all
other measures have failed in the treatment of this affection, in cases at St.
Thomas's Hospital, perfect success has folloAved the application of  a caustic
issue, by rubbing potassa fusa along the chief veiu between the ulcer and
the heart.                                            Part xxii., p. 256.

   Ulcers  external to  the Anal  Aperture.—Mr. Hilton directs these to be
treated by the  recumbent position to relieve the hemorrhoidal veins, keep-
ing the boivels open  by castor oil, which  acts on the entire course  of the
intestinal  canal, and  lubricates the hard exterior of the fecal mass as it
passes through the rectum; and by applying  the following  ointment:
ungent. opii, 3j.; ung. hydrarg. fort.,  3iij.»  to be applied tAvo  or three times
a day.                                              Part xxiii., p. 11Q.

   Cicatrization of an Ulcer promoted by  the  Electric Moxa.—[The atten-
tion of Mr. Cooper was formerly directed to this process for the promotion
of the cicatrization of obstinate ulcers, by Dr. Hull, of the United States.
Instead, however, of employing the galvanic battery which is cumbersome,
he used  one  introduced by Dr. Golding Bird, merely using two plates, one
of silver and the other of zinc, connected  by  a copper wire.  The case  in
which the apparatus Avas used,  was  an ulcer originally produced  from a
gun-shot wound situated on  the inner side of  the right foot and below the
ankle.  The charge of shot  passed obliquely through the soft part  of the
right  instep, and injured the navicular bone.   During the treatment several
small  pieces of bone came away, as  often as tAvo or three times a week.
The wound  never, however, completely healed, and previous to the appli-
cation of the electric moxa, it ivas the size of the hand.]
   Carrot  poultices were first used, and  leeches  were from time to time
apphed round  the sore.  Warm water dressing ivas subsequently employed,
and the  patient took sarsaparilla, but this treatment continued  for about
six weeks, proved unavailing as  regarded  the cicatrization of the  ulcer.
   At this period Mr. Cooper ordered the  electric moxa to be applied; this
was done in the folioAving manner : a small oval piece of blistering plaster,
about the size  of a crown piece,  was  placed six inches above the sore.  On 
744*
ULCERS.
the following day, a blister having formed, the cuticle was removed, and a
plate of zinc, previously cut so as accurately to fit the vesicated surface, was
applied on the same.  A silver plate ivas  then placed on the original sore,
and the two metallic agents connected with  a  copper ivire.  This simple
apparatus was secured on the limb by means  of a few narroiv  strips of
adhesive plaster, the ivhole being covered with  Avet lint, and a loose band-
age, which latter was kept constantly moist.
   On the next .day the silver plate w*as raised for the purpose of examining
the sore, and a most decided improvement was  observed, the granulations
looking more healthy and active.  On the second day, however (the moxa
having remained in contact with the limb for forty-eight hours) there was
pain and considerable  redness over the whole leg, with enlargement of the
inguinal glands.  The moxa was therefore removed, the stimulating effects
having evidently caused inflammation of the absorbents;  yet the original
sore had a more healthy appearance, and was evidently decreasing in size.
On the fifth day the  inflammatory symptoms  had considerably subsided
and the sore ivas improving fast.  On the ninth all pain and redness in the
leg had disappeared, and a slough separated from the blistered  surface to
 which the zinc plate had been applied. The original ulcer was found much
 decreased in size, being  now no larger  than a crown piece; the granula-
 tions assumed a healthy appearance ; they rose to the level of the margins,
 and were covered  and protected toward  the centre of the  sore  by a
 whitish layer of healthy pus.  The  borders were becoming flattened and
 regular, and the gradual extension of the  cuticle could  be  distinguished
 within them.
    The cicatrizing  process ivent  on uninterruptedly.  About four months
 after admission, the ulcer ivas quite healed up,  and the patient left the hos-
 pital in good health.  He was, however, recommended not to bear the whole
 weight of his body upon the leg for some time to come, and  allow the soft
 parts about the ankle to gain tone before he used them freely.
                                                     Pari xxiii., p. 293.

    Phagedenic Ulceration.—Sarah H----, aged 6, a strumous child of low
 powers, living in an  unhealthy neighborhood, ivas  admitted as an out-
 patient on  July 18th, with acute phagedenic ulceration of the side of the
 tongue, gums, and lips ; it  ivas of  one week's duration, and was  now
 spreading rapidly.
    Caustic was freely apphed.  Ten grains of chlorate of potash in water
 to be  given three times a day ;  and the sore to be sponged frequently in
 the course of the day with a solution of nitrate of silver (three grains  to
 the ounce.)   In a  few days the phagedenic action  was checked ; and  at
 the end of a fortnight, healthy granulations ivere  seen  fast repairing the
 breach.  Bark and soda Ave re now substituted. On August Sth, the child
 was perfectly cured.
    Phagedenic  Ulceration of Labia and  Bend of Thigh—Recovery.—
 Jane J----, aged 20 months, a stout, healthy-looking child, brought up by
 hand, had been ailing one iveek, was brought to the surgery Aiith exten-
 sive, spreading, superficial ulceration of both labia and bend of the thigh
 on the right side, almost running into gangrene.   This Avas accompanied
 with great oedema, and excessive pain and difficulty in micturition.
    Ordered stale beer grounds poultice ; nutritious diet;  and ten grains of
 chlorate of potash in barley-water three times a day. 
ULCER8.                            745
  This treatment was pursued with speedy success, subduing the phage-
denic tendency, and causing a healthy action to be set up in the ulcerating
surface.  In a few days, a simple bread cataplasm was substituted ; and at
the end of three weeks the child was quite cured.
  The above cases fully prove the value of nitrate of silver in solution and
stale-beer grounds as appfications in phagedenic action ;  at the same time
the effects  of  chlorate of potash must not be forgotten as an important
agent  in checking acute ulcerative spreading.          Part xxiv., p. 220.
   Granulating Surfaces.—To protect raw granulating surfaces from  the
atmosphere, lay a thick semifluid aqueous  solution of gum tragacanth on
the raw surface ;  if it is imperfect in any part  repair  such  by another
layer.   This application, says Professor Miller, produces no irritation, and
being  translucent permits a complete surveillance.   Vide " Collodion."
                                                    Part xxiii., p. 288.
   Obstinate Ulcers—Tincture of Cantharides.—Mr. Tait gives the follow-
ing mixture, ivhich has been recommended as being of great utility in these
affections: Tinct. of cantharides, 12 drops; iodide of potassium, 3ss.; com-
pound tincture of cinchona  bark, §j.; water,  seven.ounces.  Mix.  §j. ter
die; and apply the  following  lotion: Tincture of  cantharides, tAvelve
minims;  diluted nitric acid, twenty drops; compound tincture of cinchona,
two drachms; water, one ounce.  The tincture of cantharides is of great
utility in indolent ulceration, dependent either upon  atony of the engaged
parts, or system generally.   It is useful—1st. Where  the granulations are
exuberant, but pale, weak,  and flabby.   2d.  Where there is deficiency,
or total absence of granulations, the ulcers being deep  and scooped out,
with  raised and indurated edges.   3d.  Where the granulations .are  not
defective, but  cicatrizing  irregularly,  sometimes in the  centre,  at  other
times  on  one  side,  the lymph ivhich  is throivn out and organized on one
day being absorbed the next.                         Part Xxiii.,/). 325.
   Chronic and Secondary— Use of Phosphate of Lime.—In chronic ulcers,
resulting from scrofulous diathesis, Dr. Reneke  recommends the use of
phosphate of lime, in doses of from eight to  twenty grains per diem.  It
should be ordered to be taken Avith the breakfast, dinner, and supper, so as
to be  thoroughly mixed ivith  the food.  These  cases  are accompanied
ahvays by a ivant of the  proper cell  growth,  ivhich the phosphate is  said
to increase in  a remarkable  manner.  The phosphate, nevertheless, cannot
be said really to cure the scrofulous dyscrasia, but we shall certainly pro-
mote  the cure  in the most efficient manner by  its administration.
   In persons who have suffered from secondary ulcers, ulcers of the bones,
etc., and who  have become exceedingly weak  and emaciated, give (along
with the preparations of mercury, of which the iodine may be preferred)
the phosphate  of lime in  doses of fifteen to twenty grains during the day.
                                                    Part xxiv., p.  303.
   Ulcers.—Mr. Holt,  of Westminster Hospital, recommends to exclude
the atmospheric air by the following treatment, after the inflammation has
subsided.  From a piece of adhesive plaster somewhat larger than the
sore, a portion, just the  size of the  sore itself, is  cut out; the  plaster is
then applied to the part, and painted ivith collodion.   Oiled silk is now
placed over the ulcer, and made to adhere to the plaster by means of the
collodion, by which process the air is completely excluded from the ulcer-
ative  surface.   The ivhole  is  then secured by  strips of adhesive  plaster 
746
ULCERS.
placed crosswtise,  and by  a roller running from the toes to above the
knee.                                                part xxv., p. 266.
   Treatment of Ulcers of the Leg.—The facilitation  of the flow of blood
toward the heart is the great object to be attained in treating uleers of the
leg.  Many methods have  been  proposed whereby to effect this.  That
employed in the Middlesex Hospital, is the most  easy and rational; the
limb  being  raised  high above the level of the body on an inclined plane.
By such a plan ulcers commonly heal rapidly.
   The out-patients  of the London Hospital are  treated as recommended
by Mr. Critchett, by strapping the whole leg  from the toe to  the knee
with inch-wide strips  of plaster, and applying a  bandage as tight as can
be borne.  The plaster should be made of unirritating material, and spread
on unglazed calico.  In the London Hospital the  emp. plumbi is used.  At
St. Bartholomew's, Mr. Wormald directs  the application of a folded com-
press of  lint over the trunk of the internal saphena, immediately below the
knee, to  be fixed ivith considerable tightness, by means of a broad strip of
sticking-plaster.  The same object is  gained  yet more effectually by Mr.
Startin's elastic spiral bandage, as used at the Hospital for  Diseases of the
Skin.  These ulcers are essentially of an inflammatory character, and the
blistering the edges by some blistering fluid (Bulleyn's is the best) is often
followed by remarkable benefit.  At the Hospital for Diseases of the Skin
the patient is put under a continued course of iodide of potassium, or binio-
dide of mercury, and the folloiving ointment is applied to the ulcer: Hyd.
bisulphuret, hydrarg. nitric, oxyd. aa. |ss.; creasote, mxx.; adipis recentis,
3xvi. Misce.

   In  ah  obstinate case of this disease, Mr. Gay, finding  the  skin imme-
diately in the  neighborhood of the ulcer very tense,  and  unable to yield
further to the contracting power of the scar, divided that part of the skin
where the tension existed in the greatest degree.  Three weeks  after, the
ulcer was quite closed.  Mr. Gay observed that it was only by altering the
direction of the traction, and transferring it to more healthy and movable
parts, that any advantage  can  be expected from measures similar to the
above.                                              Part xxvii., p. 159.
   Cancroid.—Dr. Roe, of Westminster Hospital, recommends from one
eighth to one-fourth of a grain of ammonio-sulphate of copper three times
a day.  It may be continued for many months.         Part xxvii., p. 248.

   Ulcers—Indolent and Callous.—Instead  of employing the expensive
and troublesome plan of strips of adhesive plaster, Professor Syme recom-
mends to apply a large blister.  This quickly relieves the hard swelling  of
the limb, and alloivs speedy heating and sound cicatrization without further
trouble.

   Varicose.—Professor Syme recommends to apply  simply the common
black-wash lotion.   Under this plan they generally readily heal.
                                                    Part xxvii., p. 352.
   Venereal Ulcers.—Instead of the violent treatment wdiich has been com-
monly employed for this kiml of ulcer—such as rubbing over the surface
with caustic potass, and pushing it into the several sinuosities—Prof. Syme
recommends  to apply a blister over the sore, and  administer small doses 
ULCERS.
747
of iodide of  potassium to the extent  of two grains twice or thrice a
day.                                               Part xxvii., p. 353.

   Treatment of Indolent Ulcers by Incisions.—The principle in Mr. Gay's
method of treating ulcers which have resisted all other modes, is to relieve
the tension  of the skin or other tissues, by making incisions at right angles
with the line of tension ; or Avhere the tension is at the edge of the sore,
to supply neAV skin altogether by a species of plastic operation.
   Mr.  Chapman  proposes  a  modification  of  Mr. Gay's neAV  operation,
Avhere the edges of the  ulcer are  adherent to the tissues beneath ; this is,
to glide a double-edged bistoury  under the tense margins of the sore, so
as to set them free, and allow of  their edges being brought  as  near into
contact as possible across the suppurating surface.     Part xxviii. p. 240.

   Treatment  of Callous Ulcer by Excision of the Margin.—Mr. Hain-
worth thus describes the disease: The  apparently sunken, nearly circular
or oval ulcer, varying in diameter  from one-third of an inch to three, four,
or five  inches, having a level, pale-red, glassy surface, void of granulations,
excreting a thin, scanty, unirritating fluid, with a hard, precipitous, Avhite
or dusky edge, surrounded by integument, thickened and indurated by
infiltration  of lymph and serum, even now occupies too many a bed in our
great hospitals, and too frequently exhausts the patience of sufferer and
surgeon,  dresser and nurse.
   From this  description it will be seen, that those  ulcers are purposely
excluded from consideration which are either inflamed or irritable—which
depend simply on a varicose state of the veins—ivhich are complicated
with diseased bone, or with any special local or constitutional cause.
   The  primary obstacle to the  successful treatment of this ulcer is the pre-
sence of  a  compact and effete solid ring of cuticle.  This must be  excised
by carefully  shaving off the accumulated cuticle  without wounding  the
cutis.                                               Part xxix., p. 242.

   New Mode of Treating Ulcers from Irritation of the Nails.—[Mr. Ure
related the folloAving case of a young Avoman, aged 23, who Avas  under his
care at St.  Mary's Hospital.]
   Four months before admission, the great toe of the right  foot became
uneasy and swollen, the patient having pared the nail the day preceding.
Ere long, a painful and irritable  sore made its appearance by the  side of
the nail, ivhich discharged from time to time a quantity  of thick, bloody,
and sometimes black-looking matter.
   As the sore was rather in an inflamed state  on her admission, poultices
were applied.  On the  third  day,  when all surrounding inflammation
seemed to  have subsided, Mr. Ure prescribed the use of a salve composed
of one grain  of finely levigated arsenious acid, incorporated with an ounce
of spermaceti ointment.  He was  led to try this remedy by the suggestion
of Mr. Copeland, who deemed it  almost a specific in ulcers of this nature.
This was steadily employed for about  ten  days, without producing any
marked change on the sore.  Mr. Ure  then ordered, instead, the  contin-
uous application of a hot saturated solution of alum.   This induced rapid
absorption  of the thickened parts, and prompt cicatrization of the ulcerated
surface, so  that the patient was enabled to leave the hospitaf, cured, in the
course  of three days.  Mr. Ure observed that, ivhile alum is soluble in five
parts of ivater at 60° Fahr., it is soluble in little more than its own weight 
748
ULCERS.
of ivater at the boiling  temperature.   A hot saturated  solution is, conse-
quently, more energetic in its action than a cold one.   Part xxix.p. 247.
  Extensive Phagedenic Ulceration, Successfully Treated by the Actual
Cautery.— [This patient, 25 years  of age, ten days after exposure to con-
tagion, observed a small pimple near the frenum on the penis.  Caustic was
liberally applied, apparently with  success.   At the end of  a fortnight,
swelling in ttie groin came  on, an  abscess formed, which burst spontane-
ously,   ddie sore on the penis  was nearly healed.   Subsequently the open-
ing in the groin extended rapidly, and he soon labored under all the symp-
toms of irritative fever.]
   Where the chancre had  existed there ivas a slight depression, some dis-
coloration, but no hardness of the base; it had been cicatrized for two or
three weeks.   In the  groin  was a foul ulcer of the size of the palm of the
hand;  its surface presented a yelloAitish dark  aspect;  the edges of the
wound  were  ragged, uneven, and undermined,  secreting a thin, fetid,
sanguineous discharge; an areola of a livid tint surrounded, the wound for
a considerable extent.  Ordered to be confined to bed, to live on broths,
jellies, and farinaceous food.  The compound decoction of sarsaparilla with
nitric acid, twelve grains of Dover's powder, at bed time. To the ulcer,
the  nitrate  of silver, an  opiate lotion, and  poultice of  linseed-meal.  To
give the symptoms and treatment of this protracted case inextenso would
be tedious.  Suffice it to say he took the compound decoction and extract
of sarsaparilla, the mineral acids, quinine, opium, and various  preparations
of iodine; to the wound ivere applied the strong nitric acid, muriate of
antimony, the\balsam of Peru, different kinds of lotions, ointments, and
poultices.  The  edges  of the ulcer ivere cut  away by means of curved
scissors;  a moderate  alloAvance of stimulants and a suitable  regimen en-
joined ; still, however, the phagedena continued progressing, so that Allien
all treatment to  stay its progression had failed,  it was determined  to apply
the actual cautery.  It was done at once; and the parts covered with hut,
spread with cerate composed  of two parts of resin cerate, and one of oil
of turpentine; forty drops  of tincture of opium  were  given to procure
sleep.   The recovery of the patient thereafter was truly remarkable.
                                                     Part xxix. p. 247.
   Cancerous  Ulcers.—Mr. Weeden Cooke  recommends a carrot poultice
to be applied to cancerous sores when  offensive.  It should be changed
every few hours.  Mr. Chatterley says  that wood soot (not powdered
charcoal) answers very well for the same purpose.  The wood soot should
be sprinkled from an ordinary tin pepper box, on the outside of the other
dressings used.   It may be obtained from chimneys of fire-places in which
w*ood and nothing else is burned, or from the ovens of ham  and  bacon
curers.                                              Part xxix., p. 321.
   Treatment of Phagedena.—For a considerable period past, a mild form
of hospital phagedena  has  been prevalent  in the various London insti-
tutions.
   It has generally attacked superficial wounds, wtiiether those resulting
from accidents or operations, and, in a few  instances,  even  stumps have
been affected wdth it.   The treatment which  has certainly been found of
most general benefit  has been the application of pure  nitric acid.  In a
case under the care of Mr. Coulson, a man in good health, admitted on
account of a laceration on  ttie  dorsum of the right foot, had the wound 
ULCERS.
749
bo severely affected by phagedena, that amputation was seriously pro-
posed.   The nitric acid Avas freely applied, by soaking a piece of tint, and
then pressing it inte the sore ; it was  allowed to remain seven hours, and
completely achieved its intention.  The gangrene ceased to spread, the
sore took on  healthy action, and  rapidly cicatrized.   Neither in this nor
in any one of several other cases in which the dorsum of the foot was the
affected part did any sloughing of the tendons folloAV the  use  of the acid.
It appears to be in cases of simple phagedena that the local use of nitric
acid is  most to be depended upon, since those of syphilitic origin not un-
frequently resist its influence.  A case of the latter character, occurring in
a young and  seemingly healthy woman, was lately under  the care of
M1'- Stanley, in St. Bartholomew's Hospital, and, in spite  of all measures,
ultimately terminated in death.  Nitric acid bad more  than once been
freely applied, and opium,  cinchona,  chlorate of potash,  etc.,  had been
fairly tried.   In the Middlesex Hospital, the favorite treatment for phage-
dena is by opium pushed freely until  its effects  become apparent.  Some
very successful cases are accredited  to this plan.  It is observed, that
there seems scarcely any limit to  the  quantity ivhich  may be borne, and
that, generally, before any narcotic effects become apparent, the sore takes
on  a healthy action.  Now and then the acid  succeeds admirably in syphi-
litic cases ; as a rule, however, they seem more amenable to constitutional
than local measures.
  The most convenient mode of applying nitric acid is by means of a glass
brush ;  in the absence of which, hoivever, a glass rod succeeds very well.
                                                     Part xxx.,p. 111.
   Ulcer of the Leg in Elderly  People.—According to Mr.  Skey, of St
Bartholomew's, opium has a wonderful  effect as a stimulant in these cases.
Give good diet, and a  common  opium and  soap pill at bedtime.   Assist
by  strapping and  bandaging  if necessary.  The soap and opium pill may
be  given, once,  twice,  or  three  times  a day if necessary, and if other
symptoms do not forbid its  exhibition. Sometimes the soap and opium
purges; in this case leave off the soap, and give half a grain of extract of
opium night and morning, or once a day; increase to one grain if nece-sary.
Opium  gives energy to the capillary system of arteries, promotes warmth,
and thus secures  an  equable balance  of  the  circulation.— Vide  Art.
"Opium."                                           Part xxxi,p. 192.
   Use of Acid Nitrate of Mercury—For Sloughing  Ulcers.—The prac-
tice of treating  unhealthy ulcerations  wherever situated, by means of
caustics, is much pursued at this hospital, and with excellent results.  The
pain attending the application of nitric acid has been much overrated by
the profession generally.
  Its powers in case of phagedena are  noiv widely recognized.  The pain
spontaneously caused by an unhealthy sore during a single night is proba-
bly much more than that produced by an application of caustic.  In most
cases of  sloughing or  unhealthy ulcers, Mr. Startin  employs  either the
solution of the acid nitrate  or the arsenical paste.  The  rapidity with
which the surface granulates afterward is often surprising.
                                                     Part xxxi., p. 240.
  Spender's  Chalk Ointment in Ulcers of the Leg.—The following for-
mula has been very successfully used in chronic non-specific  cases of this
kind:  R Cretse prep., fbiv.; adipis suilli, tbj.; olei olivas,  §iij. 
760
ULCERS.
  Having heated the oil and lard, add gradually the chalk, finely pow-
dered.
  The ointment and a  bandage being once applied, it  is left until the
cicatrix forms and becomes firm.                     Part xxxii., p. 196.
  Phagedenic Ulceration.—When situated  upon an  extremity, and the
sore can be well exposed, Mr. Cock, of Guy's Hospital, advises to try con-
stant irrigation.  You must have a reservoir above the bed filled with luke-
warm water, to which a little chloride of lime or soda has been added as a
preventative  of smell.  Then by means  of an  elastic tube a stream must be
kept continually flowing  over the sore.  By this means all panicles of dis-
charge, etc.,  are washed  away as soon  as  formed, and a speedy arrest of
morbid action is secured; of course  this is based on a supposition that
phagedenic action is a process of local  contagion, the  materies morbi  by
which the ulcer spreads being its own pus.           Part xxxiii., p. 233.
  Astringent Lotion for Ulcers.—A lotion, consisting of half a drachm of
the tincture of catechu, to a pint of the  decoction of oak bark, is a favorite
one  at the Aldersgate-street Dispensary, as  an  application  to foul and
indolent wlcers on the leg.  Mr. Savory, the surgeon  to  that  institution,
finds it superior in efficiency to most-other astringents.  It is applied freely,
a piece of lint being well soaked in it and laid over the sore.
                                                   Part xxxiii., p. 238.
   Cancerous Ulcers.—From a trial of  a great variety of applications, the
following lotion seems to answer perhaps the best: R Plumbi acet., 9ij. ad
3j.; creasoti mxl. ad 3j.; aq. fluvial., §xij.  M.  Ft. lot.
  The acetate of lead and the creasote form  a uniform mixture, and there
is  no separation of the  latter ingredient.  A piece of tint  soaked in the
lotion, and applied to the ulcer twice  or three times a day, is Mr. Valen-
tine's mode of applying  it.   The wtiiole is covered by an  oiled silk.
                                                   Part xxxiii., p. 239.
   Ulcers—Spreading and Sloughing.—Mr. Stanley, of Lock Hospital, says
that the best of all the  usual remedies for such affections is the external
application of the  "Friar's  Balsam," (tict. benzoin co.)
                                                    Part xxxiii.,^). 237.
  Treatment  of Ulcerated Legs.— The  most  important point, in the
opinion of Dr. Thos. Westlake is to get rid of the superincumbent column
of" blood which impedes the circulation;  this is  best done by means of  a
flannel bandage, from seven to eight yards long and three inches  wide,
applied very  carefully, so as to give complete and uniform support to the
affected limb.  In indolent  ulcers the compound  tincture of iodine  is the
most safe and efficient  stimulant.  In  irritable ulcers, the application of
the following lotion—iodide of potassium, one scruple;  hydrocyanic acid
(Scheele's) half a drachm ; camphor  mixture, one oz.—applied for four or
nve  minutes  with  lint well  saturated acts like  a charm.  The following
ointment may be  afterward  employed;  spermaceti ointment, half  an
ounce ;  iodine, fii*e  grains; extract of belladonna, one drachm.
                                                   Part xxxiv., jo. 197.
   Ulcers  of the Leg.—Dr. J. K. Spender  says: we must  endeavor to
preserve the  purulent secretion ivhich nature has  provided as a protective
covering; if  this be deficient, the best ointment as a substitute will be one
composed of tw*o parts of lard and three of chalk mixed when heated and
« 
ULCERS.
751
fluid ; this must be applied spread on linen and over this a flannel or calico
bandage.  If the  ulcer be extensive and the discharge great, it should be
dressed  eiery day, but  generally ulcerated legs are  disguised  much too
frequently; all interference should be postponed as long as possible.  One
great  advantage of the  chalk ointment is, that it neutralizes  the acrid
secretion, and alloAvs the dressing to remain much longer than otherwise,
without interfering with the healing process.   When removing the dress-
ing, be careful that you  do not take aivay the ointment  Avhich may adhere
to the ulcer, or you will  very much hinder its healing.
  General principles of treatment often require some modification in prac-
tice.  The instances in wdiich the chalky incrustation and compression has
answered best are superficial  ulcerations, hoAvever extensive the  surface,
and Avhether dependent  on varix or not.  Deep and callous ulcers require
a "special treatment, Avhich is best fulfilled by the addition of a stimulant to
the chalk ointment, and the best is, the nitric oxide of  mercury;  ointments
of tar and chalk, and iodine and chalk, are found to subdue many forms of
irritable ulceration.   Dr. Hughes Bennett and others confirm the value of
tar in all dermal affections of a psoriasical character.  The use  of ban-
daging is of equal importance, to afford a  support to the veins.   Poultices
are generally injurious, and cannot be condemned in too emphatic terms ;
they relax and weaken the structures and granulations,  which rather require
tonics and support.   The application of a poultice is nothing less than a
mischievous interference with the  natural  heating process.  Lotions of
every kind are equally prejudicial.   The constant application of cold water
is exceedingly injurious.  To  keep  patients in bed is a useful element in
the treatment  of varicose ulcers of the leg,  but compression answers
every object  to be gained by  the assumption of the recumbent position;
and ivhenever compression is  resorted to, exercise confers the direct and
positive benefit of assisting and sustaining those processes necessary for
restoration, it sets up an additional  energy in the process of reparation by
its direct effects as a stimulus.  Of the various measures Avhich  have  been
proposed for the treatment of varicose ulcers of the leg, we may notice
Mr. Syme's proposal for blistering the edges of the callous ulcer. Mr.  Holt
has proposed the exclusion of  atmospheric air by the application  of plaster,
oiled silk, and collodion.  M. Denonvilliers has recently brought glycerine
into notice as a clean  and useful  application  to ulcers.   Dr. Neumann is an
advocate for the application of charcoal.   Mr. Gay maintains that the edge
of the ulcer is not free to contract, being bound donm to the tissues be-
neath, and therefore  recommends  an incision  to be made through the
healthy skin  and superficial facia, Avithin a  short distance of the edge of
the ulcer, in a direction parallel to the direction of the axis of the limb.
Mr. Chapman adopts a modification of this, but considers  the cases  very
rare where it Avould be required.  To Mr. HainsAvorth is due the credit of
reviving the ancient  practice of excising the margin of the callous ulcer.
The late Dr. Golding Bird and Mr. Spencer Wells  have  explained  and
illustrated the application of the electric  moxa.   Mr. Skey advocates the
use of  opium upon  principles  which are  unquestionably authentic and
sound.                                             Part xxxiv., p. 202.

   Ulcers of the Leg.—If the  ulcers  are gangrenous, they may readily bo
made healthy by applying a powder made of equal parts  of fine charcoal
and chalk, and over this a poultice, or dry lint and bandage.  If very pain- 
752
ULCERS.
ful and heritable, apply a dossil  of tint dipped  in chloric ether, and over
this the bandage.  If sanious, or fungoid, apply freely the nitrate of silver,
or sulphate  of copper.  If sluggish, they must  be roused into action, by
applying the nitric oxide of mercury ointment.   If the edges are bard and
cartilaginous, draw the edges  tightly together  by straps of plaster,  and
apply a flannel bandage as tightly as possible,  to awaken the absorbents
into activity.  For simple sores, the simple ointment is best, wdth a band-
age as tightly applied as it can be borne.  If much matter is  discharged,
they should be dressed daily, and in all troublesome cases a flannel band-
age is absolutely indispensable; it will be found to be very much  superior
to .the usual calico bandage, if properly applied.  (Dr. Hunt.)
                                                    Part xxxv., p.  166.

   Ulcers—Old Callous.—Dr.  Watson, surgeon to the Royal Infirmary,
GlasgOAV, says:  If an ointment consisting of anhydrous sulphate of zinc,
mixed with  glycerine,  spread  upon bits of tint the size of the ulcers, he
applied to them, and allowed to remain a few hours, most acute pain will
be caused, and the ulcer will be corroded; but  when the slough separates,
the granulations will rapidly spring up to  a level with the surrounding
parts,  and in most cases will soon become skinned over.  The sulphate of
zinc is as suitable, but not superior to the chloride for this purpose.
                                                     Part xxxvi., p. 259.
   Powdered Chlorate  of Potash as  an Application to  Ulcers, etc.—Mr.
Hutchinson, of  the Metropolitan Free Hospital, says that finely powdered
chlorate of potash is an excellent application to cachectic ulcers ; it seems
to speedily induce cicatrization, and  is very convenient  of use; it is of
great use in cracked nipples and open buboes; it should be dusted into the
sac with the finger, and it may also be prescribed  internally at the same
time.                                              Part xxxvii., p. 175.

    Ulcers of the Leg.—At the  Hospital for Skin Diseases,  the patient is
always directed to bandage  the limb,  though no very particular attention
is paid to this part of the treatment.  Internally the mistura hyd. com. is
mostly ordered, and to the sore itself the unguentum rubrum is applied.
If the ulcer is sloughy or very unhealthy looking, the acid nitrate of  mer-
cury is applied as a caustic previous to the use  of the ointment.  Confine-
ment  is not  insisted  on.   From the rapid healing which often ensues,
probably the mercurial induction, both internal and  local, has  usually a
considerable  share in the cure.                     Part xxxviii.,^?. 173.

   Caustic Lint.—Nitrate of silver is  never applied to sores, except in the
solid state or in solution.  In the former case its action is often too severe;
in the latter it is sometimes too transient.   M. Riboli has conceived the
idea of dissolving nitrate of silver in a small  quantity  of water, soaking
pledgets of lint in the solution, and drying them.  This caustic lint, applied
to ill-conditioned  ulcers, produces a more permanent effect than the remedy
in a liquid state;  and as the author proposes different degrees of concen-
tration for the solution the activity of the treatment may be varied,  accord-
ing to the nature of the case, and the more  or less advanced stage of the
affection.                                            Part xxxix., p. 232, 
UMBILICAL CORD--UMBILICUS.                 753
                      UMBILICAL GOIT).
  Advantages of retaining Undivided for a Short Time after Birth.—In
all cases where the infant is born weakly or in a state of asphyxia, M. Bau-
delocque recommends not to cut the umbilical cord for some time at least
after birth.  He relates that since he has folloived the opinions of Smellie,
Levret,  Chaussier, etc.,  on this  subject, he  has  not lost,  a  single case,
although Avhen born  the  child  might be in a state of pretty complete as-
phyxia or apoplexy.  He states that, though a child be born in an apoplectic
or asphyxiated, state, the circulation still continues through the  umbilical
vein, even though the umbilical arteries should have ceased to beat, and
that premature section of the umbilical cord  takes away one of  the chief
aids to its revival.                                      Part iv., p. 135.
   Treatment of Hemorrhage from  the Navel of New-born Children.—
Ordinary remedies are insufficient to arrest  the bleeding.   Kolophonian,
alum, the various styptic fluids, turpentine, ice, amadou, compression, etc.,
have been employed in vain.  Cauterization has been several  times tried,
both with  the nitrate of silver and the actual cautery.  In fact, the use of
the ligature appears to be the only means worth dependence upon as capa-
ble of restraining the bleeding, and the mode of its application en masse, as
advised by Dubois, is to be preferred.  But in the best manuals and trea-
tises we find no advice  given  as to the method of  securing immediately
the umbilical arteries, and, so  far as ive know, it has never been  accom-
plished, from the many difficulties attendant upon its performance.  It has,
therefore,  been  proposed to secure all the three vessels together,  by pulling
the navel-knot forward,  and passing around it a ligature with  the  help of
hare-lip pins.  At first sight this operation seems to have much in its favor,
though  experience does  not  confirm  it.  Nevertheless, up to the present
time, it has been of most service.—Roger, in Journ.fi Kinderh.
                                                    Part xxix., p. 311.

                               ---»>»


                           UMBILICUS.
   Treatment of Urinary Discharge from the Umbilicus, in Infants.—B«
Cooper says that, in infancy it is not uncommon for a urinary discharge to
take place from  the umbilicus, in consequence of the open  state of the
urachus ; in such a case you should first ascertain that there is no obstruc-
tion to the  passage  of  the  urine through its  natural  canal, and if that
should be the case, as frequently happens  from congenital phymosis, the
cause of the obstruction should be removed, and  then, upon  gentle  pres-
sure being applied to the umbilicus, the urachus generally closes, a.though
there have been instances in  ivhich the defect Avas never remedied.
                                                     Part xviii., p. 203.
   Hemorrhage from the Umbilicus after Separation of the Funis.—When
a disposition to  this hemorrhage  is known or suspected, says Mr. Ray,,
apply collodion after the separation of the funis, and before the  usual com-
press is applied; and examine the part  every day. When the bleeding
actually occurs, it is necessary  to adopt mechanical means to check it with-
out the least delay.  For this purpose, first pinch up the umbilicus between
     A'OL. n.—48 
754:                           URETHRA.
the finger and thumb, in the manner recommended  for leech-bites ;  and if
this is successful, fill the depression of the umbilicus ivith cotton wool, and
coat it over with collodion, or apply plaster of Paris mixed up with water.
If these means do not control it, make an eschar with a probe, director, or
skewer, heated to whiteness, and afterward coat with collodion.  Lastly,
if other means fail,  tie the vessel, first introducing  a fine probe  into it, to
act as a guide for the incision.  Ligature is not  recommended  except as
a last resource, because in these cases there  seems to be a hemorrhagic
diathesis, and, consequently, it is undesirable to make incisions.
                                                     Part xix., p. 256.
                          URETHRA.
  Inflammation of Mucous Membrane of  Urethra—New Mode of In-
troducing the Catheter.—Dr. Patterson, of Rathkeale Infirmary, gives the
following case: The patient labored under most distressing inflammation
of the mucous membrane of the urethra, and his bladder was greatly dis-
tended with urine, which he could only pass  in drops and in extreme
agony; there was  a most unbearable desire to empty the bladder, occa-
sioned, in a great measure, it may be presumed, by that  organ's partaking
of the inflammatory action.  The morbid  sensibility of the  urethra was
such  as  that no  instrument of any  kind could be  introduced, and the
patient's impatience could  not wait  the  abatement of  the inflammation,
under the employment  of the most active means.   In this case I attached
an  injecting apparatus  to a curved  elastic  catheter, and, having inserted
the extremity of' the tube a little  way within the orifice of the urethra, I,
in the gentlest manner, injected, or  rather insinuated  a little warm decoc-
tion  of  linseed, just so  as to moderately  distend the urethra; I then
gradually urged the catheter onward, and succeeded in  getting it into the
bladder, with tittle or no pain or inconvenience to the patient.
                                                        Part 'ii\.,p. 97.
  Mechanical  Injury of.—Obstructions  of the urethra may arise from
mechanical injury to various parts  of the urethra, as, from the violent
pressure of some circular body, as a ring round the penis, or a Woav upon
the urethra as it passes  under  the pubes where  the mucous membrane is
especially liable to  suffer  from such  a cause. Sir B. Brodie gives the fol-
lowing directions with regard  to the treatment:
  " In all cases," he says, " in which there  is  reason to believe that the
urethra has been divided, or lacerated in consequence of an injury inflicted
on  the perinasum, it is  the duty of the surgeon not  only to look at the
great and immediate danger, but to guard against future ill consequences;
and much may be done  at this period toivard  pre\renting a most serious
inconvenience,  which would  be  relieved with difficulty  afterward.   If
there be a penetrating lvound, in Avhich the urethra is probably implicated,
an elastic gum catheter  should be introduced with the least possible delay,
and allowed to remain in the urethra and  bladder until the healing of the
wound is far advanced, or, at all events, until it is  ascertained that the
urethra  has  not  suffered;  the  catheter  being, however,  occasionally re-
moved for a limited time, if it seems to act as a source of irritation'.
  In  cases of contusion  of the  perinaeum, when  the effusion of blood in the
perinasum and scrotum,  and more especially the discharge of blood from 
URETHRA.
755
 the urethra, or  any other circumstances, lead  to  the  suspicion that the
 urethra has been lacerated, the same treatment should be had recourse  to,
 the gum catheter should be introduced as soon as possible, and alloAved to
 remain for at least some days after the occurrence of the accident. The extra-
 vasation of blood does not in  itself justify the making an incision in the
 perinasum ;  and indeed, according to my experience, there can be no worse
 practice than  that of making an incision in a case of simple ecchymosis,
 either in this or in any other situation. But where such extravasation exists,
 there is  always  reason to apprehend that there may be further mischief;
 the progress of the case, therefore, should be carefully watched, and,  on
 the first appearance^f any symptoms which might be supposed to indicate
 that urine had escaped into the cellular membrane, or that suppuration had
 begun to take place, a staff should be introduced into the urethra instead
 of the gum catheter, and a free incision should be made from the perimeum
 into it, the gum catheter being replaced afterAvard.
   But it may be that these measures of precaution  have not been adopted
 in the first instance, and that you are not consulted  until after the lapse  of
 a considerable time, when the wound or laceration of the urethra is already
 healed, leaving  the urethra contracted  in  the  situation of the  cicatrix.
 Here  you  may, perhaps, succeed in gradually dilating  the urethra,  as
 Avhere there is an ordinary stricture.   But  in a case ivhich I  have already
 mentioned, I have stated that  "this was not accomplished ivithout a great
 deal  of  local  and constitutional disturbance;" and  so it has been in  all
 cases of this kind ivhich have  fallen under my observation.   Nor will the
 occurrence of such difficulties be a matter of surprise to  any one Avho bears
 in mind that here  the object is to  dilate, not  a genuine stricture, but a
 cicatrix, of the urethra, and. who has not observed how the cicatrix of an
 old sore leg inflames  and cracks when the subjacent muscles  begin  to
 increase  in bulk  from exercise, or how the endeavor to extend forcibly the
 contraction after an extensive burn produces the same result.  It may  be
 that these difficulties are insuperable, under the method of  treatment by
 simple dilatation ; and under these circumstances, a small staff having  been
 introduced into  the bladder, the cicatrix of the urethra  should be divided
 by an incision from the perinasum, a gum catheter being introduced after-
 ward,  and allowed to remain until the wound is  healed over  it.  But
 even  then  much remains to  be accomplished.   The cicatrix  has still a
 greater disposition to contract than an ordinary stricture; the bougie  or
 catheter must be had recourse to almost daily, and the patient  must be
 contented  if he can persevere  in the  use of instruments of a moderate
 diameter, as the urethra  will invariably resent the attempt to keep  it
 dilated by those of large dimensions."
   The condition of the  patient is improvable, where  the  injury of the
 urethra is limited.   But where there has been actual  loss of some portion
 of the canal, the patient  must either be content  to void the ivhole of his
 urine by the perinasum, or submit to an operation  for establishing a  com-
 munication between the anterior and posterior portions of the urethra.
 This operation is best explained by a case.
  " A young man, in making a leap on horseback, received a violent blow
 on the perinasum from  the pummel of  the saddle.  The immediate conse-
 quence  of the  injury  Avas hemorrhage  from the urethra,  and this was
followed by extravasation of urine  and sloughing of the perinasum to a
considerable extent.  A catheter was at first introduced into the bladder, 
756
URETHRA.
but it ivas afterward removed.  The  sloughs having separated, the sore
in the perinasum gradually closed, a small fistulous opening only being leti
immediately behind the scrotum, through which  the whole  of the urine
was discharged.  He Avas in this state seven months after the occunence
of the accident, when he arrived in London, and  Mr. Baker advised him
to have my opinion on  the case.
   On introducing an instrument into the urethra, I found an obstruction
of the canal  immediately below* the pubes.  Several ineffectual attempts
having  been made to  penetrate the  obstruction in the usual manner by
bougies and sounds of  various sizes, I bad recourse to the following opera-
tion :   The patient having been placed in  the same  position  as  in lithoto-
my, a staff* was introduced into the urethra, and held by Mr. Hilles, who,
with Mr. Baker, assisted me in the operation, with the  extremity of it
resting against the obstruction.  I then made an incision in the  perinamm,
extending backward from the part in ivhich the staff was to be felt, in
the direction of the prostate  gland.  It was now evident  that not  less
than three-quarters of an inch of the urethra ivas deficient below the pubes,
the place of it being  occupied by a rigid cicatrix.  This having been
divided longitudinally by the point of the scalpel,  I was enabled,  though
not without some difficulty, to pass the staff from the  part at ivhich the
extremity of it rested,  into the sound portion of the urethra toward the
bladder, and then into the  bladder itself.   The staff was then withdrawn,
and an  elastic gum catheter having been substituted for it, the latter  was
allowed to remain in the urethra and  bladder.   On the ninth day after the
operation, there being  some degree of irritation at the neck of the bladder,
the catheter was removed, being  reintroduced,  however after two days
more.  From this time it was removed at intervals, ivhich were sometimes
longer, sometimes shorter, according to circumstances.  The wound in
the perinseum graduady healed, and in-less than ten weeks from the time
of the operation was reduced to the diameter of a small pea.  The patient
was now able to introduce a silver catheter of the size of his urethra  into
the bladder without difficulty, and he repeated this operation so as te draw
off his urine three or four times daily.  When he  voided his  urine without
the catheter, by placing the point of his finger on the opening in the
perinasum, he was enabled to discharge the "whole in a sufficient stream by
the urethra.                                           Part  id., p.  101.

   Importance of Discriminating Diseases of the  Urethra.—(M.  Civiale
mentions tivo mistakes ivhich are often made in the treatment of diseases
of the  urethra.)  One consists  in regarding  as a poisonous discharge
produced by gonorrhoea, that which is innocuous, and caused by irritation
merely in the passage; such, for  instance, as the presence of a stricture;
the former being a virulent poison capable of  reproducing ad infinitum,
wdiile the latter is perfectly harmless.
   Want of due discrimination in this case not unfrequently infliets  an irre-
parable injury on the patient.  For example;  when a stricture, attended
with a discharge from  the passage, is observed  soon  after an attack of
gonorrhoea, the patient naturally considers ttiat  he  is  suffering from the
gonorrhoea, wdiich had not been  properly cured ;  and should  the person
who has the  treatment of the case entertain the same opinion, the result
will be that  the patient will continue taking copaiba, cubebs, etc.,  off and
on for  months,  perhaps years,  to the great injury of his stomach  and 
URETHRA.
757
system in general, while  the  stricture all the time  is gradually getting
worse.  There is a curious point in  reference to the effect of copaiba on
this kind of discharge, and it is this—the discharge is always relieved,  but
never removed by copaiba, unless in conjunction  with the use of bougies.
This fact again tends materially to perpetuate the erroneous treatment, as
the inference at once  suggests itself, that copaiba, etc., will cure this  dis-
charge if persevered in, inasmuch as it always exerts a marked influence
on it. But however  good the  argument, the practice is bad, for it  will
never cure such a discharge.  The practitioner very commonly remains in
ignorance of his error, by  reason of the patient becoming dissatisfied ivith
his  treatment, on feeling  no permanent benetit  from it,  and therefore,
soliciting the assistance of various others for the relief of what he and they
regard as an incurable clap.
  Occasionally, the  discharge  caused by  the irritation of a stricture is
attended with many of the symptoms of a regular gonorrhoea; but when
it  is generally knoAvn that it is so,  there ivill be experienced but little
difficulty in practice, in distinguishing these discharges, ivhich differ so
materially in their effects on the system.
  The other mistake refers also  to the presence of a stricture.  It is  the
received  opinion, being  so laid  doivn  in  all ivorks on surgery, that  the
stream of urine through the urethra bears an  exact ratio to its calibre.  It
would be so, were  the urethra  a dead body, but being endoAved with
vitality ivhich is acted upon by muscles—whether  in  its substance or  not
is  immaterial—the  result is,  that a person afflicted with a  permanent
stricture may pass his urine  in  a good stream,  because when he  feels  a
desire to evacuate, his urethra, obedient to his will, opens out, so to speak,
at its strictured part, and discharges  a  larger-sized stream  than  would
have passed through it, had it been an  inanimate body.
  In  practice  this consideration is  of high  importance, for if a psrsou
afflicted with a permanent stricture passes his water in  a fair stream,  a
surgeon in this particular,  misled by his teachers,  will pronounce the case
not to be stricture, to  the great  injury of his patient.  Indeed, no error
that can be made in surgery is attended wdth  more serious results than
this, because the case, from being misunderstood, gradually gets worse, in
spite of all treatment, bougies' not being  introduced, until some exciting
cause having supervened, irritation  comes on in the passage ; no  urine
Avhatever can be passed; and  the patient's life will be in extreme danger,
should he not then be efficiently treated.               Part x\.x.,p. 185.
   Vascular Tumors at the Orifice of the Urethra.—Mr. Norman, Surgeon
to the Marylebone General Dispensary, directs to remove them by excision
or by the ligature, the latter being preferable in consequence of the serious
hemorrhage ivhich sometimes attends excision:  in  either case apply  a
powerful caustic afterward  to  prevent  the groivth being  reproduced.
For very small tumors it will  be sufficient to use the actual  cautery, or
caustics, such as potash, nitric acid, and pernitrate of mercury: nitrate of
silver is less efficient and much more painful.             Part xx., p.  162.

   Vascularity of the Lining Membrane  of the Female Urethra.— Under
the name of "Vascular Tumor  of the Orifice of the Meatus Ur nanus,"
says Dr. Gream, of Queen Charlotte's Lying-in-Hospital, this affection  was
first described by Sir Charles Clarke, in  his valuable work on the "  Dis-
eases of Women." 
758
URETHRA.
  I have ventured to refer to this affection under  another name, because
my oivn experience, confirmed  by that of others, tends  to  show  that it
does not  always appear  as a  tumor, but that it  may be present under
other forms, accompanied by the same general as well  as  local symptoms.
  Dr. Ashwell has correctly described the disease, but  he  speaks of it
more especially as a tumor, and  states that it is rarely seen  after the
cessation  of the menses.  I am  led to think that he is mistaken in this
respect, for I have witnessed the disease as often in elderly women as in
the young.
  It may  be present as a simple vascularity of the lining membrane of the
urethra, without any elevation Avhatever, extending some little distance
toward the  bladder; the membrane itself being highly florid in color,
and extremely tender w hen touched, or during the passage of  the urine.
This is the usual character of the disease, when it is  confined within the
canal; but Sir Charles Clarke relates the case of a patient  in St. Bartho-
lomew's Hospital, in whose  urethra  there was a tumor of a scarlet color,
nearly filling up the canal.  The occurrence of a  tumor, however, within
the urethra is unusual.
  The second form in ivhich  the  disease appears, is that  of a flattened
vascular spot, with but slight elevation, surrounding the  orifice  of the
urethra, highly florid in color, and  exquisitely tender wdien touched; it is
so  little elevated that  it can  scarcely be called  a tumor.   The  redness
extends from  it into the canal  for some little distance, but the membrane
within, although  florid  in  appearance,  is quite smooth on its surface ;
whereas the external spot of vascularity is slightly granulated,  because it
is not modified by pressure from the sides of the urethra.
  In the  third stage, the disease consists of a distinct tumor, granulated,
and attached, sometimes by  a broad base, sometimes by a narrow one,
and, in some instances,  even by  a slender pedicle,  to  the side  of the
urethra, or just externally to  it; and, in  almost  all  cases, some  dilated
vessels will be seen extending from its  base to within the urethral canal.
  When there is an actual prominent tumor, the local  pain mid the consti-
tutional symptoms are greatly increased in severity.   In some cases, the
peculiar scarlet  color of  the part has attracted the notice of the patient;
but in  many instances, particularly wdien 'the vascularity  is within the
urethra, not only has the actual seat of the disease escaped her observation,
but it has also been overlooked by her medical attendant, who has referred
to the uterus  as the diseased organ, has stated that its  cervix was inflamed
or ulcerated, and caustic has sometimes for weeks, or months, been applied,
without affording the least advantage to the patient.
  This vascular disease is not at all to be considered as similar to an affection
situated in the same parts, having its origin in a varicose state of the veins.
  In the vascular disease in question, the blood contained in the vessels is
arterial, Avhile in  the venous  enlargement it  is dark colored, and the dis-
tended veins have the same appearance ivhich veins have in other parts of
the body ivhen in a varicose condition. Attention is first called to the vascu-
lar  disease, by an uneasy sensation at the lower part of the body, and pain
passing down the thighs; and pain when urine is voided, or when the part
is touched ;  slight bleeding also occurs occasionally, ow ing  to the rupture
of some dilated vessel, whose covering is always much attenuated.  There
may be frequent desire to pass urine; and walking causes great suffering;
while accompanying these symptoms, there is always  copious mucous dis- 
URETHRA.
759
charge, which is excessive when the disease appears in the form of a tumor.
Owing to which, as lvell as to the constant uneasiness and frequent acute
suffering, the patient  become*-emaciated and weak, and it is surprising to
find  so  many and  such severe  symptoms arising from a disease ivhose
extent is confined within such limited bounds ;  but there is clear evidence
that it does produce them in  the fact  that, immediately upon the destruc-
tion  of the vascular  spot, or ei'en on  its partial removal, a comparative
freedom from the symptoms is at once enjoyed.
  The only mode of cure is  the destruction of the entire  congeries of
vessels ;  and if the smallest part of it  is left, the disease will most certainly
return.
  Having several times been called  upon to treat cases which had been
before apparently cured (by myself and others) it occurred to me that the
application of strong nitric acid, in the manner adopted by Mr. Henry Lee
for the  destruction of  hemorrhoids (and which proves so successful,)
would be equally applicable to the A*ascularity of the female urethra.
  But there is a difficulty in exposing the part sufficiently, and in prevent-
ing the sides  of the  vagina from  collapsing too soon after the application
of nitric acid;  and this is overcome by  the use of a speculum, invented, I
believe, by Mr. Hilton, for the removal  of hemorrhoidal excrescences. A
portion  of the side of the speculum,  extending nearly to its internal
extremity,  can be removed after its introduction into the vagina, and if
this  part of it is just under the pubes, the spot of vascularity Avill project
into the tube; but should only the  lining membrane of the urethra be
vascular, it will be readily exposed by pressing the speGulum firmly  toward
the pubes against the surrounding part; and the acid can be applied Avhile
the pressure is kept up.
  A small rod of glass, or a piece of hard wood in the form of the stick of
a camel's hair pencil, is the best thing with which to  apply the acid;  and
this should be held  to the part for about a minute, care being taken  that
each enlarged portion of the vessels is completely destroyed, and in about
'three or  four minutes the pain attending  it ceases, and the speculum can
be removed.   It w ill be better to examine the  part  in  about four  days
from the time of the  application of the acid, and it  often will  be found
healed ivith no trace of the complaint  left.  More frequently it presents an
unhealed sore, but an absence of the disease.   If, hoivever,  there  be  any
vessel remaining  having  the peculiar  scarlet color,  it  should  be again
touched  Avith the nitric acid, otherwise  the symptoms will rapidly return.
                                                    Part xxv., p.  297.

  Impermeable Urethra.—In cases of complete obstruction from wounds,
Prof.  Syme would introduce an  instrument  like the common lithotomy
staff, but grooved on the concave side, through the fistulous opening of the
perinasum into the bladder, then pass  the guide director employed for the
division of strictures by external  incision, down to the seat of obstruction,
and thrust it through the opposing structures (in the course Avhich it ought
to take were the canal free) forivard into the bladder;  the obstruction  may
then be divided in  the same way as in the usual operation for stricture.
It must be  remembered  that this is not the remedy for stricture, but for
obliteration of the canal.                             Part xxxv., p.  125.

  Dilatation of the Female Urethra.—There are  various means of dilating
the female urethra, as sponge-tents and metallic dilators; but  these cause 
760
t'KIXE.
great pain, and, worst of all, are very liable to be followed by pcrnmnent in-
continence.  Weiss' dilator, though simple and easily applied, dragi> the ure-
thra into a sort of triangle, the pressure falling entirely  upon three p( hits.
What is wanted is a uniform pressure, and  one capable of dilating quickly,
as being less liable to be followed by incontinence.  This desideratum is
supplied by fluid pressure. The apparatus, used by Mr. Weds, surgeon to
Samaritan hospital, is an elastic tube, having at one end a syringe and at the
other a female catheter, the  latter having  a piece of India-rubber tubing
closely fitting oyer it.  The syringe must be furnished with a stop cock.
The catheter being introduced, the India-rubber tubing may be gradually
distended with water by means of the syringe.  The whole  process will
not  occupy more than  ton minutes, and,  besides, the other advantages
possessed by it, will not be accompanied by much pain.
                                                 Part xxxi iii., p. 223.
  Urethral Caruncles.—If these florid painful growths be removed by the
knife alone, even  if the  piece of mucous membrane upon which  they are
seated be also removed, a permanent cure is seldom effected.   The use of
caustics is not attended with better results. The actual cautery alone, says
Prof. Simpson, will destroy these  growths effectually.  An  iron of pro-
per size and  shape, adequately heated, may be  employed, or the  requisite
degree of heat  may be applied through the galvano-caustic  wire.  The
latter method is especially useful when the caruncles extend up the urethra
higher than  the  orifice, because you can  introduce  and apply the wire,
before heating it by the transmission of the  galvanic current. Apply im-
mediately afterward cold water and cloths soaked in it; and subsequently
treat the ulcerated surface, after the slough separates, with very frequent
applications  of  black wash, zink  lotion,  or other surgical  applications.
Though this is the best mode of treating these growths, yet even this is not
absolutely a  certain method  of cure, as cases now and then occur in which
the growth will return in spite of all.  Round the larger projecting tumor
a number of small painful red  spots of mucous  membrane generally exist,
and the removal  of these is  essential to the radical cure.   The best local
application to relieve the irritation and pain is an ointment made up of two
drachms of the dilute hydrocyanic acid of the pharmacopoeia to an ounce
of lard.  A bit  of this  ointment, about the size of a pea, applied to the
part three or four times a day, often relieves the pain more effectually than
any quantity of opium  administered internally, or than any other form
of local anodyne.                                       Part xl, p. 209.

                               ---•-•-*—•


                             URINE.
  Retention of  Urine— Case Relieved by the action of Cold.—The opera-
tion of cold  as an excitor of the  expulsor fibres of the bladder, has been
most interestingly illustrated  by Dr.  Currie, in his "Medical Keports."
" My friend, Dr. Ford, has mentioned to me the  case of Mr. C----, of Bris-
tol,  who was instantly  relieved of an obstinate stricture of the  bladder,
of thirty hours duration (during all which time not a drop of water  had
been passed), by placing his feet on a marble slab, and  dashing cold water
over the thighs and legs.   The effect was instantaneous; the urine burst
from him in a full  stream,  and the stricture ivas permanently  removed. 
URTXE.
761
The common remedies, particularly opium and bice ling, had been tried in
vain."   Facts of this kind have been noticed by several other observers.
                                                      Part viii., p. 47.
   Urine as a means of Establishing the Diagnosis and Treatment  of
Diseases.—Dr.  F. Simon  uives the  following  valuable communication:
Among the earlier investigators who paid attention to the urine, though very
partially, I may mention Brandt, Kunkel, Boyle, and  Bellini; Boerhaave,
however, attempted an analysis of the urine, which, considering the time,
was extremely goad.  Scheele's discovery of uric acid, and Ci uikshanks' of
urea, contributed essentially to a more correct knowledge of this secretion.
The  latter surgeon had already examined  the  urine in several  diseases,
especially in diabetes and dropsies.  At the commencement of the present
century it was chiefly Berzelius and Prout who made the urine the subject
of extended inquiries; Berzelius demonstrated the existence of lactic acid,
Avhich, by the earlier chemists had been considered to be acetic acid ; the
analysis communicated  by Berzeliu*,  in 1809, of the composition of the
urine, has been till wdthin'the last few yeirs the only correct examination
of the same ; Prout has continued his inquiries up to the latest period.  Of
the more  recent works on the constitution of the urine, those by Lecanu
are the  most promi ient; wdthin the last years, Becquerel, Lehmann, and
Simon, have  employed themselves with examinations of the urine in the
healthy and morbid state.   Several constituents of the urine, both in the
state of health and disease,  are Aery accurately known, as  uric acid, urea,
lactic acid, the salts and the sugar of the urine; of others, probably not
less important, Ave have a very imperfect knowledge, as of extractive and
coloring matters.   Regarding the quantitative composition of the urine,
ivhich is rather changeable, numerous investigations have been  made by
the above-named  chemists.   Lecanu also  investigated the varieties ivbich
may be shown in healthy urine, according to age and sex.
   The quantity of urine passed in the tw:enty-four hours, and its color, are
.frequently of importance.   A diminished  quantity of the  urine passed in
tAventy-four hours, is under  circumstances a sign  particularly of acute dis-
eases; an excessive increase of the urine, if permanent, is  oftentimes indi-
cative of serious  diseases.   A dark-colored, flaming, or fiery red  urine
commouly indicates an inflammatory affection ;  a dark brown red is gene-
rally observed in typhus.  But the urine may also be colored blood-red or
broivn-rfd by bile-pigment, ivhich  is  easily detected by its  reaction with
nitric acid;  the  latter  constantly  indicates an  affection of the liver;  a
blood-red urine commonly contains blood ;  there is then for the most part
 found in  it a sediment of blood-corpuscles,  ivhich are recognized with the
microscope; but should a little blood be contained in the urine and this in
a state of solution, it may be discovered by adding nitric acid, ivhich occa-
sions a precipitation of coagulated albumen colored red by  hematine.  This
bloody  urine indicates a bleeding in the kidneys, bladder, or, in  the case
of women, of the uterus.  Blood flouting from the urethra  comes in drops.
If the blood is discharged  in masses  after clear urine, it  comes from the
bladder, and in that case it often stops up the passage from the bladder by
coagulation ; if the blood is  distributed through the urine, partly dissolved,
and  not in very large quantity, it comes from  the kidneys ; if it be dark,
and  mixed with mucus and pus, it owes  its origin to an ulcer.  The pre-
sent of stone-colic shows that the blood has been poured out during the
decent of a renal calculus. 
762
URINE.
  Blue urine has been observed, though not  frequently; in the majority
of cases it probably owes its origin to the use of certain medicines ;  black
urine has likewise been observed; the connection, hoivever, is not yet
known between the coloring matter and the morbid process ;  greenish urine
indicates, according to Prout, an oxalic acid diathesis ; sediments of oxalate
of lime form, or mulberry calculi puss away; a urine, which is pale-colored,
and  has a bias  to green, frequently indicates the presence of albumen,
ivhich is readily detected by heating to boiling or by nitric  acid.  In this
case  the  urine is not perfectly clear, but slightly opalescent;  its quantity
may be increased, diminished, or natural.  The oxalic acid diathesis of the
urine indicates,  according to Prout, functional disturbances in the chylo-
poietic system ;  albuminuria  ordinarily indicates dropsy  and  an  affec-
tion  of the  kidneys.  The reaction  of the  urine is  important  for the
physician.   Natural  urine,  it is well  known, has an  acid  reaction ; the
quantity of free acids in the urine and the intensity of the reaction may
increase to an extraordinary degree in diseases,  more particularly in rheu
matism, gout, in disturbances of the digestive organs, and in certain stages
of typhus  ; to judge correctly of the intensity of the acid reaction, reference
must be had to the quantity of the urine; the greater or less acid reaction
is known  by the effect of the urine on  litmus paper of a weak blue color,
which  becomes  colored  so much  the more  rapidly and  the more deeply
reddened, the greater the  acid  contents of the urine are.   Urine with a
neutral reaction  commonly forms the transition  from the acid to the alka-
line  reaction, and vice versa.  The alkaline reaction of the urine is of great
importance  to the physician ;  it  commonly depends on carbonate of am-
monia, the presence  of ivhich  is recognized by the odor, and  the  white
cloud,  ivhich a glass  rod develops  when moistened w ith  an acid salt and
brought near to it.  The urine also may have an alkaline reaction through
its containing carbonate  of soda, which salt finds its way into the urine by
the long-continued use of carbonate or bicarbonate of soda wdth vegetable
acids.  The urine, alkaline by carbonate of ammonia, is but seldom evacu-
ated in this state  from the ladder; during its discharge it is  commonly
neutral, and becomes alkaline only in a shorter or longer time after ; badly-
cleaned vessels  may moreover  contribute much  to  this, a circumstance
wdiich  ought to  be taken into account.  Urine ivhich  already on voiding
it has  an ammoniacal reaction,  and has also a very bad smell, indicates
always a  serious  affection  of the  nervous system, and especially of the
spinal cord.  In  certain unfiVvorable stages of tabes dorsalis, phthisis  of the
spinal cord, paralysis of the  lower extremities  and  of the bladder, the void-
ing  ammoniacal urine is ever an unfavorable sign ; in other affections of
the nervous system, also, as in typhus, ammoniacal urine is observed, which,
however,  assumes this reaction in the majority of cases not  till after it has
6tood for some time.  In typhus the reaction of the urine  may be of im-
portance for the prognosis when the urine, after it Avas observed to have
an acid reaction  through one, two, or three periods of seven days, is finally
found to be neutral, and then to hav*e an ammoniacal odor and reaction ;
when this reaction lasts for several days, probably during one entire period
of seven days, and then again passes into the acid, this seems in most cases
to indicate a favorable termination to the disease.  The urine having an
ammoniacal reaction in typhus  has usually a dirty, turbid, yellow-brown
or red-brown appearance, and forms sediments wdiich disappear in a great
measure on the addition of free acids; also in catarrhus vesicas, or in phthisis 
URINE.
763
vesicas, the urine becomes ammoniacal in a very short time after being
voided ; the large quantity of vesical mucus or pus indicates this affection ;
finally, the formation of urinary concretions, consisting of earthy phosphates,
is  in part occasioned by the neutral or alkaline reaction of the urine ;  the
urine voided in this urinary affection, is not so dark as the urine in typhus,
and  commonly forms  sediments of phosphate of lime, and of  ammonio-
magnesian  phosphate.   If the vesical calculus exercise an  irritating influ-
ence on the parietes of the bladder, a great quantity of vesical mucus is
commonly mixed wdth the urine.
   The specific gravity of  the urine, though by itsedf it possesses no great
diagnostic value, as it depends on  the  variable quantity of water in  the
urine, may, hoivever,  claim the attention of the physician under certain
circumstances ; the clearer and the  more like w-ater the urine appears,  the
less  is its specific gravity ; the  deeper and darker-colored, the higher  the
specific gravity.   This general law may admit of an exception in one case,
namely, in diabetes mellitus ; in this disease a urine is voided either normal
or pale, seldom deeply-colored, the  high specific gravity of ivhich (1020-
1060) is in  contradiction to the color ; this high specific gravity imperative-
ly requires a more strict examination of the urine.  More than all other signs,
the correct examination of the sediments is of importance to the physician.
Healthy urine forms only after long standing a light, sinking cloud of vesical
mucus; every other separation in the urine is of a pathological nature. The
urinary sediment consists  either of  organic formations,  as mucous corpus-
cles, purulent corpuscles, blood, etc., or of heavy, insoluble salts or acids, or
lastly, of an admixture of both ; the microscope will throw light on this.
   The  sediment  consists  of organic formations.  If the urine has not a
blood-red color, the sediment is white,  grey, dirty-yellow, and with  the
microscope can be seen mucus, or pus-corpuscles ; here the  sediment is
constantly mucus, if the urine contain no albumen ;  it is probably pus, if
the sediment is deposited rapidly after the urine is voided, and the urine
contains albumen.   It is not necessary now to state of what importance it
is  to discover and  appreciate mucus and  pus in the urine; in  catarrhus
vesicas  the mucous sediment frequently assumes  a very glutinous quality ;
this, hoivever, happens only when the  urine begins to become ammoniacal,
which, in urine containing mucus, often occurs in a very short time, as ive
have already  mentioned ;  the same may be said of pus, and it is good in
this case to test the presence of albumen not by boiling heat, but by nitric
acid.  If the sediment is blood, the blood-corpuscles are then seen with  the
microscope; the urine standing over this is also of a blood-red color.   Of
the import  of blood in the urine I have no remark to make.  If the urine
contain albumen, and  there  exist at the bottom a mucous sediment, it is
of great importance to  examine this with the microscope.   We may find
therein, as I have observed, peculiar long prominences, partly filled, partly
transparent, and round spheres, twice or thrice as large as mucus corpuscles,
filled with dark, granular contents, which beyond a doubt have their origin
in  the kidneys, and  denote a morbid state of this organ.  These peculiar
forms I have frequently, and at different times, found in the urine of a per-
son laboring under morbus Brightii.
  The sediments which  are not of an  organic nature, may in like manner
be easily recognized ivith the microscope  and some few reagents ; they
are either  crystalline or  amorphous, present themselves  either in acid,
neutral  or  alkaline urine, and are readily  distinguished;  in  acid  urine 
764
URINE.
sediments of uric acid present themselves, urate of ammonia, urate of soda,
oxalate of lime, cystin.  The greatest number of sediments ivhich present
themselves in acid urine consist of urate of ammonia ;  less frequent are
those consisting of uric acid, still rarer are those consisting of oxalate of
lime, and the most uncommon of all are those consisting  of cystin.  Sedi-
ments-consisting  of  earthy phosphates do  not occur in urine having a
strong acid reaction.   Every sediment occurring in acid urine from yellow
to brown, from  red to purple-red, appearing under the microscope as an
amorphous precipitate, or as large and small globules aggregated  together,
which is  dissolved entirely or  almost  entirely on warming the urine, is
urate of ammonia; to this belong accordingly all the so-called critical  sep-
arations in the urine;  the species of separation of the urate of ammonia is
very various, and  it appears sometimes  as mere turbidness, ivithout form-
ing any sediment Avhatever, sometimes it lies at the bottom of the vessel
as colored mucus or pus, at other times heavy, like an earthy precipitate.
In the case of those diseases, which in  the  course of  their development
admit a termination by a critical separation in the urine,  the kind of sepa-
ration is of importance.  The heavier the sediment lies at the bottom, and
the clearer the  urine is that stands over it,  the more decided  is the crisis
alloAved to be ;  whilst the lighter the sediment floats, and the less disposi-
tion there  is to  a perfect deposition, the more imperfect  is Nature's effort
to break down  the disease by a crisis.   The various colorings of the sedi-
ment are characteristic of some diseases ; in acute rheumatism of the joints,
in intermittent fevers, the critical sediment is observed to  be colored red up
to a brown red; in acute diseases of the liver the sediment is rose-red ;  in
typhus it has a dirty-red color ; in some diseases the appearance of the sedi-
ment appears to be of no constant critical import, as, for example,  in typhus.
   A sediment in  the acid  urine, which is not dissolved on  heating the
urine, and which appears crystalline when observed either by the unarmed
eye, or with the microscope, and  is colored yellow up to vermilion-red, is
uric acid.   It ordinarily appears in the form of rhombic plates, and in the
majority of cases mixed with urates of ammonia, where it then  forms the
undermost ami dark-colored layer  of  the sediment.  That the deposit of
uric acid is of  critical import,  is scarcely to be doubted ; in gout and  in
cases of renal calculi, where the deposits consist of uric acid, uric acid or the
discharge of gravel form the most perfect crisis ; in many other diseases
we still want  the  necessary observations concerning the critical value of
uric acid secretions.   The sediment of oxalate of lime presents itself more
rarely than those  before mentioned ; it usually forms a white precipitate ;
observed wdth the microscope, it appears in the form of small octahedra, or
of little spheres arranged one by the other;  it is not soluble in acetic acid,
but readily in hydrochloric acid ;  when sulphuric acid is poured on  it, it
disappears, and after  some time long lancet-formed  plates of sulphate of
lime are seen.
   Respecting the diagnostic value of the oxalate of lime in the sediment,
sufficient observations are still wanting ; it is probable that it is  connected
with serious  disturbances in the chylopoietic system ; that we  should be
attentive to the possible formation  of stone of oxalate  of lime, where the
sediment  shows itself frequently  and  permanently in  the  urine, is of
importanc '; however, the physician, in  order to judge of the phenomena
more correctly, must also have reference to  the diet, as  oxalic  acid  may
be conveyed into  the body  by various sorts  of food. 
URINE.
765
  The  occurrence of cystin  in the urinary sediment is very rare.  It is
easily recognized by its remarkable form ; it forms faint  yellow-colored
hexahedral plates.  According  to Prout, the appearance of cystin in the
urine is a very unfavorable sign, it indicates the formation of cystin calculi.
In neutral  urine, or that with  an alkaline reaction, besides the sediments
already mentioned, precipitates of  earthy phosphates present themselves ;
they are readily known by  this; that they  disappear  on acidifying the
urine with acetic acid or acid salts ; the phosphate of magnesia, commonly
combined with ammonia, is distinguished  by its crystalline form ; it appears
in colorless  prisms  obliquely tinctured, very frequently in the form of a
roof; the  calcareous phosphate appears almost ahvays  as  an amorphous
precipitate; as the earthy phosphates are constantly present in the normal
urine, their precipitation is commonly to be looked on as a consequence of
the  formation of ammonia,  the free  acids by  which  the earthy phos-
phates were previously dissolved being neutralized by this alkali; in some
cases, on the contrary, the appearance  of earthy phosphates in  the  sedi-
ment is of diagnostic value.  In affections of the spinal cord the phosphate
of magnesia, more especially, appears tojbe secreted in great quantity ; in
affections of the mucous membrane of  the bladder, the phosphate of lime
appears in  large quantity; in three cases of inflammations of  the respira-
tory organs, at the time when resolution of the disease set  in,  I have seen
the previously acid  urine become neutral, and have observed, as a precipi-
tate, the secretion of a considerable quantity of already  formed crystals of
ammonio-magnesian  phosphate, perceptible to the naked eye,  at the same
time that in two of these cases the clear  urine held so large a quantity of
urate of ammonia in solution, that  precipitates of uric acid" were  instantly
produced by every acid.  When calculi of the bladder are present, ivhich
consist of  earthy phosphates, the urine  frequently contains sediments of
earthy phosphates, with which  a greater or smaller quantity  of  mucus is
mixed. In scarlatina the urine is observed to be turbid at the time of the
desquamation, often also before the occurrence of the same on the outer
cuticle; wdien it is observed with the microscope, an extraordinarily great
quantity of the epithelium of the vesical  mucous membrane is seen  in it.
It is, therefore, to be admitted, that the  desquamation goes on also on  the
mucous membrane of the bladder;  and if, as frequently appears to be  the
case, the scaling off takes place earlier on the mucous  membrane of  the
bladder than on the external skin, one may determine the  commencement
of the scaling off by examining the urine.
   The knoAvledge of the chemical composition of the urine is of very great
value  for  diagnosis and  prognosis;  especially as  far as concerns  the
presence of matters which are not found in the normal state of the urine ;
albumen is readily discovered in the urine by^heat or by the  addition of
nitric acid ; if the urine is acid, heat  is  preferred; if alkaline, nitric acid.
The presence of albumen in the urine is ahvays of great import, and  the
correct estimation of the same as a means of diagnosis not altogether easy ;
cases are known in ivhich albumen was observed in the urine of healthy
individuals, or set in in consequence of disturbance occurring in the diges-
tive organs;  in the great majority of cases, albuminuria  is the attendant of
dropsical  phenomena, or the forerunner of them, the  urine  is then com-
monly clear,  evinces a tendency  to  green, and contains much albumen ;
bat  there  are  cases  of dropsy known,  which  set in altogether Avithout
albuminuria.  That  tlm  presence of albumen in the urine does  not infer 
766                            URINE.
 the presence of Bright's degeneration of the kidneys, has been sufficiently
 proved ;  where degeneration of these organs is suspected, great attention
 must be directed to the mucous sediment of the urine.  In violent inflam-
 mations, as well as in typhus, small quantities of albumen are sometimes
 found in the urine;  the urine is then generally very dark,  and  has an acid
 reaction ; according to Becquerel, this appearance of albumen in  ca<es of
 inflammation appears  to  be connected  with  a  congested  state  of  the
 kidney, and as this, unless  the  disease  is itself an inflammation of the
 kidneys, seems to occur only in  very violent  and intense inflammations,
 the appearance of albumen in  the urine accompanying inflammation might
 be a sign of the intensity of the inflammation.  In consequence of inflam-
 matory exanthems, especially in the desquamatory  stage  cf scarlatina,
 albumen sometimes is  observed to exist in the dark-colored urine,  and
 sometimes,  though more seldom, blood.  It  is, therefore, a matter of
' importance for the physician carefully to examine the case, as this hetero-
 geneous mixture is not unfrequently the forerunner of dropsy; hoivever,
 dropsy has  been observed after  scarlatina Avithout albumen in the urine,
 and  albumen in the urine without dropsy folloiving thereon.  At the com-
 mencement  of diabetes mellitus,  albuminuria is no rare phenomenon,  and
 of great importance to the physician.   The occurrence of albumen in  this
 case is not  constant, but  alternating, it appears, before a trace of sugar
 can  be observed, and when  the sugar begins to form, it sometimes ceases
 again, and passing off, it gives way to the albuminuria.
   To demonstrate the presence of sugar in the urine is the principal means
 of satisfying oneself of the existence of diabetes mellitus.  If the quantit)
 of sugar is considerable, it is easily discovered in the alcoholic extract ot
 the  urine after evaporation ; if only traces  of sugar are  present,  tht
 sulphate of  copper is used to demonstrate its presence, as we shall see a;
 another  time.   Gall  pigment in the urine is constantly a  sign of  the
 liver being affected; Ave have already stated that this can be discovered
 by the addition of nitric acid ; but to infer the presence  of gall  pigment
 from the color of the urine is sometimes fallacious.       Part viii., p. 49.

    Changes  produced in  Urine by Disease.—Dr. Shearman gives the fol-
 lowing :
   Excessive indulgence in animal food, with too little bodily exercise,  dys-
 pepsia, and  want of perspiration, are ahvays attended by increase in  the
 quantity of uric acid and urates.  Uric acid is frequently produced in great
 quantity in the bladder, by the hydrochloric acid formed in the stomach
 from disease of that  organ  ; which,  being absorbed  into the blood,  and
 secreted by the kidneys, forms hydrochlorate of ammonia, and deposits the
 uric acid.  In fever, and in all diseases accompanied by rapid emaciation,
 the urine is  of a high specific gravity, a dark brown-red color from excess
 of urea, uric acid, urate of ammonia,  and sometimes blood and purpurine.
 The lateritious sediment, is urate of ammonia.   And in extreme cases of
 acute rheumatism and hypertrophy of the heart, very large quantities of
 uric acid and urate  of ammonia are commonly found.  In all  acute diseases
 attended by great emaciation, inflammation, or disorganization, with  un-
 healthy digestive organs, as long, as the kidneys rematii healthy, uric acid
 is secreted in abundance ; but if the  kidneys become diseased, as in mor-
 bus  Brightii, diabetes, etc., then the  secretion  from the kidneys is  per-
 verted ; part of the nitrogen remaining in the circulation, and the carbon, 
URINE.
767    "
 hydrogen, and oxygen, assuming the forms of albumen, sugar, hippuric and
 oxalic acids, etc.  In  diabetes mellitus, wdien starch, sugar, etc., do not
 unde'rgo the changes required to be converted into carbon or fat the starch
 is converted into grape-sugar by oxygen, and the sugar is excreted by the
 kidneys. In gout and rheumatism, urate of soda is found both in the urine
 and deposited in the joints and sheaths of  the tendons.  When pressure
 on the renal veins exists to such an extent as to prevent  the return of
 blood  to the cavae, as from a tumor, pregnancy,  or diseased viscera, the
 elements of the blood are often poured  out by the kidneys ;  and on exam-
 ination, we find albumen, blood-discs, and the coloring matter of the blood
 (hematosine).  And in granular diseases of the kidneys, and anasarca after
 acute disease of the skin—as  scarlatina and extensive  burns—albumen in
 large quantities is detected, but when the kidneys and skin regain their
 natural functions, uric  acid and  urea  are again  secreted in the place of
 albumen.  In all diseases of an anaemic or chlorotic nature, attended by
 languid circulation and extreme debility,  independent of  acute  disease,
 deficiency of urea and uric acid is found, and no deposit takes place un-
 less there is a very small secretion of urine.  In hysteria there is a large flow
 of limpid urine, of low  specific gravity, and of a green  color. In chlorosis,
 the urine is also of a low specific gravity, and green ;  and this green color
 is oiving to the* mixture of cystine with hemaphaein.   When the functions
 of the skin are impaired  only, an excess of  urea  and  urate of ammonia is
 always the result;  and if, in this case, profuse perspiration occurs, the fluid
 goes off by that process instead of the kidneys, the specific gravity of the
 urine becomes increased, and deposits frequently take place  in the bladder
 in consequence, forming  calculi, owing  to deficiency of fluid ; but, if the
 skin is imperspirative, then the kidneys carry off the extra quantity of water,
 and the urine  becomes lighter ; but the animal  acid  (lactic  or butyric),
 which ought to go off by the skin, is secreted by the kidneys, and com-
 bining wdth the ammonia or soda of the urates, produces uric acid.  When
 the functions of the liver are deranged, carbon is  eliminated  ivith  hydro-
 gen and cholesterine from the kidneys, ivhich gives the peculiar color to
 the urine in all cases of jaundice.  In  organic mischief in  the liver and
 spleen, or great congestion of the vena portas, the urine is  very red, pur-
 ple, or copper-colored, oiving to  purpurine  and  urate of ammonia;  but
 when bile is circulating in the system from  disease of the gall-ducts, etc.,
 the urine is very brown, and easily shows the bile by the proper tests.  In
 contracted, hobnail, or  cirrhosed liver, the extent of the disease may gene-
 rally be measured by the quantity of purpurine in the urine ; and usually
 in ascites from diseased liver we find purpurine ;  but in  ascites from peri-
 toneal  disease we find none.  The purpurine appears  to proceed from the
 altered condition in the portal circulation.   When the liver and lungs are
 both so diseased as to prevent the proper quantity of carbon being carried
 off by their functions, hippuric acid is sure to be found in the urine.
   In cases Avhere organic mischief exists  in the kidneys, the urine is fre-
 quently semi-solid when cold, and of a dark color, like a mass of black cur-
 rant jelly.  And when hemorrhage from some part of the urinary organs
 takes place, the urine is red, and shows  quantities of blood-discs under the
microscope.   In fungus  heinatodes  of the kidney, the urine  looks  like
infusion of roses while  warm, and like red currant jelly when cold, taking
the form of the vessel.  During the progress of pneumonia, less carb.ni will
be eliminated from the lungs, and therefore more will  be in the urine  and 
768
URINE.
liver;  consequently hippuric acid is often found.  And in-confined  situa-
tions, Avhere animals are obliged to  breathe impure air, the globules of the
blood  are not  sufficiently  supplied ivith  oxygen, carbon cannot be'con-
verted into carbonic acid in thedungs, and life could not go on unless the
kidneys secreted more nitrogen and carbon in the forms of urate of ammo-
nia and hippuric acid.   In hepatitis, the carbon is not converted into bile ;
and, as long as the other secretions are going on properly, the carbon wdiich
ought  to form  the bile is converted  into fat and oil, and.is found in the
blood and urine. We often meet Avith melancholy, highly nervous, emaciated
patients, simulating diabetes mellitus, but even more depressed in spirits,
ivho merely complain  of great  debility and  exhaustion, ivith some little
pain in the back or loins, for which we find it very difficult to prescribe
effectually.  Dr. G. Bird  has clearly shown that most of these cases are
owing to imperfect assimilation  in digestion, converting the urea of the
nitrogenous part of the food into that state  which is secreted by the kid-
neys as oxalic acid and ammonia instead of sugar, which, combining with
the lime of the  phosphates, produces the oxalate of time diathesis; and it
is to the derangement of the stomach, duodenum, and liver, that we must
look for success in the treatment of these cases.
  Alkaline  Urine.—When, from any cause,  as the  consequence  of wear
and tear in old  age, excess of study, or great excitement cff the brain, an
injury to the spine, or stone  in  the bladder, the  kidneys  or bladder are
deprived of their natural  supply of nervous power, the elements of urea
combine with the elements of water, and are  converted  into  carbonate of
ammonia, ivhich, hy irritating the mucous membrane, and neutralizing the
solvent phosphoric acid, throws down the triple phosphates, and phosphate
and carbonate of time, and renders the  urine  alkaline.   Thus we  find in
almost all cases of long-continued calculi in the bladder—let the calculus be
composed of wdiat it may—that the urine is strongly alkaline, ammoniacal,
and deposits phosphate of lime,  which sticks to the bottom  of the vessel
like birdlime.   The fusible calculus  is composed of ammonio-phosphate of
magnesia and  phosphate  of time.  In persons who  are confined to very
sedentary habits, w ith  great mental exertion,  for a length of time, and then
obliged to use violent muscular exercise for a few* days,  as clergymen with
small livings, kiAvyers, and  schoolmasters, alkaline urine, with abundance
of earthy phosphates, is usually the  consequence ; and this unnatural  secre-
tion brings  on  a degree of debility not easily accounted for in any  other_
maimer.  In irritative  dyspepsia  in gouty habits, the urine often  contains
the phosphates in  abundance ;  and whenever the triple phosphates, with
alkaline urine,  are  deposited  for a length  of time together, both in the
night and morning urine, accompanied by emaciation, there will always be
found organic disease,  either in the  digestive organs, kidneys, or bladder,
if not in the spine.  Dr. Golding Bird gives  the following  rule respecting
the phosphates, which will  be found very useful in practice: That where
the presence of phosphates is  only found in the evening urine, organic dis-
ease is rarely the cause of it; but where they are found equally in the morn-
ing and evening urine, you may be sure organic disease exists.  In bad cases
of typhus fever, the urine is  frequently ammoniacal toward  the  close of
the disease, the nervous system  of the kidneys being  too  depressed to
secrete urea, and its elements being converted into carbonate of ammonia,
just as they would be in conmn n chemical decern) osition out of the  body.
During retention of urine  fron   diseased prostate gland, stricture of the 
URINE.
769
 urethra, or where a catheter is  obliged to be worn, the urine  is alAvays
 alkaline, owing to irritation in the mucous membrane.
  It is easy, after a few* trials, to discover, in a few minutes, the contents of
 almost any ordinary specimen of urine; and, without this knowdedge, it is
 quite impossible to become acquainted wdth the changes ivhich  are  con-
 stantly occurring in the urinary organs.  For instance, you are called to a
 patient complaining of excruciating and deep-seated pain in the  abdomen,
 shooting down the thigh, which resists the  usual  soothing mode of treat-
 ment.  Examine the urine, and you may there  find blood, pus, oxalate of
 lime, uric  acid, or phosphates.  This at  once explains the nature of the
 malady, and you can confidently tell your patient  that he has a small calcu-
 lus  of a certain description in the ureter, and your treatment is  no longer
 empirical.   Or  you may be consulted by a  person  wdth various anoma-
 lous symptoms of a cachectic nature, which you would find it impossible to
 give a name to unless you examine the urine chemically, when you discover
 either albumen, sugar, or oxalate  of lime excreted ; and this at once  ex-
 plains the case.  A patient  consults you,  much  reduced in  strength,
 depressed  in spirits, and emaciated, his appetite being good, and  digestive
 organs healthy, as far as you can  discover, there  being no evident cause
 for such a state.   Take the specific gravity and quantity  of the urine.  If
 it is high,  ivithout deposit, and the quantity not great, add nitric acid to
 it in a watch-glass, and you will  most likely discover a  large  quantity of
 urea, sufficient at once to account for the symptoms ; or if the quantity of
 urine be large, you may discover sugar.  During  the course of febrile and
 inflammatory diseases, urate of ammonia is generally deposited.   But if the
 symptoms increase, instead of diminish, under this deposit, examine it, and
 perhaps you may find the deposit to consist  of phosphates and purpurine,
 and the urine alkaline.  This ivill at once warn  you to be ivatchful of your
 patient, and cautious in your prognosis.   Suppose you have a surgical opera-
 tion to perform on a  patient apparently out of health, but with no decided
 disease.  If, on examining the urine, you find  albumen,  oxalate of lime,
 or the ammonio-phosphates of magnesia in abundance, you may feel assured
 the person is in an unfit state to bear any operation ;  and by waiting,  and
 attending  to his general health, you will  feel more confidence in  the  suc-
 cessful event of such  an operation.                        Part xii., p. 96.
  Test for Sugar in  Urine.—Lowig recommends the followting : Evapo-
 rate the urine to the  consistency of sirup ; treat Avith alcohol;  then to the
 solution add an alcoholic solution of potash; if  sugar be  present, a  white
 precipitate is formed, consisting of a compound of sugar and potash ; wash
 this with  alcohol, and dissolve  in  water; thus a saccharine  solution is
 formed, wdiich may be examined in any way, and if required, the amount
 of sugar determined  quantitatively.                     Part  xii., p.  111.
  Alkaline Urine.—TJse  stryclinia  when the affection follows  injury or
lesion of the spine, as recommended by Dr. Golding Bird.
                                                      Part xiv., p. 91.
  Influence  of the  Rhubarb  Plant in  producing  Oxalate of Lime in
 Urine.—[The oxalate of lime in  urine, can only be considered diagnostic
of disease,  when the oxalic acid  is  known  to have been  generated wdthin
the  economy, and not introduced from ivithout, for, says Liebig, the  ana-
lysis of urine, when made without respect to the inorganic salts, acids, and
bases of the aliment,  teaches nothing.   Are there  any kinds of food ivhich
     VOL. II.—19 
770               *            URINE.

may be the means of impregnating the urine with  oxalate of lime ?   Dr.
Wilson says:]
  The young stalks of the rhubarb plant, ivhich  of late years have come
into  such general use in this country for tarts in the spring, and sorrel, of
ivhich our neighbors, the French, consume a good deal in salads, and in
other ways, both contain oxalic acid ; and hard water contains lime.  Dys-
peptic persons wdio drink such water, and cat such  articles of food, and
are thus  daily introducing, without suspecting it, the constituent ingredi-
ents of the mulberry calculus, are very likely indeed to incur the pain and
the exceeding  peril  of a  renal concretion of that kind.   You must see,
therefore, the great importance  of  detecting the  oxalic diathesis, and of
forbidding, to those who have it, all such idands as contain the oxalic acid,
and of recommending them to use pure water,  even distilled water for
drinking.                                            Part xix. p. 108.

   To Render the Urine acid.—Dr. Bird  states, that,  the benzoic is the
only acid, the exhibition of which will render the urine acid.
                                                     Part xv., p. 143.

  Alkaline  Urine.—Wash the bladder out every  day or  tAvo with warm
water ; the  urine is rendered  alkaline by retention of a  few drops in the
bladder.   But Dr. Snow considers it important to distinguish those cases
in which the urine is secreted alkaline.                 Part xv.,p.  144.

  Incontinence of Urine in  Children.—[In the incontinence of urine oc-
curring during sleep, in children, and unconnected with  organic disease,
Dr. Chambers  advises the following treatment.]
   Let the patient abstain from  drinks for three  hours before bed-time;
empty the bladder on going  to bed, and aAvaken in three hours to make
water again.  Blister the sacrum occasionally, to prevent sleeping on the
back, and to stimulate the  bladder ; use cold shower bath or douche, and
give ten drops each  of tinct. cantharid. and tine, ferri mur. thrice a day.
Sometimes cauterize the orifice of the urethra, that the passage  of urine
may excite pain.                                      Partxx.,p. 145.

   Incontinence  of Urine in Young Persons.—M. Gerdy advises to give
strychnine,  gr. \ to gr. £ daily, and  small enemata of quinas sulph.; or
give  ext. belladon.  gr. iij. daily.   Continue the  remedies  for some time
after it is apparently cured.
   When the urine is catarrhal, inject into the bladder a solution of nitrate
of silver ; give ergot of rye and camphor, aa. gr. x. daily, and rub the
perineum and pelvis  with camphor  ointment.  Or give strychnine or qui-
nine, or four grains of cantharides powder daily.        Part xv., p. 146.

   Benzoic Acid in Incontinence of Urine.—Dr. Fraene  recommends giv-
ing six grains, night and morning, increasing the  dose to twelve grains.
He succeeded  in curing a case with this after three Aveeks of unavailing
treatment Avith other means.                           Part xv.,p. 146.

   Retention of Urine from  Spasmodic Stricture.—Dr. Lanyou recom-
mends tine, secale cornutnm; half a drachm  infused  in  three  ounces  of
boiling water, and strained when cold;  one ounce  to  be given  every
six hours ; or two Scruples of ergot of rye may be  given twice a day, an
lour vr two before the  bladder  is distended.             Part xv.p.111. 
URINE.
771
  Retention of Urine treated by Galvanism.—Mr. Donovan gives the case
of a lady who, after delivery, could not evacuate her bladder.  The cathe-
ter had to be used thrice a day, and Drs. Radford and Goodwin employed
all the usual remedies for a fortnight, when it ivas decided to  try galva-
nism ; the first application Avas successful.               Part xv., p. 234.
  Dry Cupping in Retention of Urine.—M. Vandenbroeck, principal phy-
sician at Mons, informs the Society of Medicine at Anvers, that for more
than twenty years he has  replaced the use of the catheter in both sexes by
the application of large cupping glasses to the superior  and internal part
of the thigh.  In nine cases  out of every tivelve, the emission of urine,
he says, was made at the end of some seconds.   He does not assert that
tlus has any effect in mechanical retention of urine.     Part xvii., p. 181.
  Ergot of Rye in Retention of.—In retention  of urine from paralysis of
the bladder, cerebral or otherwise, Dr. Allier, of Marcigny, recommends
small and repeated doses of ergot, up to seventy-five grains a day, to be
continued in decreasing doses, for eight or ten days  after the cure.
                                                   Part xviii., p. 143.
  Suppression of Urine.—Dr. J. C. Hall advises to  give a drop of croton
oil, with a  full close of calomel  and colocynth ; follow this by a  draught
containing  sulphate of magnesia, cream  of tartar, and infusion of senna;
and  then  give a large stimulating clyster; so  that the boivels may be
freely purged.  Then cup over the loins, or bleed, if the state of the pulse
admits; and  give warm baths.  Afterward apply a blister to  the loins,
and give full doses of powdered cantharides,—a remedy, which, hoAvever
mapplicable theoretically, has been followed by  the best  results.
                                                      Part xx., p. 100.
   Uric Acid Diathesis.—Mr. B. B.  Cooper would order Ioav  diet  and
vegetable  food; employ  the warm bath, and give carbonate of soda or
potash, or liquor potassjc, taking care not to give them  till three or four
hours alter a meal, otherwise  they may interfere with  digestion.  Some
vegetable acids may be given, but everything liable to  generate acid in
the stomach must be scrupulously avoided.               Part xx.,p. 149.
   Use of Test Paper.—II. Bence Jones believes that the  reaction of  test
paper on urine made at any  one hour of the day should  never determine-
the use of acid or alkaline medicines.  The different deposits wtinch take
place in the urine are far better tests of the state of the  urine, and of the
necessity for these  remedies.   If you are guided by the reaction of  test
paper, the  total quantity of urine made in tAventy-four hours must be
examined.                                            Part xxi, p. 161.
  Relation of the Specific Gravity of the  Urine to its Solid Contents.—
Tables have been constructed professing to tell  how much solid matter  is
contained in urine of any specific gravity.  It is said, that by taking the
specific gravity and referring to the table, the quantity of solid matter may
be immediately determined.
  From experiments, Dr. II. B. Jones has come to the conclusion that the
quantity of solid contents cannot be determined by taking the  specific
gravity.                                              Part xxi, p. 162.
  Detection of  Oxalate  of Lime in the Urine.—Dr. II. B. Jones says:
Oxalate of lime is so frequently found in the urine of tho: e who are  in a 
772
URESTE.
good  state of health, that I do not consider it as indicating any disease,
but only a disorder of no serious importance.  It scarcely indicates a more
serious  derangement of the general health  than a  deposit of urate of
ammonia does.   It may occasionally be found in the urine of all wdio lead
sedentary lives, taking insufficient  air and exercise, and more food than is
requisite for the daily wants of the system.   I have found it in the urine
of those who are free from every complaint.  Even in the urine of healthy
children it may very frequently be seen.  I have met Avith it in every kind
and  stage of disease.   In the fracture wards of St. George's Hospital, I
have very frequently found it.   The most severe case I ever saAV, was an
artist, aged  thirty, dying of an abdominal aneurism.  In cases of indiges-
tion, especially where flatulence occurs; in cases w here no indigestion ever
was felt;  in skin diseases; in cases where the skin never was affected ;  in
cases of acute rheumatism, of acute gout, of fever ; in sciatica in a gentle-
man,  seienty-four  years old, wdth  spermatorrhoea ; and in the diseases of
women  and children, octohedral crystals occur.  So  frequently is oxalate
of lime  mixed with urate of ammonia in  sediments and calculi, that I have
returned to  the conclusion which Dr.  Prout  originally published  in the
second  edition of  bis work.  After giving some details of twelve cases of
oxalic calculus, he  says, '* We are authorized to draw the following conclu-
sions :  6th. That  from  the dissection  of calculi formerly mentioned, it
appears that the  oxalate of lime  diathesis is preceded and folloAved by
the lithic acid  diathesis—a circumstance ivhich seems  to be peculiar to
these two forms of deposit, and when taken in conjunction with the other
circumstances already related, appears to show that they are of the same
general nature, or, in other words, that the oxalic acid merely takes the
place, as it were, of the lithic acid, and  by combining w ith  the lime natu-
rally existing in the urine, forms the concretion in question.  7th. (Dr-
Prout continues :)   The diathesis  being of a similar nature, the principles
of treatment adapted for counteracting the original tendency to it must be
also similar."  And, as a medicine, muriatic  acid was used  to change the
diathesis from the  oxalate of lime to the lithic acid.
   I find that the tAvo deposits together may be met with daily on careful
examination, by the microscope, of the urine in different cases of disease ;
Thus at one  hour  we may find oxalate of lime alone; at another, oxalate
of lime with urate of ammonia; and at  a  third examination, oxalate of
lime and phosphate of lime, or phosphate of lime only; the variations in the
acidity  of the urine being the chief cause of the difference in the deposit.
  It requires no skill and no preparation of the urine to find the oxalate of
time.  The urine should be left to  stand for twenty-four hours in a bottle,
or tall glass; the upper part of the fluid should be* poured off, and the last
feAv drops remaining in the glass or bottle should be examined.  A magni-
fying power of 320 times is generally sufficient, but the crystals are some-
times so small, that  twice  this  power is necessary to determine the form.
Generally oxalate  of lime octahedra are  thus found  without the least
difficulty, sometimes in large single crystals, very frequently in aggregations
of small octahedra, forming microscopic  calculi.  Dr.  Golding Bird was
the first observer who  stated that  these crystals, ivhich had for some time
previously been  observed in urine, were  oxalate of  lime.  The chemical
proof is difficult, if not impossible, to obtain, for the octahedral crystals
are rarely present  in sufficient  quantity to admit of  perfect examination.
                                                     Part xxi.,2>. 163. 
URINE.
773
   Test for  Sugar in Liquids.—Chlorine, M. E. Maumenc, (of Rheims,)
.observes, contrary to the assertion of Liebig, acts on  sugar at a tempera-
 ture of  212° Fah., and  even in the cold, after  a long period.  A broivn
 substance, partly soluble in water, is produced by its dehydrating poiver.
 The chlorides e. g. chloride of tin, bichloride of mercury, chloride of anti-
 mony, by their  affinity for water, possess this property in  a still greater
 degree.
   A strip of any kind of tissue that is not acted upon by chloride of tin—
 e. g. white merino—is to be saturated ivith a strong solution of this salt,
 and then dried.  Thus  prepared, the tissue forms a convenient test of the
 presence of sugar in any liquid.  A feAv drops of a very dilute saccharine
 fluid placed on the merino, and exposed to a temperature of from 260° to
 300° Fah., Avill immediately produce a dark broivn or black spot.
   By the help of this test the presence of sugar in the urine can be readily
 detected.  Ten  drops of diabetic urine, the author stated, diffused in half
 a pint of water, would in this way yield a broivnish black spot.  Ordinary
 urine, urea, and uric acid, produce no results of this kind.
                                                      Part xxi, p. 168.
   Incontinence of Urine in Children.—Examine the urine ;  and if, as wdll
 usually be found, it contains lithic acid, Mr. Simon recommends the follow-
 ing treatment:  Give hydr. c. creta, or some mercurial, till the  tongue is
 clean, and the intestinal secretions are healthy (for they wdll generally be
 found disordered).  Then give a little quinine twice a day, before break-
 fast and before dinner;  and give daily, a single large dose of bicarbonate of
 potash in copious solution, five hours after dinner.   Let the quantity and
 quality of the  diet  be also carefully regulated.  If these measures are
 adopted, blistering, etc., will seldom be called for.      Part xxi, p. 242.

   Retention of Urine.—When the bladder  cannot  be evacuated by the
 catheter, after  leeching,  aperients, warm baths,  and  opium, are we to
 puncture the urethra behind the strictured  portion (Sir A^ Cooper,)—or
 make a free opening in  the perineum over the strictured part (Listen,)—
 or perforate the bladder through the rectum ?  Mr. Gay, of the  Royal
 Free Hospital,  advocates the latter, and states that he has never met with
 one unfavorable result from the practice.               Part xxii., p. 232.

   Retention of.—Mr. Tatum, of St. George's Hospital, reports a case in
 which retention of urine had taken place  from stricture.  All means of
 passing the catheter both before  and after the  warm  bath, and after the
 most patient and cautious manipulation in trying to accomplish this object
 had failed, and it was only after a large dose of laudanum had been tAvice
 given, and the  Avarm bath  repeated with a soothing enema, that the cathe-
 ter could be introduced. The symptoms again coming on after some time,
 the same means ivere  again repeated, but it ivas not  before a purgative
 draught had been  given, eight  leeches applied to the perineum, and the
 opium and warm bath again resorted to, that the stricture yielded so as to
 allow the instrument to be passed, and the bladder to be emptied.
                                                     Part xxii, p. 234.
   Hints in Treating Urinary  Affections.—[Dr. Bird  concludes his work
 on the above subject by the three folloiving rules.]
   1.  Whenever it is desirable to  impregnate the urine wdth a salt, or to
 excite diuresis  by a saline combination, it must be exhibited in solution, so 
774
URINE.
diluted as to contain less than 5 per cent, of the remedy, or not more than
25 grains in an ordinary draught.  The absorption of the drug  into the
capbdaries will he insured by a copious draught of  water, or any diluent,
immediately after each dose.
   2. When the urine contains purpurine, or presents  other evidence  of
portal obstruction,  the  diuretics  or other remedies employed should  be
preceded or accompanied by the administration of mild mercurials—tarax-
icum, hydrochlorate  of ammonia, or  other  cholitic remedies.  By these
means, or by local depletion, especially by leeches to the anus, the portal ves-
sels will be unloaded, and a free passage obtained to the general circulation.
   3. In cases of valvular disease, or other obstructions existing in the heart
and large vessels, it is next to useless to endeavor to excite diuretic action,
or appeal to the kidneys by remedies  intended to be excreted by them.
The best diuretic ivill, in such cases, be found in whatever tends to dimin-
ish the congested state of the vascular  system, and to moderate the action
of the heart;  as digitalis, colchicum, and other sedatives, with mild mer-
curials.                                              Part xxiv., p. 155.
   Conditions of the Urine as Indicative of the State of Disease.— [The fol-
lowing valuable remarks on the state  of the urine are made by Dr. Dick,
in considering the subject of dyspepsia.]
   Urine ivhich immediately on being  voided gives out a sensible  smell of
ammonia, generally indicates that the vital  powers have suffered declen-
sion ; that disease has become  chronic ; that  the patient is past middle life,
or is prematurely aged, etc.
   In  arthritic  and  rheumatic  cases, the mineral and vegetable acids are
carefully to be shunned. Among the latter the oxalic is the most objection-
able ; next, the malic ;  then, the tartaric, citric, and acetic.  There can be
little doubt that these acids act injuriously by their astringent effect on the
cutaneous and  mucous surfaces, by their thus interfering ivith their own
elimination and that of the uric and lactic acids ; thereby loading the blood
with acidulous principles; whence follows that peculiar irritative condition
of the nerves,  constituting local affections, such as sciatica, lumbago,  gout,
or the systemic disturbance of rheumatic fever. It is amazing how difficult
it is to rid the blood of this acidulous  diathesis (if the expression may be
used) when once it has been  formed.  The excernents  seem to  find it a
peculiarly hard task to eliminate acids.  Years of rigid attention to the
dietetic ingesta are necessary.  Hence the rarity of radical  cures of gout
and rheumatism.                                      Part xxiv., p. 160.
   Phosphatic Diathesis.—Dr. Beneke found the phosphates to be present
in the urine in very different  and  nearly all sorts of diseases, varying on
different days in one  case, and  always  remaining of nearly the same amount
in others;  proving that it is not the disease  itself which  causes the excre-
tion of  phosphates,  but that there  must  necessarily exist some < tlier
cause in the economy to account  for the  excretion alluded to.  In  all
cases  of rapid emaciation there Avas  a  large excretion  of  the phos-
phates, and sores of blisters in these cases  scarcely healed at all, or not
until  long after.   We may  provide  persons in * this  condition  with
the largest quantities of albumen and fat,  but .we shall never  produce
thereby a remarkable increase  of tissues or complexion—that is to say, of
formation of cells, if we do not diminish at once the  excretion  of  phos-
phates hy the urine.   A hypernormal  excretion of earthy phosphates  by
the urine is independent of the nature of the disease.   When we observe 
URINE.
775
gnch an excretion, we find a corresponding deficiency of formation of cells, ,
emaciation, and loss of strength ; but this deficiency is not alivavs exclu-
sively caused by a hypernormal loss of phosphates", it is  often only the
result of fever or suppuration, or of any other loss  of  material necessary
for the regeneration  of tissues and organs.  It is to be observed we shall t
never be able to judge of the quantity of the earthy phosphates present in ■•
an ounce of urine, unless we examine the ivhole quantity wdiich is passed t
during the tAventy-four hours.   Although albumen and  fat are present, the ■?
phosphate of lime increases the produce of cells, and in this manner we may;.'
promote the cure of diseases showing a deficiency of formation of ceilk,,
especially in scrofula.  On the other hand, in all wasting diseases, a hyper-
normal quantity of phosphates is alw*ays excreted, especially in those cases
where the phosphate of lime proves most  beneficial. This  quantity, from
Dr. Beneke's investigations, is not increased by the administration of the
phosphate of lime, but on the contrary, by its use the quantity in the urine
often decreases considerably.                          Part xxiv., p. 312.
  Urine—Deficiency of Urea in.—In all cases where the renal secretion is
deficient in urea and uric acid, these existing in the blood,  Dr. Maclagan,
of Edinburgh,  recommends colchicum.                  Part xxx., p. 38.

  Causes of Albuminous  Urine.—In the normal state the albumen is burnt
in the blood, and the nitrogenized residue of this combustion, viz., urea and
uric  acid, is eliminated by the urine.  The combustion  is, hoivever, not so
complete as not to allow* some little albumen to escape with the renal secre-
tion  ; but this albumen, besides being i*ery small in amount, is someivhat
different from  the ordinary kind.  M. Robin thinks that if during a suffi-
ciently long time the albumen underwent in the circulation  a much smaller
amount in the combustion than is habitually the case, it might pass unaltered
into  the urine, instead of being thrown off in the form of urea and uric acid.
  The urine becomes albuminous in croup, in complete ascites, and in cases
of capillary bronchitis, with emphysema, accompanied by much dyspnoea ; in
pulmonary phthisis, especially when complicated by pneumonia and marked
wdth difficult breathing; in gestation, when sufficiently advanced to occasion
a habitual congestion of the kidneys, oiving to an impeded abdominal cir-
culation ; and in such states of the system in ivhich a very incomplete respi-
 ration causes a marked diminution of combustion.   The urine is also albu-
minous in cyanosis, of whichever nature it  may be; in  affections of the
heart wdien they exist in such degree as to keep the patients in a state of
Bemi-asphyxia; and, of course, in such cases where an obstacle to the circu-
lation of the blood, or of malformation of the heart, prevents the bematosis
from being  as rapid as under ordinary circumstances.  The urine is likewise
albuminous in idiopathic or traumatic lesions of the nervous centres, which
cause a lowering of  temperature, and thereby a marked decrease of com-
bustion ; in diabetes, a  disease w here very often a  lesion  of the nervous
centre seems to be the origo mali;  where the great abundance of sugar in
the  blood  seems  to be  an obstacle  to  the combustion of albumen; and
where  finally the natural heat is lowered by  one  or two degrees wdth
patients who are severely affected.   The urine is albuminous in that kind
of nervous exhaustion which characterizes the state of frame called lum-
bago, wdiich exhaustion  must be connected with a great  diminution  of
calorification, and sIoav combustion.  The urine is likewise albuminous in
Consequence of severe exposure to  cold of a large surface of the body. 
776
URINE.
 Finally, Bright's disease, where the urine is ahvays albuminous and anaemic,
 is especially attributed to  many of the causes which  have been above
 enumerated as capable of exciting the passage of albumen into the urine.
   When the activity of the combustion which takes place in thevblood is
 too  feeble to burn the w*hole of the albumen which, in  the  normal state,
 should be consumed in a given time, the general vitality  is diminished, and
 thus more or less albumen is alloived to pass unaltered into the urine, viz^
 just so much organic matter as escapes the  transformation into urea or
 uric acid.  The proportion  of urea contained in albuminous urine  should
 therefore be smaller than it is found in  normal urine, and such is found to
 be the case in the following diseases, the only ones, according to the author,
 in wdiich experiments have been made, viz.: pulmonary phthisis, diseases
 of cerebro-spinal axis,  extensii*e and acute bronchitis  with intense  dys-
 pnoea, and Bright's disease.                          Part xxv., p. 134.

   Urazmia, or Uraimic Intoxication.—According to  Frerichs, a train of
 symptoms  frequently arises in Bright's disease, due to the contamination of
 the blood with the excrementitious constituents of the urine.   There are
 two forms of uremia, acute and chronic.  Early in Bright's disease, patients
 often complain of headache or of a confused sensation in the head; their
 eyes grow dull and expressionless ; they are forgetful and indifferent; and
 slow and inactive in their movements.   If the urinary secretion becomes
 more abundant, these symptoms diminish, or they may disappear entirely.
 In other cases they increase in intensity, the drowziness passes into stupor;
 at first, the patient maybe aroused by loud  calling and speaking, and then
 he gives rational ansAvers; subsequently, the  coma is complete, and the
 respiration becomes stertorous.  Delirium is an infrequent symptom ; when
 it does occur, the patient will repeat over and over again the same word
 or sentence.   Convulsions frequently precede death.
   The acute form of uremia commences suddenly, and manifests itself in
 the  three following ways:  by depression of the functions of the brain, by
 irritation of the spinal cord, and by both sets of symptoms conjoined.  In
 the  first form, the patients sink suddenly into a state of deep stupor, out
 of which  they are  very soon unable to be aroused.  The face is  mostly
 pale, and the pupils immovable;  in other cases there is circumscribed red-
 ness of the cheeks, the conjunctivas are then injected, and the pupils small.
 The pulse ranges betAveen 60 and 90 ; on the occurrence of coma, it usually
 increases in size and  hardness.   The respiration is sometimes stertorous,
 the character of the stertor differing, as Dr. Addison pointed out, from that
 in cerebral hemorrhage.—In the second form, convulsions occur suddenly,
 similar in character to  those seen in  eclampsia and  epilepsy.  The whole
 muscular system is  usually affected.  Consciousness is  undestroyed.—In
 the third form, coma and convulsions are conjoined.
  These acute forms of uraemia are usually the result of sudden suppression
 of urine, particularly in Bright's disease, from scarlet and typhus fevers.
  Acute uremia may be readily confounded with cerebral  hemorrhage, hys-
terical convulsions, reflex  spasms  of various  kinds, narcotic poisoning,
typhus fever, etc.
  Closely allied to the foregoing disorders  of the nervous system, as  con-
 sequences of uremia, are certain affections of the senses.   The most strik-
ing of  these is loss of vision ; Amaurosis urwmica.—Like coma and  con-
 vulsions, this local nervous  affection may be slowly developed, or it  may 
URINE.
777
manifest itself in a few days  or  even hours.  The patient complains of a
sensation, as though a mist lay  before his eyes, which  from time to time
becomes denser. "The only  change perceptible to the physician is some
sluggishness of the pupil.  Landouzy affirms that amaurosis is  one  of the
most constant symptoms of Bright's disease.
  The sense of hearing is affected by Bright's  disease about as frequently
as that of vision.
  During the convulsions, the pulse, on account of the  disturbance of the
respiratory movements, is  accelerated, and at the  same< time it is often
irregular; in the intervals betiveen the attacks of convulsions, it resumes
its normal rate and regularity.
  A febrile disturbance  (febris urinosa) closely resembling typhus fever m
its general characters, is sometimes produced by uraemia.
  The cessation of the  symptoms of uraemia is usually accompanied by a
profuse secretion of urine.
  Vomiting is one of the  most  constant and  early  symptoms of uremia.
The vomited fluid is generally alkaline, and contains  carbonate of  ammo-
nia • when acid, the presence of ammonia in the egesta is proved  by the
addition  of liquor potassae.   Frerichs says, " I have frequently sought for
undestroyed urea in the vomited matters, but always in  vain."  Further,
in urasniia produced by  extirpation of the kidneys, and injection of urea
into the blood, Frerichs always found a large quantity of carbonate of
 ammonia in the vomited matters, but not a trace of urea.
   It is doubtful in what relation the diarrhoea, which occurs m Bright's
 disease, stands to the uraemia.                                    .
   The older physicians frequently asserted, that in cases  of suppression ot
 urine, the breath and perspiration  had a fetid urinous-odor.  Many mo-
 dern observers have denied this.  Frerichs says, that whatever  difference
 of opinion there may be as to the existence of  this odor,  it  is  a  fact,  that
 when the symptoms  of  uremic intoxication, coma, convulsions, etc., com-
 mence, carbonate of ammonia is mixed in considerable quantity with the
 expired breath, and that the quantity of the ammonia is in proportion to
 the intensity of the uremic phenomena.
   " I have," he writes,  " repeatedly demonstrated the  ammonia contained
 in the expired air of sick men, antfof animals  into whose veins  urea was
 injected after extirpation of the kidneys ; reddened  litmus paper  quickly
 turned blue in the air issuing from  the  mouth and  nostrils; a rod moist-
 ened with hydrochloric  acid produced, when held in the same air, a more
 or less thick cloud.  Animals into the veins of which  urea Avas injected,
 continued quiet and  awake so long as the expired air was free  from ammo-
 nia, but  as soon as a rod dipped in hydrochloric acid produced a white
 cloud when held in the expired air, the disorders of the nervous system
 characteristic of urasmic poisoning manifested themselves."
   Frerichs' own observations have not enabled him  to say anything defi-
 nite as to the state of the sweat in urasmic intoxication.
   After  death from uraemia, no lesion of structure of the central organs of
 the nervous  system can be  detected.  The  membranes  of the  brain and
 spinal cord are normal; the quantity of fluid  in  the ventricles  rarely ex-
 ceeds an ounce—i. e., is within the range of health.  In four cases ot amau-
 rosis urasntica mentioned by Landouzy, in one recorded  by B ight, and in
 one observed by Frerichs, the  optic nerves and  the vis i;d  app iratus
 appeared normal.  The stomach, a o,  even whei  during life  it has  been 
778
rRINE.
the seat of severe symptoms,  is usually found after death unchanged in
texture.   So the intestinal mucous membrane may be normal in appear-
ance, when  during life there has been profuse diarrhoea.  The kidneys
exhibit the lesions characteristic of one of the three stages of Bright's dis-
ease. The blood is sometimes firmly, at others imperfectly coagulated;
Frerichs thinks that in all the cases of uraemia he has seen occurring spon-
taneously or produced artificially, it has exhibited a peculiar shade of vio-
let.  Christison, Jaksch, and  Hamernjk, have observed cases in ivhich the
blood had an ammoniacal odor similar to that of decaying urine.  Chem-
ical analysis proves, Frerichs affirms, that the blood, in every case in ivhich
the symptoms of uraemia are  present, contains carbonate  of ammonia, and
also, usually, traces of undestroyed urea.   The  quantity of carbonate of
ammonia varies greatly.
   The above are, according to Frerichs' researches,  the most important
facts known concerning uraemia.
   The cause of the symptoms of  uraemia has been  generally sought in the
retention of the constituents  of the urine in the blood.
   The following  is Frerichs' oivn theory  of uraemia.  The symptoms of
urasmic  intoxication,  he says, arise  in  consequence of the urea accumu-
lated in  the blood being converted, by the agency of a  suitable ferment,
into carbonate of ammonia, while yet within the vessels.  For the super-
vention, then, he adds, of urasmic intoxication, two agents are necessary—
1st, an accumulation  of urea in the blood ;  2ndly,  the presence of a fer-
ment by the  agency  of ivhich  the decomposition of the urea may be
effected.
   If the urea, after collecting in quantity in the blood, be suddenly decom-
posed, then the symptoms are those of apoplexy ;  if  its  decomposition is
effected more gradually, then the symptoms resemble those of typhus ter-
minating in coma and convulsions.
   With the causes ivhich occasion the development of the ferment, we are,
Frerichs says, but imperfectly acquainted.  In the acute blood-disease—
e. g., typhus, scarlet fever, and cholera—this  agent is  rarely absent.  Slight
febrile disturbance, as from exposure to cold, or trifling local inflammation,
seems in some cases to give  the impulse necessary for the  destruction of
the urea.   In cases  of Bright's  disease which arises during pregnancy,
the ferment is usually developed.
   The presence of the ferment is manifested only  by its  effects.   Frerichs
offers no other proof of its  existence.
   In order  to demonstrate its truth, it must, he says, be proved—
   1st. That in ei*ery  case of urasmic intoxication, a resolution  of urea into
carbonate of ammonia takes  place.
   2nd.  That the symptoms characteristic of uraemia  can be produced by
the introduction  of carbonate of ammonia into the blood.
   Two series of experiments  are described by Frerichs, as offering the re-
quired proof.
   " In the first  series of experiments, a solution of from thirty to  forty-
six grains of urea w*as injected into the veins of animals, the kidneys of
which had been previously removed.   They remained for some  hours per-
fectly free from convulsions.   ...   In from 1\  to 8 hours they became
restless, vomited acid chyme, or a slimy yellow alkaline mass, according to
the state of fullness of the stomach at the  commencement  of the experi-
ment.  At  the same time that ammonia was perceptible  in the expiree! air, 
URINE.                            779
convulsions supervened, wdiich occasionally ceased and returned again, and
gradually passed into stupor with  stertorous breathing.   In some  cases,
convulsions ivere absent, and then sopor and coma  ivere the  first  symp-
toms.  After death, which took place from 2\ to 10 hours from  the time
of the injection of the urea, ammonia in  large quantity was  found in the
blood ; the contents of the stomach  emitted, in most  cases, a strongly
aumioniacal (urinous) odor, and contained much carbonate  of ammonia;
in one case only Avas it somewhat acid, and even then it contained ammo-
nia.   This basis ivas detected in the bile and other secretions.  The stom-
ach was usually injected, and  of a  dusky-red color.  The brain and  its
membranes ivere normal in appearance;  and the quantity of fluid  in the
ventricles was not increased.
  u In the second series of experiments, a solution of carbonate of ammo-
nia  was injected into the veins  of animals.  Convulsions, often very violent
in character, instantly ensued,  and  stupor  quickly supervened.   The res-
piration ivas difficult, the expired breath was loaded with ammonia, and
vomiting of bilious  matters occurred.  The stupor lasted for some hours,
and ammonia was expired  during  the ivhole time.  Gradually,  however,
the latter disappeared, and then by degrees, the animals recovered their
senses.  When more carbonate of ammonia was injected, while the animal
lay  in a  state of stupor, the convulsions and vomiting recurred, and the
urine and the stools passed away involuntarily ; after the lapse of five or
six  hours the ammonia again disappeared from the blood, and the  animal
again became lively."
  Although death  by  uraemia is the natural termination,  so to  say, of
Bright's disease, yet the fatal result is sometimes caused  by other lesions
—e. g., by inflammation of serous or parenchymatous structures, by sink-
ing from vomiting, diarrhoea, dropsy, tubercular suppuration, asphyxia, etc.
  The diagnosis of uraemia from apoplexia cerebri, typhus,  gastritis, con-
vulsions of various kinds, and narcotic poisoning, is to be made by a care-
ful examination of the  quantity and quality of the urinary secretion, the
presence of ammonia in the expired air,  and the symptoms of disease de-
rived from the organ the functions of which are disordered ; thus urasmic
coma is distinguished  from that dependent upon  hemorrhage  into the
brain, by the absence of paralysis of the voluntary muscles, the  more fre-
quent and softer pulse, and  the more rapid breathing.  The character of
the stertor, too, differs in the two.   The early occurrence  of delirium and
coma, and the absence  of the eruption and of enlargement of the  spleen,
aid  in diagnosing uremia from typhus fever.   At the same time it must be
borne in mind that an eruption closely resembling the mulberry rash of
typhus is sometimes present in the uraemia ivhich follows cholera.
  In the treatment of' urcemic intoxication, the first object to be attained is
the restoration of the urinary secretion.  Mild diuretics are the best reme-
dies for  the accomplishment of the  desired end.  Should  these  fail, then
hydragogues  are to be  employed.  Little hope can be entertained of diu-
retics acting, in the advanced stage of degeneration of the  kidney.   The
second object is to prevent the injurious influence  of the carbonate of
ammonia developed in the blood on the nervous centres.  When  convul-
sions  have commenced, this indication requires our first attention.  Hydro-
chloric and the  vegetable acids, Frerichs says, are the remedies  ivhich
naturally suggest themselves ; they pass into the blood, and  are excreted
again, either in their primitive or an altered form, with the urine.   At the 
780
URINE.
  same time the patient may be washed aa tith vinegar, and enemata contain-
  ing acetic acid administered.  If marked symptoms of cerebral congestion
  are present, purgatives and bloodletting may be required.
    Vomiting, consequent on irritation of the kidneys, is to be relieved only
  by treating the local affection;  that from chronic dyspepsia,  consequent
  on the abuse of spirituous liquors, or disease of the heart, by hitters, nar-
  cotics, and  antacids.  Uremic  vomiting is most  obstinate.   Christison
  recommends creasote.  Narcotics, Frerichs says, are of no service.
    Diarrhoea, when it occurs  during the latter  stages of the disease,  is
  very obstinate.   Frerichs has generally found relief follow the use of liq.
  ferri muriatis.
    In bronchial  catarrh, expectoration is to be favored, if deficient, by sen-
  ega,  ammoniacum, etc.; if in excess, it is to be restrained  by tannic acid,
  acetate of lead, muriate of iron, and  other astringents.   Alum is some-
  times extremely useful.
    When the disease is the consequence  of pregnancy, it is a question  in
  some cases whether premature labor should not be  induced.
                                                      Part xxv., p. 135.
     Test for Sugar.—Dr. H. B. Jones gives the following: Test  a  portion
  of urine with a solution of sulphate copper and liq. potassae ; a blue solution
  is first produced, heat it, and the blue color becomes slightly yellow on the
  surface,  and  rapidly changes into  that  of  a reddish yellow precipitate,
  which is the mixture of the color of the urine and the color of the sub-oxide
  of copper.   With  this test, independent of  sugar, a large quantity of ani-
  mal  matter or  of urea wdll produce a blue color, but when heated the
  reduction of the copper does not take  place near so rapidly.—A salt of
  another metal may be used instead of the copper, as silver with a drop of
  ammonia.  The sugar takes the oxygen from the silver, and it is deposited
  in  a beautiful metallic form on the glass.—Another easy test is  allowing a
  drop of diabetic urine to dry on  the glass, and  examining it by the micro-
  scope, when remarkable tufts of stellated crystals will be seen.
                                                       Part xxv., p. 155.
    New Test for Sugar.—It is stated by Professor Bottcher, that the least
  quantity  of sugar in urine, or any other fluid, may be detected by adding
  a little carbonate of soda and a  small  quantity of magisterium bismuthi,
  and boiling briskly ; when the liquid cools, the bismuth, if sugar be present,
  is reduced, and forms a black powder.                 Part xxx., p. 160.
    Mode  of Testing for Glucose  or Diabetic Sugar.—The only tests on
  which Lehmann places any reliance are Trommer's, the fermentation test
  and the development of the torula, and the application of Biot and Soleil's
  polarizing apparatus.  The following is the best method of applying Trom-
  mer's test to an animal fluid suspected of containing sugar:
    The fluid to be examined is treated with caustic potash and filtered  if
  necessary—that is  to say, if there be too great a precipitate; an excess of
  caustic potash is productive of no barm, as  it should be present  in more
. than sufficient quantity to decompose  the sulphate of copper; the latter,
  which must be added gradually, and in a diluted  state,  usually gives rise
  to  a precipitate, which disappears aa hen the fluid is stirred ; as the quantity
  of the oxide of  copper which is  soluble is proportional to the quantity  of
  sugar ivhich is present, very little sulphate of copper must be  added at a
  time, if Ave  suspect  that only a little  sugar is present  in the fluid.  On 
URINE.                            781
allowing the azure  solution thus obtained to stand for some time, there is
usually  formed a more pure red  or yellow powder than the precipitate,
which is at  once thrown down on boiling the fluid.  Moreover, very pro-
longed heating is improper, for there are several substances ivbich by pro-
longed boiling separate suboxide of copper from alkaline solutions of oxide
of copper;  amongst them  we may especially name the  albuminous sub-
stances, ivhich with oxide of copper and potash  yield very beautiful az ire-
blue, or somewhat violet solutions, and by very prolonged boiling, separate
a little suboxide of copper, although Aitithout the aid of heat they have not
this property.
  If a specimen of  urine contain very little  sugar, or  if we are searching
for sugar in some other fluid, it is advisable  to extract the solid residue
ivith alcohol, to dissolve the alcoholic extract in water, and to apply the
potash and  sulphate of copper to this solution.  By proceeding in this
manner,  ive usually  obtain  the  reaction in its most distinct manner.   If,
however, we are seeking for very small quantities of sugar, as, for instance,
in chyle, blood, or in the egg, we must neutralize the aqueous fluid, pre-
viously to its evaporation, with  dilute acetic  acid, in  consequence  of the
solubility of albuminate of soda or of casein in alcohol, thus preventing any
albuminous  body from remaining in solution.  If the reaction do not pro-
perly manifest itself in the alcoholic extract thus obtained, or if we would
carry the investigation further, we must  precipitate the sugar  from  the
alcoholic solution by  an alcoholic  solution  of potash, dissolve the com-
pound of sugar and  potash in water, and noiv apply the sulphate of copper:
if only a trace of sugar be  present, we obtain a most  distinct  and beauti-
ful reaction.                                         Part xxv., p. 160.
   Operation for Retention of Urine occasioned by Inveterate Stricture.—
Mr. Simon advocates  a modified perineal operation in certain cases.  He
opens the urethra by puncturing a very small incision immediately in front
of the prostate gland.  He then runs a short, elastic  catheter along this
wound into the bladder.  He then leaves the stricture untouched for ten
days more or less,  during  which the urine  floivs  through the perineal
catheter; at the end of that time, the stricture is sufficiently relaxed to
begin its dilatation Avith a middle-sized instrument.    Part xxv., p. 222.

   Retention of—Puncture of Bladder through  the Rectum.—Pass  the
index-finger of the left band into the rectum until the prostate gland  is
felt; the finger must be pushed, if possible, behind this part; seek now for
fluctuation, which, hoAA*ever, is not ahvays easy to find.   The anterior part
of the bladder having been pressed upon, and the posterior part of  the
prostate  gland recognized; glide the instrument along the palmar surface
of the  left index-finger until it  is in contact  with the distended bladder
resting upon the rectum—take out the director—introduce the trocar—and
push it upivard and forward  one or tAvo inchss into the bladder.  The
greatest  care should be taken that the prostate  gland  be not  transfixed;
it might  be a fatal mistake.
  After puncturing-the bladder through the rectum, the  patient should be
kept in bed at least three wreeks after the sinuses  are  securely cicatrized,
as from  its weak  and feeble  organization, the neAidy formed cicatrix is
liable to give Avay.
  In this case, stricture of the urethra had been  the root  of the evil.   This
had been followed by abscess, fistula in perineo, and retention of urine; 
782
URINE.
for the relief of the last of wdiich the bladder had  been punctured through
the rectum.  Mr. Hilton believes the operation is free from danger if care-
fully performed ;  there is very little risk of hemorrhage ; the operation  is
by no means of a protracted kind ; it  does not tax the patient's strength ;
is  not  exhaustinir, and entails  no drain  upon the system.  As the lower
part of the bladder is punctured, the accumulation of mucus, urine, pus, or
other secretions, is not alloAved, the viscus being completely emptied ; you
prevent the  urine finding its way into  the urethra, and give an opportunity
to the  false passages of healing, and  the natural urethra of recovering
itself.  The  seat of the stricture is kept in a state of rest; no local excita-
tion  is used, and all irritation, muscular contraction, or spasm is forestalled.
There is, on the other hand, no chance  of the bladder contracting aAvay
from the instrument; it contracts toward it.            Part xxvi., p. 216.

  Retention of Urine—Puncturing the Bladder through  the Symphysis
Pubis.—Dr. Brander recommends puncturing the  bladder  through the
symphysis pubis.  He performed the  operation first on the dead subject,
and then carefully dissected the parts and found that in all respects it had
been a successful one. The  operation has  now*  been performed several
times with complete  success.   He employs a flattened trocar.
                                                    Part xxvi., p. 251.

   Presence  of Pus  in the  Urine.—Dr.  R. B. Todd says that wdien the
urine contains pus it is muddy from the first; hence the difference between
this and urine containing lithate of ammonia, the  latter only becoming
muddy after a certain time.  Phosphatic  urine is also muddy wdien passed,
but  in this case it is  much paler ; and after standing some time  there is a
deposit as in the case of pus, but in phosphatic urine it is white instead of
being  yellow*, and flocculent and light instead of being thick and heavy.
A little acid  renders  phosphatic urine  clear, while if pus be present it
increases the turbidity.  In cases of phosphatic deposits also the  urine is
generally alkaline ; in purulent, the urine is generally slightly acid.   The
pus  is also  rendered glairy and stringy by liq.  potassae.  Again, if the
urine be  rendered  acid by  applying heat, the  pus coagulates.  Lastly,
examined by the microscope, it consists  of tivo  essential parts, liq. puris
and pus globules, Aitiiieh are characteristic.             Part xxvii., p. 89.

   Fetid, Phosphatic, Mucous Urine—Prolapsus of the Anterior Wall of
the  Vagina an  Occasional  Cause of.—Dr. Bird remarks  that  middle-
aged females sometimes  suffer great distress from symptoms similar to
those occasioned by enlarged prostate in the male ; that is to say, there is
great irritability of the bladder, the  urine when  passed being fetid, ropy,
and containing much mucus.   He endeavored to  trace these symptoms  to
a similar cause, namely, a prevention  of the complete emptying of the
bladder, and the  retention  of a  portion of urine, so as to produce in it
decomposition.  Such a cause,  he considers a prolapsion  of the anterior
wall of the vagina.  He says :  Almost the first case  in which I recognized
the condition  to ivhich I am alluding, occurred in ttie person  of a  stout,
tolerably healthy-looking woman.
   She complained of great sense  of distress in the lower part of the abdo-
men, with weight and bearing down.  Walking was painful to her, and
she was almost  constantly tortured with a  desire to  empty the bladder.
The urine was very  offensive, and contained a  large quantity of dense, 
URINE.
783
ropy mucus, mixed with phosphates.  Suspecting the possible presence of
a calculus, I introduced a catheter, but little urine escaped, and no concre-
tion could be felt.  But on examining the vagina, a large pink looking sac
depended from its anterior wall, and almost separated the labia.  She ivas,
indeed, suffering from prolapsus of the bladder into a pouch formed in the
anterior vaginal Avail.   By keeping  the bladder  emptied by the daily use
of the catheter,  the urine soon recovered its healthy appearance, and the
mucus decreased considerably.  The decomposition of the secretion in this
vesical pouch had evolved ammonia, wdiich had irritated the bladder, and
caused a copious secretion of mucus, loaded with the earthy salts, from
its lining  membrane.   I sent the  patient to my brother, Dr. Frederick
Bird, as I believed no permanent cure could be  obtained while the pro-
lapsus existed.  He applied  the actual cautery to the anterior Avail of the
vagina, and the result Avas most satisfactory.  After the slough  came away,
sufficient contraction  occurred to  prevent  the  formation of the vesical
pouch, and the patient remained free from the ailment ivhich had so long
distressed her.
  In another case the condition of the patient ivas relieved by introducing
an injection of infusion of galls three times a day into the vagina, wearing
an abdominal support with a perineal pad, and the administration of quina
and iron with dilute phosphoric acid.                 Part xxvii., p. 193.
   Characters of  Urine  Depositing  Oxalate  of Lime.—The principal
characters  which have been  noticed  as belonging to urine  containing
oxalates, are the following :   (1 )  A  density somewhat higher than natu-
ral, indicating an excessive elimination of urea,  or of the indeterminate
extractive  matters of the urine.  In the  series of cases recorded by Dr.
 Golding Bird, one-half of the specimens ranged from 1015 to 1025.  Some ■
 were as low  as 1009; some  as high  as  1030.   In the cases recorded by
Dr. J. W.  Begbie (Monthly Journal,  March 1848,) the  average density
 was 1028 ; the extremes being from  below 1015  to  above 1030, and in
 one case 1040.  Dr. Prout states, in general terms, that the urine in such
 cases is of moderate density.   (2.) A color, according to Dr. Prout, pale
 citron yellow, or greenish ;  according to  Golding  Bird, amber, never
 greenish;  according to  Dr. Begbie, amber, darker than  in  health.  (3.)
 An  odor  generally natural, rarely aromatic, like mignonette (Golding
 Bird);  on the other hand, aromatic, occasionally approaching to that of
 the sweet-brier,  noticed  in  urine containing the  cystic oxide  (J. W. Beg-
 bie).  (4.) A reaction almost alivays more or less acid, frequently power-
 fully so.                                             Part xxix., p. 131.
   Oxaluria.—The  terms oxaluria and oxalic acid diathesis are now well
 understood to mean that morbid state of the digestive  and  assimilative
 functions in which oxalic acid is eliminated by the kidney in combination
 with urine.  It is by no means an  uncommon complaint.  The prevailing
 forms of the crystals are the octahedral and the dumb-bell. It is at present
 believed that the  former consists of the  oxalate, and the latter of the
 oxalurate, of time ; and  this is likely, because  therapeutic agents do not
 act alike in both cases.  In a case  of this disease under  the  care of  Dr.
 Gray, of Glasgow, marked by the presence of dumb-bell crystals, after
 other remedies had failed, one grain of nitrate  of silver was given every
 six hours.  In two days it was diminished to half a  grain, and 3J- of the
 acidulated tinctere of calumba was given night and morning.  It should 
784
URINE.
be  observed, that where oxalate of lime appears in octahedral crystals,
the nitromuriatic acid with a vegetable tonic will generally effect a cure.
If the dumb-bell form appears, nitrate of silver is very useful.   Where
both kinds of crystals are present, these medicines  should be given alter-
nately.                                              Part xxix., p. 142.

  Morbid  Condition of the Urine connected with  Chronic Disease.—
Indigestion.—When  alkalescent  from fixed alkali, says  Dr. II. B. Jones,
it is from the stomach.  Take more air and exercise, with mild nutritious
food.   Give vegetable acids, as lemon-juice or citric acid, but not tartaric.
Seventeen grains of dry citric acid  are about equal to half an ounce of
lemon-juice, and one lemon generally gives  one ounce of juice.   Twelve
ounces  of lemon-juice, equal to 408 grains of citric acid, may be given in
one day if necessary.
  When alkalescent from  volatile alkali, it  arises  from affection of the
mucous membrane of the bladder.  In this case buchu, pareira brava, tur-
pentine, cubebs, copaiba are used.  Buchu is given when pus is present;
pareira brava when there is ropy mucus.  Buchu is good when the urine
is acid, pareira when  it is alkaline;  in  short, w hen  you want a stimulant
give buchu ;  when you want a demulcent give pareira brava; when you
w*ant an astringent give uva ursi.                     Part xxix., p. 145.

  Sulphuric  Acid, versus  Urine.—Mr. J. E. Huxley has pointed out that,
in the wards of insane establishments ivhich are wet and dirty, no scrubbing
or  scalding will effect  more than a temporary improvement, as the floor
becomes a reservoir for the perpetual  exhalation of the volatile ammonia.
But if dilute  sulphuric acid be poured over such floors, in the proportion of
one ounce of acid to twenty-four of water, and allowed to remain  twenty-
four hours, a white film (sulphate of ammonia) will form, which may be re.
moved by washing, and will leave the room sweet.  The principle is that
of  converting a volatile into a fixed salt that may easily  be got rid of.
                                                    Part xxxi., p. 232.
   Test for Sugar.—Dr. Garrod  considers that sugar in very small quanti-
ties may be detected  by treating the fluid with trisacetate of lead, filtering,
removing  the lead with, bicarbonate of soda or potash, and again filtering,
by which means a colorless urine is produced, giving, on the addition of a
few drops of concentrated solution of potash and  heat, a  bright orange
color.                                               Part xxxl,p>. 211.

  Retention  of Urine.—Dr. II. Thompson insists upon the  principle, that
when perineal abscess is found co-existing with retention of urine, it is very
rarely necessary  to  have  recourse to  any  se\*erer  measures  than  the
opening of the abscess,  and the passing of the catheter ;  and, further, that
the sooner the necessary opening is made, the less likely is the patient to
become the subject of  extravasation at the time, or to suffer from urinary
fistula afterward.                                   Part xxxii, p., 169.

   Urine, Extravasation of, from Injury to the Perineum.—Dr. Fletcher
says w-e may have extravasation  of urine from a rupture of the urethra
without any SAvelling in the perineum, and  in all such cases, where there
are all the general symptoms of extravasation and you have reason to
fear escape of urine, you must make a  free and deep opening into  the peri-
neum, exactly in the medial tine.                     Part xxxii., p. 179. 
URINE.
785
   Purulent Urine from Chronic Pyeletis.—Dr. Basham of Westminster
 Hospital says the  value of the information to be derived by examining the
 chemical and  microscopic character of the urine depends much on the'tsare
 and accuracy  ivith which these chemical and microscopic  facts  are  applied
 to the condition and symptoms of the patient.  The special characters of
 these  deposits,  if correctly interpreted,  become  highly significant  and
 instructive, great aids to  diagnosis, and the eventual basis  of treatment.
 The cause and nature of a dropsical  condition of the system are at once
 recognized, when  in albuminous urine there are found epithelial, fibrinous,
 or waxy casts of a tubular character, glandular epithelial  cells loaded ivith
 fat,  or  blood  discs with  amorphous fibrin,  stained  with hematin.   The
 pathology of dropsy with such concomitants differs materially from that in
 which the urine is free from such deposits.  But, on  the other hand, cases
 occur in which there is no dropsy—no anasarcous state, yet the urine con-
 tains albumen, to which is  added the presence of pus  corpuscles, minute
 membranous coagula entangling clots of blood, blood discs in  abundance,
 and shreds of amorphous fibrin.   If, in such cases, there is great  irrita-
 bility of the urinary organs, frequent  micturition with pain referred to the
 neck of the bladder, perineum, or penis, a suspicion at  once exists of disease
 of the renal organs very different in  character from that which we predicate
 on the first example.  It is, however,  only by a cautious comparison of the
 symptoms experienced by the patient with these morbid  products  in  the
 urine that a correct and satisfactory diagnosis can be obtained.   The  pre-
 sence of pus corpuscles in the urine is not, alone, sufficient to  induce  sus-
 picion of  renal  disease.  In  gonorrhoea, or other inflammatory affections
 of the urethra, in catarrh of the bladder, or gouty  inflammation of  this
 viscus, pus would be present  in the urine.  In stricture, in chronic  gleet,
 membranous debris, often entangling minute clots  of blood, may be,  and
 often are, present, and  yet no suspicion of renal disease from  any such
 appearances would be warranted.   It is therefore by  a careful  comparison
 of the sedimentitious matters in the urine with the  general  symptoms of
 thepatient, that we are enabled to arrive at a correct and intelligible diag-
 nosis.
   The symptoms  most  characteristic of pyeletis or  inflammation  of the
 pelvis of  the  kidney, are, rigors, with lumbar pains, sometimes dull  and
 continuous, sometimes pungent and darting;  often extending and becom-
 ing fixed at the crest of the ilium, or prolonged to the outside of the  thigh,
 wdth numbness in the direction of the external crural  nerve.  Occasionally
 there is retraction  of the testicle of  the same side; there is frequent mictu-
 rition, and great irritability of the urinary organs.  The patient complains
 of pain in the perineum, or in the  neck of the bladder, or feels a darting
 pungent sensation along the  urethra, fixing itself in the  glans  penis till
 temporarily relieved by passing urine  ; the quantity passed rarely exceeds
 one or tAvo ounces, and the urgency for passing this  small  quantity recurs
 at very short  intervals of time.  The pain in the bladder,  perineum, or
 penis, is always relieved by micturition, and there is no difficulty or obstacle
 to the tree jiassage of the urine.
  The urine wdien  first passed is cloudy, or even milky, but when set at rest,
separating  into tAvo portions, an upper,  clear,  natural-colored fluid,  not
ropy, but containing albumen ; a lower and distinct sediment of a yellowish
color, consisting of pus corpuscles,  amongst ivhich oftentimes may be seen
minute fibrinous shreds or membranous flocculi, with small  coagula of blood
     vol..  ii.—SO 
786
URINE.
attached.   Earthy amorphous  matter is also present in some cases.
Hematuria, sufficient to cause discoloration of the urine, may or may not
have occurred ; yet, in most cases, although the urine is not discolored,
scattered blood discs may be detected by the microscope.
  If the disease be of a certain duration, there may be fullness, and enlarge-
ment of the kidney of the affected side  ; for if a concretion becomes per-
manently fixed in the pelvis of a kidney, a partial obstruction of the ureter
follows, and the usual conditions of an encysted and sacculated kidney have
commenced.   If, on the other hand, the  calculus descends into the bladder,
a train of symptoms sufficiently characteristic follows, wdiich clearly indi-
cate its descent into that cavity.
  But we have to interpret from these symptoms  the  part of the urinary
apparatus ivhich is the  seat of the  disease, for these conditions, in  some
respects, are common to many different disorders; yet if they be carefully
analyzed, and a just comparison established between the one  and other,
we shall ultimately arrive at a correct diagnosis of the disease.  Turbid and
troubled urine, with painful and frequent micturition, may  occur in  stric-
ture, gleet, or gonorrhoea; but* in the tw*o latter, the character of the pain
during the passage of the urine, and the appearance  of discharge at the
orifice of the urethra, not  to say the stains on the linen of the  patient,
would make the case sufficiently clear.  In stricture, in addition to a turbid
urine, when  gleet is present, there  may be  membranous shreds, and even
minute coagula, such as tiave been noticed in the urine of the patient under
consideration.  But, in such a case, the pain  and distress are felt during
micturition,  not before; the urine passes with difficulty, or in drops, or in a
diminished stream, and an exploration  of the urethra proves the impedi-
ment to the  free excretion of the urine.  In calculus of the bladder, similar
conditions of the urine might exist, and much  pain be experienced in the
bladder, perineum, and penis ;  but the  pain in  such  cases is most aggra-
vated after  micturition; as the bladder fills the pain  diminishes;  just the
reverse  happens in the painful and irritable  bladder of renal  disease.
Moreover, an exploration of the bladder establishes the presence of a stone.
In the case  before us, the patient refers the commencement of the pain to
the region of the kidney, and describes the pain as if descending thence in
the direction of the bladder, and becoming pungent and stabbing in the
perineum, and occasionally extending itself to the extremity of the  glans
penis.  These distressing sensations are always  relieved by micturition, ana
there is a temporary lull till the urine collects again, even in small quantity.
This fact is  of much importance in the diagnosis of renal disease, and taken
in conjunction with the history of the  case, ivith  the albumen and amount
of the purulent sediment in the  urine,  and the peculiar  character of the
lumbar and  regional pain,  constitutes very fair evidence of inflammatory
action of the pelvis of the kidney.
   In cases of inflammation  of the bladder, cystitis or catarrh of the blad-
der, and limited to  that cavity, the character and quality of the urine differ
much from what is excreted in renal disease.   The urine is contaminated
by the inflammatory exudation from the vesical  mucous membrane; pus
cells, and the so-called exudation corpuscles, are present in abundance; but
ttie pus corpuscles  do not subside as a distinct and well-defined precipitate,
they are entangled in  a ropy magma, in which numerous crystals of the
triple phosphate are visible ; this vicidity and these crystals being rapidly
developed by the agency of the alkaline urine always voided in inflamma- 
URINE.
787
tion of the bladder.  This character of the urine will suffice to distinguish
vesical from renal inflammation.
  The ready separation of a turbid or milky urine into tivo parts, a clear
supernatant portion containing albumen, derived from the liquor purus, and
a sedimentary portion of pus corpuscles distinctly precipitated, voided by
a patient who  suffered from severe regional pain either in the kidney or
bladder, perineum or penis; and if, in the first-named*position, aggravated
by pressure or motion, or  wdien, in the  latter parts, relieved temporarily
by micturition, and  in whose urine gravel, or  blood, or both, had been
previously, or  at some  antecedent period, present, to such a collection of
symptoms there should be tittle hesitation in  referring them  to a chronic
inflammation of the pelvis of the kidney.
  In  the treatment  of these cases our chief reliance must be placed on
the palliative agency of opium.  If it  be a case of calculous pyeletis—that
is, chronic inflammation of the pelvis of the kidney arising from the irrita-
tion of the calculus impacted  therein—it is  quite obvious that so long as
the irritating agent remains, so long wtill the symptoms of chronic  inflam-
mation continue.  We have no remedies that can either dissolve or remove
such a concretion, and the progress of the case must ultimately depend on
the form and  composition of the calculus, some  of which escape into  the
bladder, with symptoms characteristic of their descent through  the ureter ;
and, if their diameter be but small, may be excreted through the urethra;
this is more likely to happen in the female.   These are the most favorable
terminations to renal calculus.  In other cases the calculus baiting escaped
the kidney, lodges in the bladder, and  gives rise  to  the usual symptoms,
relief from which can  only be obtained by the  assistance  of a  skillful
surgeon.  But in by far the more numerous cases of calculous pyeletis, the
concretion grows by the apposition of fresh matter, becomes  impacted in
the head of the ureter, does not completely occlude the outlet, but becomes
branched  and irregular  in shape  by the constant deposit of phosphatic
matter derived from the action of alkaline purulent fluid on the urine,  still
secreted by the intact part of  the kidney; the fluid  retained in the pelvis
of the kidney is constantly exerting a dilating influence, and in the progress
of the case a  renal tumor  is felt, distinctly fluctuating, and if the history
and  symptoms of such a case be  carefully collated, the diagnosis is  not
difficult.   It must be clear that medicinal remedies can exert no curative
influence in such a case.  To palliate and relieA*e must be the limit of our aid.
  In  the  case ivhich has formed  the  subject of these remarks, you have
seen that perfect quietude, the ivarm-bath, cupping on the loins in the early
period," and opiates, were the agents  through which  partial relief w*as
obtained.  The buchu, the  sesquichloride of iron, and  the nitro-muriatic
acid,  although  severally administered, cannot be  said to have done  any-
thing for the relief of the patient.                     Part xxxiii., p.  123.

   Oxalate of Lime Deposit.—When  examining  urine, microscopically,
ivhich contains oxalate  of lime, it is possible  that the crystals  may be
obscured by opaque urates.  When such is the  case, says the editor of the
" Medical Times and Gazette," they must first  be dissolved out by liquor
potassas, or they may very much  deceive you,  by leading you to  suppose
that there is very little oxalate of lime,  when it is present in great abund-
ance.                                               Part xxxiii., p. 127.
   Tests for Sugar.—Kledzinsky's fluid, composed of potash, glycerine, 
788
URINE.
and saturated solution of sulphate of copper, when added to diabetic urine
and boiled, turns it of an opaque amber color; with non-saccharine urine,
there is a white flocculent deposit.  Maumene's Test is made  by soaking
white merino, or any w*oollen fabric, in  a solution of bichloride of tin, and
drying  in a  water bath: when dipped in  suspected urine and carefully
dried, the cloth becomes of a darkish broivn or almost black color.
                                                   Part xxxiii., p. 128.
  Liebig's Method for the Rapid Detection of Sugar.—Dissolve a small
quantity of ox-gall in the suspected fluid in a test tube; then add rapidly
an equal quantity of strong sulphuric  acid.   If sugar is present, a beautiful
purpurine is immediately produced.                  Part xxxiii., p. 129.
  New  Test for Sugar in Urine.—Krause  advocates the use of the  test-
fluid, originally proposed by Luton, containing the  bichromate of potash
in solution.   He proposes that the fluid should be made thus: Dissolve 3j.
of bichromate of potash in 3ij. of aq. destill., wdth the addition of 5ij. of
concentrated sulphuric acid.  When glucose urine is treated with an equal
bulk  of this  fluid,  the reddish-yellow color  changes, in a  short  time
(instantly by1 the application of heat),  into a beautiful bluish-green color,
more or less dark, according  to the degree of concentration, and carbonic
and formic acids escape during effervescence.   A dirty broAvnish-red color
(with occasionally a tinge of green) results if no sugar be present. Whilst
Krause deprecates  neglect of the well-known tests proposed by Trommer
and others, he considers this one as more certain and less difficult than any
other.                                               Part xxxv., p. 64.
  Sugar in  the Urine—Tests  for.—Dr. Garrod, of University  College,
says: Moore's test, or that by boiling the urine, to ivhich an equal bulk of
liquor potassae  has  previously been  added, may be  much increased  in
delicacy by first adding a drop or two of the potash solution to insure slight
alkalinity, and then  some good bone  black  or animal charcoal.  This mix-
ture must now be  filtered, and  we  thus  obtain  a  liquid perfectly color-
less, and on adding  a further excess  of liq. potassae, and boiling, the yel-
Ioav  or  orange  color is much more readily observed  than in the urine
before preparation.  Should  no change of color take place, we may safely
conclude that no sugar  exists, or, at any rate, such traces as may safely
be disregarded.                                     Part xxxv., p. 301.
  Retention of Urine.—If a catheter cannot be passed, Mr. Forster, of
Guy's Hospital, would place the patient under the  influence of chloroform;
if the stricture be spasmodic, it will be  at once relaxed, and even if a per-
manent  one, will often  be relaxed so  far as to admit of the passage of an
instrument.                                         Part xxxvi, p. 182.
  Constituents of the Urine and their Sources.—The following, by Dr.
A. H. Hassall, of Royal Free Hospital, are the  sources from which the
different constituents wdiich  come under the name of Essenticd Consti-
tuents of the  Urine are derived:
  Urea is a  nitrogenous compound, derived from  the disintegration of
some of the nitrogenized tissues, according to Dr. Prout, the gelatinous
tissue of the body.   The principal part of the nitrogen of the disintegrated
tissues is eliminated from the system through this compound.
  Creatine and  Creatining are also nitrogenous bodies, derived, as appears
from the researches of Liebig, from the disintegration of the muscular tissue. 
URINE.
789
   Uric acid, according to Dr. Prout, results from the disintegration of
the albuminous tissues.   But it is probable that uric acid is in some cases in
part derived from elements of food rich in nitrogen, imperfectly assimilated,
and the same, perhaps, is also true in some cases with urea.
  The coloring matter of the urine, ivhich is a non-nitrogenous substance,
and extremely rich in carbon, is supposed to be modified hematin, set free
on the decay and breaking down of the blood corpuscles, and to be the
vehicle by ivhich much of the excess of carbon contained in the system is
eliminated.
  The sulphuric acid is formed in part by the oxydation of the  sulphur
contained in  the proximate nitrogenized animal  principles, as ivell  as in
taurine.
  The phosphoric acid present  in the urine  proceeds  in part  from the
oxydation of the phosphorus Avhich forms one of the constituents of the
nervous tissue, and especially of the  brain.
  The silica is set free by the disintegration of the osseous tissues.
  Lastly, the ammonia of the urine is iu part derived from the decomposi-
tion of the urea.
  On the other hand, the constituents termed Non-essential, as all the
chlorine of the chlorides, and great part of the sulphuric, phosphoric, and
silicic acids, are derived from the articles of drink and food consumed,
together Avith the several bases, excepting part of the ammonia, as  lime,
magnesia, potash, and  soda, with which the chlorides, sulphates, and
phosphates, are in combination.   Part, hoivever, of these salts are, during
assimilation, received into, and  imbibed by the  different tissues, and
become set free again on their disintegration.
  The presence  in  the urine of either of the essential constituents in
increased or diminished amount, signifies the extent of the decay and dis-
integration of the particular tissues from which they are derived. .
                                                   Part xxxvii., p. 90.

  Discrimination  of certain  Organized and Disorganized Matters and
Principles in the  Urine.—Dr. A. II. Hassal  gives the following: Dis-
crimination  of Epithelium.—Occasionally,  deposits appear in the  urine
bearing considerable resemblance to mucus or pus, and which it is impos-
sible to distinguish by the eye alone, but ivhich, when examined under the
microscope,  are. found to  consist almost entirely of epithelium.  These
deposits occur especially  in the urine of Avomen, the epithelial scales being
derived, for  the most part, from  the vagina.  More rarely, hoAvever, the
deposit consists of the epithelium of either the renal tubules  or bladder.
Each of these three varieties of epithelium possesses well-marked structural
peculiarities,  by ivbich  it  may be  distinguished,  either as  they  occur
separately or when mixed together.
  Discrimination of Pus.—A deposit of pus in urine is distinguished from
one of mucus, first, by its appearance; it is l^sre opaque and cream-like,
and forms a  more decided and  equal sediment, and when the urine  is
shaken, it becomes equally  diffused throughout, without any ropy  or tena-
cious shreddy substance being idsible.
  If, however, the urine be very alkaline, the appearance presented by the
purulent deposit is very different; it becomes acted upon by the  alkaties
of the urine, and is then converted into a semi-transparent, tenacious sub-
stauce, very closely resembling mucus, from  which, by the eye alone, there 
790
URINE.
is  no means of distinguishing it.   This change  of appearance is often
observed in urines Avhich contain  pus, and which have been kept for some
days; the  deposit; from being  soft and opaque, gradually becomes trans-
parent and ropy.   The appearances presented to the naked eye by a deposit
of pus in fresh urine are often quite decisive.
  The outward characters of the deposit having been carefully observed,
a portion of the urine, after filtration, is to be boiled in a test-tube; if this
prove albuminous, there will be stronger reason for regarding the deposit
as one of pus, for, with a mucous deposit, as already stated, the urine is
scarcely ever albuminous.
  When we come to examine a deposit of pus ivith a microscope, we find
that the granular corpuscles are much more numerous than in mucus; that
they are more  readily acted upon by dilute acetic acid;  and that  a large
number of nuclei are disclosed in them;  also, that there  is an absence of
the fibrous shreds as w*ell as of epithelial scales.
  Thus, by the several characters, external and microscopical, now  enume-
rated, pus and mucus may in general be easily and satisfactorily distinguished
when  in  a separate  state; when, hoivever, these deposits are mixed
together, the distinction is much more difficult, and in  some cases quite
impossible.
   When pus  has been acted  upon by the  alkalies of the urine, and con-
verted into a substance resembling mucus, the distinction between the two
may still, in general, be effected by means of the microscope, for in this
case, while there will be an absence of epithelial scales, the pus corpuscles
will be found to be considerably larger than they are under ordinary cir-
cumstances.
   Another difference between mucus and pus is that the latter contains a
rather larger proportion of fatty matter ; this is seen under the microscope
in the form of small, shining droplets or spherules, either free or contained in
the granular corpuscles, or the fatty matter may be extracted by means of
 ether.  The quantity of fatty matter in mucus is very small, and frequently
it is almost entirely absent. When, therefore,  fatty matter is left, on  the
 evaporation of the etherial solution of a suspected deposit of pus,  there is
further reason for  considering  that the deposit  really  consists  of  that
 substance.
   We have noticed that  pus acted upon by alkaline urine becomes  con-
verted into a ropy substance,  similar to mucus ; this conversion  is more
marked, and is almost immediately effected, by the addition to the deposit
 of a solution of either ammonia or potash.
   Urine containing pus, is most commonly either neutral or slightly acid,
 and becomes  alkaline only slowly, while mucous urine, on  the contrary
 even if acid when first passed, very quickly becomes alkaline and ammo-
 niacal.
   The  liquid portion of pus, liquor puris, differs essentially from  that of
 mucus, and holds in solution the folloiving substances : albumen, a  peculiar
 compound, pyin, or tritoxide of protein,  which is soluble in ivater and pre-
 cipitated by acetic acid, fat, and salts.   The salts consist for the most part
 of chloride of sodium, w till small  quantities of phosphate, sulphate,  and
 carbonate of soda, chlorides of potassium and calcium, earthy phosphates,
 and traces of iron, thus showing  a resemblance in composition to the serum
 of blood.
   Doposits of triple phosphate,  especially when the crystals  are small, are 
URINE,
791
very apt to be mistaken for pus—an error w hich is at once  rectified by
the employment of the microscope.
  Discrimination of Albumen.—The detection of albumen in urine is very
simple.   A small quantity of the urine is to be heated until it boils, in  a
test-tube, over the flame of a spirit-lamp.   As soon as the temperature of
the liquid  becomes raised  to  over  170° Fahr., the  albumen will become
coagulated; and if the test-tube be set aside for a time, it wdll become de-
posited, when it may be collected, dried, and weighed.  The  precipitated
albumen is  soluble in solution of potash, but insoluble in nitric acid.
  There are certain sources of failure and fallacy attending the detection
of albumen in the urine :
  Thus, if earthy phosphates be present in excess, they will become preci-
pitated  as soon as the urine is boiled ; this  precipitate resembles somewhat,
and might be  mistaken for, albumen, from which it  is, hoAvever, distin-
guished by its solubility in nitric acid.
  Again, it has been noticed, that, Avhen urates are  in great excess in the
urine, a white precipitate of uric acid is occasioned on the addition of nitric
acid, ivhich might also be mistaken for albumen.
  Dr. Owen Rees remarks, " I have  observed this in cases of typhus fever
of low type, and also in several cases of smallpox.  This precipitate is dis-
tinguished  from albumen by the fact  that the addition of hydrochloric acid
to a second portion of the urine will  occasion a precipitate equally with the
nitric acid, if it be oiving to uric acid, but no precipitate will ensue if albu-
men be present."
   A precipitate likcAvise occurs wdien nitric acid is added to the urine  of a
patient who has taken either copaiba or cubebs, and  which, at first, closely
resembles  albumen.   This  precipitate arises  from the deposition of the
resinous matter  contained in  the above-named medicines.  It is  distin-
guished from albumen by  its not  subsiding as distinct deposit, and by its
producing  a permanent opacity of the urine.
   Another method of distinguishing albumen in such cases is by acidulat-
ing the urine with acetic acid,  and then adding a solution of ferrocyanuret
of potassium. If albumen be present, it is  thus immediately thrown down;
 whereas in the other case, if acetic acid produce a slight turbidity, this ivill
not be increased by the addition of the ferrocyanuret of potassium.  Lastly,
no precipitate  is occasioned by boiling, and  the urine of persons  taking
copaiba or cubebs evolves, when first" passed, the  strong odor of those
drugs.
   But it sometimes happens that albumen is present, and yet is not preci-
pitated on boiling; this happens whenever the urine is alkaline, the albu-
men being kept in solution by  the alkali.   In this case it is necessary first
 to  acidify the urine ivith nitric acid, and then to boil.   But nitric acid in
 excess  precipitates albumen from the urine as ivell  as heat.  It is, there-
 fore, best in  most cases, to test both with nitric acid and heat, and  it is
 always proper to ascertain ivhether  the precipitate  ivhich appears on  boil-
 ing is soluble in  excess of nitric acid or not.
   In employing nitric acid, the reagent  should be  added in excess,  as it
 sometimes happens that the albumen first thrown down is redissolved; but
 when  an excess of the acid is used, the  albumen is thrown down perma-
 nently, and is not redissolved.
   Dr. Bence Jones has stated, that  he has found a few drops of a mixture
 of one part of nitric to  three of hydrochloric  acid  much more  decided in 
792
URINE.
its effects, and much more delicate in its indications, than pure nitric acid.
This is explained in the evolution of chlorine gas by the extraction of the
hydrogen of the hydrochloric acid, one of the most delicate precipitants of
the protein compounds being thus set free.  But this test, tike the ferro-
cyanide of potassium test, has the property of precipitating other protein
compumds besides albumen, as mucus, etc.
  The quantity of albumen in urine varies greatly, from a mere trace to
some grains to the ounce ; and according to the quantity present, so varies
the appearance of the urine on the application of heat.  If the quantity be
very considerable, the urine will become  almost white, and nearly solid ;
whereas, if it be very small, the  deposit may he so trifling as altogether
to escape detection, until the test-tube be set aside for some hours so as to
allow of the subsidence of the deposit.  In  this Avay the presence of a  very
minute quantity of albumen will be detected.   When but little more  than
a trace of albumen exists in the urine, it is best to take a very large  test-
tube, and to boil some five or six drachms  of the urine.
  Albumen is also precipitated by dilute hydrochloric  acid, ferrocyanide
of potassium, bichloride of mercury, alcohol, creasote, tannin, and many
other substances. It is not precipitated, hoivever, by phosphoric and acetic
acids, ivhich exert a solvent action upon  it, nor by  strong hydrochloric
acid, with ivhich, when warmed, it forms a purple-colored solution.
  A remarkable substance allied to albumen has been  detected in urine,
by Dr. Bence Jones, in case of rickets.  It differed from albumen  by not
being precipitated by either heat or nitric acid ; but on boiling the urine, and
allowing it to  cool, a precipitate fell ivhich redissolved on the application
of heat.   Alcohol added to the urine readily coagulated this substance.
  Determination  of  Chyle.—Urine  containing  chyle  is usually more
milky and opalescent than wdien it contains only oil.  In  chylous urine ex-
amined microscopically and chemically, all  the usual elements of chyle will
ordinarily be  detected, as oil, albumen,  and granular organic corpuscles,
resembling the white corpuscles of the blood.  The albumen is to be de-
tected after filtration of the urine by coagulation in the ordinary manner.
The oil may, or may not,  be visible under the microscope in  the  form  of
droplets; but if present it may always be obtained by agitation with ether;
lastly, the granular corpuscles are distinguished from the flat globules by
their size, granular texture, and by the action of acetic acid  and ether
upon them; by the first reagent, nuclei are disclosed  in the corpuscles,
while in ether they  are  insoluble, and  thus distinguished from the  fatty
globules, for some of which they might be readily mistaken.
  The milky appearance presented by chylous  urine is occasioned partly
by the oily matter and the granular corpuscles present, and partly by pre-
cipitated albuminous, or more probably fibrinous matter.   Chylous urine
when first passed, and while still warm, does not usually present the  same
degree of opacity and milkiness ivhich it acquires when it  becomes  cold.
This depends on the solidification both of the fatty and fibrinous matters
present.   If the quantity of chyle present be very considerable, the urine
will sometimes acquire a gslatinous or semi-solid consistence, owing to the
coagulation of the fibrinous element.
  In some of the cases of chylous urine wdiich fell under the observation
of Dr. Prout, the albumen did not coagulate on the application of  heat,
but it did when nitric acid was added, and hence he ivas led to consider
that this albumen was in an imperfect state. 
URINE.
793
  The proportion of fat present in chylous urine maybe  so  great that it
may interfere with the gelatinization of the spontaneously-coagulable albu-
men or fibrin, but as soon as the fat has been removed by means of ether,
the solidification ivill in some cases, take place.
  Determination of Fatty  or  Oily Matter.—Urine  containing  fatty or
oily matter is usually, but not ahvays, more or less turbid, and  if the  fat
occur in connection wdth chylous matter, it wdll not only be turbid, but it
will possess a whitish and milky appearance more or  less marked.   Usu-
ally when a drop of such urine, especially if it has been allowed to stand
at rest  for some time, and it be taken from the surface, is examined under
the microscope, droplets or spherules of oil will be seen, which are readily
distinguished by their strongly refractive properties,  as well as by  their
solubility in  ether.
  Should the presence of fat be suspected, and no globules of oil be visible
under the microscope,  a portion of the urine should be agitated wdth ether,
which will dissolve out any oily or fatty matter which may be present, and
which may be obtained in a separate state on the evaporation of the* ethe-
real solution.
  That the substance thus contained consists really of fat is known by its
greasy appearance, its insolubility in cold water, by its  breaking  up into
droplets when agitated ivith hot water, and its solubility in ether.
  It is  not very often that a urine is met ivith containing only fat, for when
this is present, it is usually derived from chyle, some  of the  constituents
of Avhich are generally present in the urine with it.
  But minute quantities of fat  may be  present in  urine, independent of
chyle, as in certain forms of Bright's disease, and also  without occasioning
the slightest turbidity.  In this case, the fatty matter is found  in  the cells
and renal casts thrown off,  and ivhich  have become  deposited from the
urine after it has stood for some hours.
  The  microscope affords the only means by which  the presence of oily
matter in connection ivith the renal cells and tubules cau be ascertained.
  In the Mauritius, fatty urine is epidemic, and it accompanies  a  peculiar
form of irritative fever.
  A peculiar kind of  fatty matter,  to  which  its discoverer, Dr. Florian
Heller  (Heller's Arch., 1844 and  1845), gave the name of uro stealith, has
been detected in one instance in the urine.  The patient, a weaver, twenty-
four years of age, labored under all the symptoms of  calculus, and passed
some small concretions, which,  on examination, were  found to be com-
posed of the peculiar  fatty matter  in question.  These concretions pos-
sessed the folioAving characters: When fresh,  they  were soft,  becoming
when dry, hard,  yellow, wax-like, brittle, and amorphous, and  presenting
by transmitted light a greenish-yellow color.  On the application of heat,
they puffed up, inflamed, emitted a peculiar  pungent  odor,  between that
of shellac  and benzoin, and left  a  voluminous ash.   In hot water  they
softened, but did not  dissolve; they ivere  readily  soluble in  ether; the
residue, on the evaporation of the ethereal solution, assumed a violet color.
On the application of a gentle heat, nitric acid dissolved them with a slight
effervescence, forming a colorless substance.
  Determination of Fibrin.—Fibrin is distinguished from albumen by its
undergoing solidification when effused from the blood-vessels.   It usually
occurs  in the urine in connection with blood,  but not always so.   Some-
times it exudes from the blood-vessels of the kidneys,  and solidifies in  the 
791
URINE.
renal tubules, in the form of casts.   In other,  but v.^ry rare cases, the
effused fibrin does not solidify until after the urine has been voided.
  When the fibrin solidifies in the kidneys, the casts are usually met with
in the urine.  Whenever, then, these casts are observed under the  micro-
scope, or the urine becomes at all gelatinous on cooling, and this  Avhether
it contain blood or not, fibrin is present.
  Now*, almost constantly, albumen is voided at the  same time with the
fibrin ; whenever, therefore, the latter is present in the urine, the former is
almost sure to be found.
  There is a form  of deposit  of frequent occurrence in the urine, and
which, since it  bears much resemblance to a renal cast, may here  be no-
ticed.  It consists of long threads of very variable diameter but ivhich are
all more or less striated, showing that they are made up of fibrillas of fibrin.
They are met with in abundance in urines depositing oxalate of lime; also
in those containing excess of earthy phosphates and mucus,  or which con-
tain semen; besides, wherever irritation of the  bladder from any cause
exists, and as  an evidence  of which irritation they are to be regarded.
They are found alike in the urine of men and women.
  Determination of Keistein.—Another substance of great interest, met
with in the urine of pregnant women, and with  the characters of which it
is necessary to  become acquainted, is that known by the names of keistein
and gravidine.
  After the urine of a pregnant lvoman has been exposed to the air in a
cylindrical glass vessel for two  or three days  (and never  later  than the
sixth day), a fatty looking pellicle forms  upon  the  surface, ivhich at the
end of tivo or three days, when the  urine  is becoming alkaline, gradually
breaks up, and falls  to the bottom as a sediment,  frequently evolving  at
this stage a powerful odor of cheese.
  This scum or pellicle, vieived under the microscope, is seen to be con-
stituted of three distinct elements, and to consist of a granular base  in
which are imbedded ivell-defined crystals of the ammonio-magnesiau phos-
phate, and droplets of oil.  The only essential and distinctive constituent
of keistein is therefore  the granular matrix.   This is not  acted  upon by
acetic acid, but is dissolved by ammonia, and this it is that  evolves during
decomposition  the cheesy odor above  referred to.  When  this scum is
collected in any quantity, it presents a greasy and  opaque appearance, re-
sembling spermaceti, arising partly from the large quantity of triple phos-
phate present.
  The triple phosphate may be  dissolved out by means of acetic acid, and
the oil by ether ; the cheese-like substance being left behind.
  The scum of keistein is distinguished from the ordinary phosphatic crust
or scum, not only by the presence of oil and the  casein or cheesy substance,
but also by its  not  remaining on  the surface beyond three or four days
from its complete formation.
  The urines on which keistein is formed rarely become turbid on boiling,
or throw down any deposit on the addition of nitric or acetic acid, show-
ing the absence of albumen but not necessarily that of casein, since this
would not be precipitated by acetic acid unless  it were present in large
amount.
  Determination of Blood.—When blood is contained in urine in  amount
 at all considerable, its presence is sufficiently indicated by the  eye alone.
 The urine will be observed to possess a reddish color, and "if it be set aside 
URTNE.
795
for some time, a reddish or rust-colored precipitate will subside,  the  pres-
ence of Avhich is so peculiar that it cannot be  confounded with  any other
colored deposits which occur in the urine, as uric acid and the urates.
  Moreover, if the quantity of blood be very considerable, the urine  will
become more or less gelatinous, and if a portion of it be boiled,  it  wdll be
found to abound in albumen.
  When the quantity of blood is very minute,  the  microscope affords the
only ready and  certain means of determining its presence.  By this instru-
ment, if the urine be fresh, the presence of the  red and white corpuscles of
the blood will be revealed in any sediment from urine  ivhich  has  been
allowed to remain at rest a sufficient  time.  If the hemorrhage proceed
from the kidneys, casts, containing blood corpuscles,  are  sometimes  met
with.
  Determination of Bile.—When bile is contained in urine in  considerable
quantity, its  presence  is  sufficiently indicated  by the color of the urine ;
this is especially the case in jaundice,  in ivhich  the urine usually  possesses
a dark-yellowish green or broivn color, which is exceedingly characteristic.
  When the quantity of biliary matter in the urine is less,  the tint of the
urine is only deepened and rendered of a broivn or reddish hue.  When
this is the case, it becomes necessary to seek for the presence of bile, for
which there are several tests.
  One of these  is Pettenkofer's test, which consists of sulphuric  acid, free
from sulphurous acid, and sugar.   It is used as follows:
  To a small, quantity of the urine, in a test-tube, about two-thirds of the
bulk of sulphuric acid is  to be added, drop by  drop, so that the tempera-
ture of the mixture may not be raised above 144° Fahr., at which the  color
characteristic of bile is destroyed.
  To this mixture a grain or tivo of sugar  or  sirup is to  be added, the
whole shaken, and then allowed to stand at rest a few minutes.  Should
bile be present, the liquid ivill have assumed  a more or less intense red color
Aidth a tinge of violet.   This  remarkable  development  of color is  not
due to any change effected in the coloring matter of the bile, since it takes
place equally Avhen the above  reagents are  added to a solution of decolor-
ized bile.
  Should the suspected urine contain albumen, this should be first removed
by coagulation  and filtration, because Avith albumen and sulphuric acid and
sugar a nearly  similar color is developed.
  If the quantity of bile present be very small, the urine should  be evapo-
rated to dryness on a water-bath before the test is  tried, and  the bile dis-
solved out either by means of a little  water  or  alcohol.
  Another test for bile is that commonly known as Heller's test, which is
thus employed:
  A little Avhite of egg is added to a small quantity of the suspected urine,
and after the mixture has been well shaken,  a few drops of nitric  acid; this
causes the precipitation of the albumen, in  combination Avith  some of the
coloring matter of  the bile, the precipitated albumen  thereby assuming  a
dull-green or bluish color.
  When the quantity of bile is very small, the urine should be evaporated
as before, and the albumen added to the aqueous solution.
  A third test  for bile in urine depends upon the action of nitric  acid upo?i
the  brown coloring matter  of the bile,  called biliphoein.  Tavo or  three
(tiops  of nitric acid are to.be  allowed to fall upon a little of the uriiu 
796
URINE.
spread out in a thin layer on a white surface.  When bile is  present  in
amount at all considerable, the mixture assumes a variety of changing and
evanescent tints, green, violet, yellow*, and  pink, the latter color usually
predominating.  As in the case of the previously described tests, should
the quantity of bile present be very small, the urine must  be evaporated
before the nitric acid is added.
  According to the late Dr. Golding Bird, it occasionally happens that
bile exists in urine in a modified, and, perhaps,  oxydized state, in which it
does not exhibit, with  the tests above noticed, the characteristic reactions,
the urine becoming merely imperfectly  reddened.   Ammonia, Dr. Bird
states, then becomes a valuable test, it immediately producing a deep red
color.   There are  certain fallacies attending  the  ammonia test, arising
chiefly from the  presence  of vegetable  coloring matters  in the urine, as
those of rhubarb and senna, and on ivhich ammonia acts in a nearly simi-
lar manner.
  Lastly, there is the microscopic test, wdiich  has already been described,
for bile when present in urine in small quantities.
  Detection of Seminal Fluid.—In some  cases a mucus-like deposit occurs
in urine, wdiich, on examination with  the microscope, turns out to be
semen; this  is shown by the presence of the  well-known  seminal animal-
cules  and  corpuscles.   The animalcules  are nearly always dead, owdng,
perhaps, partly to the length of time which usually elapses before the urine
is examined, and partly to the injurious action exerted upon them by the
urine itself.  Spermatic animalcules are occasionally seen in urine in small
number where there is no visible deposit.
   Mixed up with the  spermatozoa, octahedral crystals of oxalate of lime
are frequently noticed.  Some observers  have  gone so far  as to state that
whenever these  crystals occur in urine, spermatic fluid is always present, a
statement which is certainly erroneous.                Part xxxvii., p. 91.

   Mode of detecting Sugar in the Urine.—Dr. A. Becquerel, physician at
the Hospital of La  Pitie, in a series of lectures, pointed  out the following
facts :  " First,  that nearly all urines become discolored, impart a green
color to, and  even precipitate the cupro-potass  solution of Barreswill, or
that of Frommerz, if heated wdth  these  reagents.   Second, that a great
number of these same urines become brown, in like manner, on the addi-
tion of caustic potass,  however pure that  may be."
   He strongly insisted on the erroneous conclusions to wdiich the reaction
afforded by these tests might lead, and showed that  nothing is more easy
than to avoid this source of error, and that there  is at our disposal a much
more sure, expeditious, and certain method of detecting the presence of
sugar in the urine than is usually employed.
   " We take a certain determinate quantity of urine, say 60 grs.; this we
treat  wdth a small quantity of solid and crystallized acetate of lead, say 4
grs.;  on heating this mixture,  there is immediately formed a copious pre-
cipitate of a dirty ivhite color; the liquor is then to be filtered,  and the
solution treated by sulphate of soda in excess.   If, for example, we have
added four grs. of  acetate of lead, we add eight  grs. of sulphate of soda.
This  being done, the mixture is again  heated, and sulphate  of lead  is
deposited ; we then filter once more,  and  there is afforded  a clear transpa-
rent liquid, ivhich  contains the sugar, when there is any,  and some unim-
portant salts.   The  liquid thus  obtained is  neither acted  on by the 
UTERINE HEMORRHAGE.
797
cupro-potass reagents, nor broivned by the caustic potass, unless sugar  is
present.  These  tivo re-agents are in this  way perfectly reliable,  very
accurate, and afford no results when no sugar is contained.
  '• Should the urine under examination contain albumen, it is immediately
coagulated by the acetate of lead at the same time as other organic matters,
and gives no further trouble.
  " Thus, in all cases where it is desired to ascertain the existence of sugar
in the urine, whether along with albumen or not, we possess two excellent
reagents in the cupro-potass solution, and in the caustic potass itself; only
ive require, in the first place, to treat the urine with the acetate of lead and
the sulphate of soda, by which means we get rid of all such matters as decom-
pose or discolor the cupro-potass or caustic potass tests." Part xxxvii.,/>.104.
            UTERINE  HEMORRHAGE.
   Oil of Ergot of Rye.—Diffused through water, recommended by Dr.
Samuel Wright to be injected into the uterus in severe cases of flooding.
                                                       Part ii., p. 42.
  Modes of Arresting  Uterine Hemorrhage.—[Dr. W. Tyler Smith treats
this subject under several heads.   He speaks first of]
   The Different Modes of exciting Reflex Contraction of the Uterus in
 Uterine Hemorrhage.—Keflex contractions may be  excited by  stimuli
applied to certain organs at a distance from the uterus; by stimuli applied
to certain other organs and surfaces in the vicinity of the uterus ; and lastly,
by stimuli applied to the uterus itself.
  [Under  the first division Dr. Smith mentions as exciters of contraction,
the mammary nerves (called  into exercise when the  child is put  to the
breast,) thepneumogastric (when food, hot or cold drinks, or emetics are
taken into the  stomach,) and the abdominal intercostal nerves.  Respecting
the latter, he says:]
  The  cutaneous nerves of  the  abdominal parietes  are excitors  of the
uterus in an extraordinary degree.  The sudden impression of cold or heat
upon the abdominal surface ivill almost always excite  the most energetic
contraction of the uterus affected wdth inertia, and from which hemorrhage
is taking place.  We may contract the relaxed and diffuse uterus to a firm
ball, by douching the  abdomen with cold water  from  a height; or  by
plashing a towel, taken out of cold  water, upon the naked abdomen ;  or
by suddenly placing the hand, taken out of iced water, upon the umbilicus.
If the  surface  of the abdomen should be cold, the sudden impression of
heat produces a similar contraction.
  About  the  true mode  of action of irritation  of  the mammary and
pneumogastric, and  the  abdominal  intercostal nerves, there can  be  no
doubt Avhatever.  These nerves are too  remote from  the uterus, in  their
peripheral extremities,  to admit of any other explanation save that of the
reflex function.
  [Under  the second division, or organs and surfaces in the vicinity of the
uterus, Dr. Smith refers  to  irritation of the vulval, vaginal, vesical, and
rectal nerves, induced by the application of cold to those parts. He says :]
  This group of organs, it will be observed, is in the immediate vicinity of
the organ  from ivbich the  blood flows, and they are in great measure 
798
UTERINE  HEMORRHAGE.
supplied  by nerves having  the  same origin as  the  uterine nerves.   But
what I w tish to insist upon is this, that all the actions 1 have been describ-
ing are reflex in their  nature.  Physiology repudiates the idea of uterine
contractions, excited  by means of continuity or contiguity of the organs
excited with the organ which contracts.  The peripheries of the nerves of
the bladder, rectum, vulva, and vagina, receive the impression, and the
incident  nerves, the  spinal  centre, and  the  motor  nerves  of the  uterus
distributed to its muscular structure, are all concerned in the muscular
contraction which ensues. Though the organs excited are near the uterus,
which contracts, the route of the nervous action is precisely the same as it
was in the case of the stimuli applied to the mammary or the pneumogas-
tric nerve.
  I now* come to the  consideration of the contraction of the uterus, and
the arrest of hemorrhage by irritation  of the  uterus itself, through the
medium  of stimuli applied to
   T/ie Uterine Nerves.—The  power  we possess over the uterus by this
means is very great indeed, and the modes by Avhich we  can exert it are
very various.  We may excite the nerves of the  external surface  of the
uterus, the  nerves  of the internal surface, or the nerves of  the os uteri.
When w*e produce  uterine contractions  by irritating the uterus through
the abdominal surface, ive act on the first series  of nerves; when we inject
cold water  into  the  uterine cavity, we act on the second, and when we
irritate  the os uteri by digitation, w*e act on the third.   These measures'
are of great importance in our attempts to rouse the uterus itself to action.
We may excite the organ by introducing ice into the cavity,  by injecting
cold water into the cavity, or by injecting stimulating solutions.
   Besides digital irritation of the uterus through the abdominal parietes,
there is another  external mode of inducing uterine reflex action, in the
use of the abdominal bandage.  The  compression of the uterus thus occa-
sioned, increases  uterine action,  or evokes  it when it has disappeared; it
is certainly one of  the best  means ive have of preventing that  inertia of
the uterus after delivery wdiich so strongly tends to  hemorrhage.
   The introduction of the hand into the uterus, or the irritation of the os
uteri by  the fingers, or the ivhole hand, excites the uterus very powerfully.
Besides the mere introduction of the hand, irritation of the internal surface
of the organ by the tips of the fingers is sometimes practised.
   The different modes of exciting direct or centric Spinal Contractions of the
 Uterus, in Uterine Hemorrhage.—If we administer a dose  of the ergot of rye
to a patient  suffering from hemorrhage, we observe  in many cases that
uterine contraction will follow*.  I have no doubt that  the true  channel
through  ivhich the ergot acts is the blood,  and the organ it  reaches and
affects, through this channel, is  the spinal  centre.  We  may illustrate its
modus operandi  by referring to the  action of  emetic substances on the
stomach.  There are certain substances which, when taken into the stomach,
immediately excite all the  motor actions of vomiting.   This  happens, for
instance, when sulphate  of zinc comes into contact with  the mucous mem-
brane of the stomach.  Sulphate of zinc, then, appears to  excite the actions
of vomiting in a reflex form.   But again, in the case of the stomach, there
are other medicines—the potassio-tartrate of antimony, for instance, which
acts as an emetic only after it has been taken into the circulation, and ivhich
acts more promptly wdien injected into the blood  itself.   I believe the ac-
tion of this medicine  to be perfectly analogous  to the action of the ergot 
UTERINE HEMORRHAGE.
799
of rye; that the one acts upon the medulla oblongata and the motor nerves
of vomiting ; the other, upon the lower medulla spinalis, and the motor
nerves of uterine action. The ergot, therefore, is a remedy of centric utero-
Bpinal action.
  Ipecacuanha is another medicine which is sometimes given in uterine he-
morrhage.  This medicine, by its emetic action, excites contraction of the
abdominal muscles, and compression of the uterus, which in turn may re-
excite some amount of uterine reflex action, but over and beyond this it
appears to have a special action upon the uterus, increasing its contractile
power beyond what we could imagine to occur from the merely secondary
effects of vomiting.  Ipecacuanha, then, appears to influence both the me-
dulla oblongata and the lower medulla spinalis.
  Opium is also, in hemorrhage, a remedy of direct spinal action.  In mode-
rate loss of blood it undoubtedly promotes uterine contraction, and arrests
the flow of blood.  Opium is an excitant of spinal action  of the direct kind,
and thus it is that its administration is beneficial in hemorrhage, with ute-
rine inertia, and injurious in puerperal convulsion, of the active kind.  As
a minor remedy of the same spinal relations as the foregoing, the biborate
of soda may be mentioned.  It  may be said, briefly, that  all stimulants
taken into the stomach and received into the blood have a centric spinal
action in hemorrhage from the  uterus.  But one of  the most important
agencies of a centric kind, and one different in its nature from the forego-
ing, consists in the influence of emotion.  Where sensibility is present, the
influence of emotion comes in aid of the  reflex action.  It is only the hope-
ful and  confident emotions ivhich excite muscular contraction.  The de-
pressing passions paralyze  the uterus as well as  other muscles, and  they
are, in truth, not unimportant as causes of hemorrhage.
  [Dr. Smith next speaks of " the different modes of exciting uterine action
by stimulating the muscular irritability of the organ," as distinguished from
the excitement of muscular action through the nerves.   He mentions three
methods by which this is  performed: the application of cold, mechanical
irritation with  the hand, and the use of galvanism.   With  regard to the
latter, he says:]
  In patients perfectly paraplegic, with  entire loss of reflex uterine power,
the uterus has been excited to contractions sufficient to expel the foetus by
means of galvanism.  Dr. Radford, of Manchester, applied  this power to
the arrest of uterine hemorrhage.  One pole of a galvanic  trough being
placed within  the os uteri, and the other applied over  the  fundus, it has
been found, that, on making and breaking the galvanic  circle, powerful
uterine contractions occur.
  The Different Modes of arresting Uterine Hemorrhage mechanically.—
There are various modes  of compressing the uterus  mechanically, which
are resorted to in cases of hemorrhage.   One mode is that of grasping the
uterus through the abdominal parietes,  and holding the organ so firmly as
to prevent the further effusion  of blood, while other  means are being ap-
plied to insure the permanent contraction of the organ.  Another mode
sometimes followed is that of introducing one hand  into the uterus, and
then exerting pressure with the other hand externally,  so as to compress
the bleeding portion of the organ betAveen the two  hands.   A third mode
of mechanical arrest,  and  one Avhich is  exceedingly useful, consists  in the
abdominal bandage, made  to embrace the pelvis tightly, and having several
toAiels or napkins folded into a corneal shape placed underneath. 
800
UTERINE  HEMORRHAGE.
  Compression of the aorta, so as to cut off the supply of blood to the
uterus, and prevent arterial hemorrhage, has been  insisted on by Baron
Dubois, M. Chailly, and others.  Several years ago,  I pointed out that the
directions given by obstetricians ivere wrong, and  that ive should make
pressure upon the inferior cava instead of the aorta.  The great hemor-
rhages, those which kill, are from the veins, and not  from the arteries, and
further, not from the veins ivhich are returning blood from the uterus, but
from the vena cava and the heart itself.  When the uterine veins are open,
there is a great column of blood betAveen the uterus and the right auricle,
to the sudden escape of Avhich there is no let or hindrance except uterine
contraction.  The compression of the great vessels is,  hoAvever, at best
palliative, not curative, but it  may give time for the application of other
remedies.
  The various  forms of plugging the vagina and the uterus are a distinct
class of obstetric remedies in  hemorrhage.  Mechanical plugging is ex-
treuutiy useful in hemorrhage in many forms of abortion, in certain hemor-
hages during delivery, and in cases of placenta prasvia.  The sponge or
linen plug is useful in moderate floodings of the impregnated, and also of
the unimpregnated uterus.  This form of plug, when it fills the whole of
the vagina, acts by preventing the escape  of blood externally;  this favors
the coagulation of the blood effused behind the plug, and though the plug
itself does not reach to the bleeding surface, the coagulated blood is con-
verted into a secondary plug, wdiich acts directly upon the mouths of the
bleeding vessels. But beside  the common form of  tampon, ive often con-
vert the  foetus itself into a plug, having precisely the same mechanical
action.   Thus when, in hemorrhage before delivery, we rupture the mem-
branes,  beside the other results, the body and limbs of the fostus  come
into direct contact w ith hemorrhagic tissue.  So in placenta previa,  when
the presentation is alloived to remain, but the placenta is torn aivay, the
fastal head becomes in effect a tampon to the os and cervix uteri of the
most powerful  kind.  Again, when  turning is performed  in  these cases,
the feet are brought down, and engaged in the os uteri as a plug.  These
instances only  differ from the plug of sponge or linen in their being more
effective, and in being applied from wdthin instead of from Avithout. After
delivery, no form of plugging can be of much service.
   The arrest of Uterine Hemorrhage by Astringents and Refrigerants.—
These remedies, consisting of the acetate of lead, the mineral acids, alum
given internally, and used in the form of injection, the sustained applica-
tion of local cold, etc., are useful in all hemorrhages ivhich do not proceed
from patulous vessels  sufficiently large to require the  contraction of the
muscular organ in order to close  them, or when the uterus is so far unde-
veloped  as to  render its  muscular contraction impossible.   Such are he-
morrhages occurring in the course of uterine  disease, or in menorrhagia;
uterine floodings in the early months of pregnancy, and the profuse lochial
discharges which sometimes occur a few days after delivery, when the
uterus has become perfectly contracted.                Part xix., p. 237.

  Principle of Treatment by  Cold in Uterine Hemorrhage.—Dr. Gooch
mentions the case of a lady ttiat he attended, in whom, both before and at
the time of labor, the force of the  circulation was  very gnat; "she ivas
flushed  and  had a quick pulse."  After delivery, she had a most violent
flooding;  and Gooch remarks that, "after the violence of the hemorrhage 
UTERINE HEMORRHAGE.
801
was over, although the abdomen was covered Avith pounded ice, it returned
again and again, slightly in degree, yet sufficiently, in the debilitated state
of the  patient,  to produce  alarming occurrences of faintness ; the uterus,
too, which had become firm and distinct, became so soft, it could no longer
be felt.  Finding the ice so inefficient, I swept it off, and taking a eiver of
cold water, I let its  contents  fall from a height of several  feet upon the
belly;  the effect was instantaneous;  the uterus, ivhich, the moment before
had  been  so soft  and indistinct as not  to be felt wtithin the abdomen,
became small and hard, the bleeding stopped, and the faintness ceased—a
striking proof of this important  principle, that cold  applied with a shock
is a more powerful means of producing contraction of the uterus than a
greater degree of cold ivithout the shock."              Part xix., p. 246.

  Accidental Hemorrhage.—Prof. Murphy, of London University College,
says: The  treatment must be prompt  and  decisive.   Accidental hemor-
rhage usually occurs  in the first stage of labor, Avhen  the  membranes are
unbroken, and the liquor amnii prevents the uterus contracting about the
body of the child.  In  order, therefore, to control  flooding, the uterus
should be made to contract as much as possible, and coagulation promoted
in the spongy structure of the placenta; both objects are -accomplished by
rupturing the membranes, because the uterus contracts on  the body of the
child, and the placenta being compressed  betiveen both, the blood is pre-
vented escaping so freely from its uterine surface.   This effect may be ren-
dered more perfect by using means to increase the tonic contraction of the
uterus, Avhich rupturing the membranes alone Aitill not  always accomplish.
Therefore, ergot of rye, or the electric current, may be used ; a drachm
of the former infused in a wine-glass of Avater, may be given alone, or,
Avhat is better,  in  combination with opium.  Thirty or forty minims of
tincture of opium may be added to the infusion, and in proportion as ex-
haustion increases, larger doses of opium may be repeated.  When you Avish
the aid of the electric current, the  electro-magnetic  apparatus  should be
employed, and  currents passed either  transversely or in the longitudinal
axis of the uterus; rods, holding sponges moistened in a saline  solution,
are connected by ivires to the apparatus, and  may be applied to any part
of the abdomen ; a sponge may be introduced  within the vagina, and con-
nected in the same  manner wdth the battery ; by these means currents may
be made to  pass in  any direction.   The only objection to this  mode of
exciting the uterus  is  the delay which  might arise in preparing the
instrument.
  Turning was  formerly a universal practice in cases of accidental hemor-
rhage.  It is now very  rarely resorted to, and Dr. Murphy thinks it will
very seldom be  found necessary.  Stimulants must be  given even largely,
and if all means fail,  transfusion  may be cautiously resorted to.
                                                     Part xix., p. 248.
  Post-partum  Hemorrhage.—Post-partum  hemorrhage may occur either
before or after the expulsion of the placenta. In the former case, its causes
are three, inertia of the uterus, irregular contractions of the uterine fibres,
and morbid adhesion of the placenta.   Professor Murphy observes :
  Liertia of the uterus is equally the cause  and the effect of hemorrhage.
You  should be careful  to recognize true inertia as soon as it  presents
itself; you may do so before  any hemorrhage takes place, even when the
child is being expelled.  The fundus of the uterus has not its usual firm
    vol. II.—51 
802
UTERINE HEMORRHAGE.
feel under the band ; it seems spongy or like  dough, and is larger than it
ought to be, because it very seldom contracts  to its full extent.  After the
delivery of the child, when  the uterus generally remains contracted, it will
not do so.  You may have  followed the contracting uterus with the hand,
moderately compressing it, and in a short time you find that it has eluded
your grasp, and cannot be felt.  Strong  frictions  over the loAver part of
the abdomen may again excite  its action ; but it is  only for a moment—
again it is lost.  While this want of tone may be observed in the uterus,
a corresponding amount of constitutional irritation may be noticed in the
patient.  The pulse  is increased in  frequency, and  assumes the jerking
hemorrhagic character; the patient is watchful and restless ; complains of
sinking, and  does not experience that relief from  the termination of her
sufferings that is usual after delivery.  All these symptoms may precede
any hemorrhage, and should be most carefully Avatched ;  they are the
monitors of  what is approaching.  Hemorrhage generally begins wdth a
slight draining from  the vulva, just  sufficient to soil the napkins that are
applied, but in a short time, if no means for prevention are used, the stream
rapidly increases to a torrent, deluging the bed, and forming a pool on the
floor beneath.  If the attendant is not on his guard, this may be the first
notice of danger, because the patient is sometimes too much exhausted to
give any intimation of her condition ; she lies on her side in a listless, dosy
state ;  syncope may folloAV, and hemorrhage for a moment cease, but it
soon returns with the pulse,  a violent gush of blood places the patient at
once " in extremis;" a more prolonged  syncope returns, from which she
may never recover.   Sometimes a fit of convulsions precedes dissolution.
   The treatment of such cases must  be direct: 1st.  To restore  the tonic
contractile power of the uterus.  2d.  To remove the placenta. 3d. To pre-
vent, as far as possible, any subsequent relaxation of the uterus.
   In  order to  accomplish  the  first  object, you must endeavor, by every
means in your poAver,  to  support the general circulation, ivhich  every
symptom points out to you is struggling to maintain itself.
   If there be great  exhaustion, the  patient  should be given a drachm of
tinct. of opium in  brandy; this may be repeated in more moderate doses,
until  the pulse  becomes  steady.  If the stomach be very irritable, and
reject  this, it will sometimes bear broth wdien  taken cold, and morphia
may be substituted for tincture  of opium.   Smellie  used to give potable
soups, dissolved in water.   The patient should be  kept in a perfectly hori-
zontal  position.   The arms and legs should  be wrapped in hot flannels,
the curtains  drawn  back, the window raised, and  a free circulation  of air
secured in the apartment.   Locally, every means must be employed to re-
tard the force of the circulation in the uterus.  The most convenient mode,
I think, is to have a bucket containing flannels, over which may be thrown
lumps  of ice, and  a  sufficient  quantity of water poured  over the ivhole.
These  flannels may  be wrung out, and applied from time to time to the
hips and vulva.   At the same time that these means  are being carried
into effect, the strongest pressure should be maintained on the fundus uteri,
to prevent its relaxation.   The success of your treatment becomes evident
when  you feel  the  fundus first  become distinct, and  then more  firm,
under  the  hand.  In many cases the pressure is sufficient to  cause the
expulsion of  the afterbirth, but if not, it  becomes  your duty, in this favor-
able opportunity,
   2d!y.  To remove  the placenta.—For  this purpose, let one  hand still 
UTERINE HEMORRHAGE.
808
compress the fundus, or assign this duty to an assistant, clearly explaining
ivhat is to be done, and then pass the hand into the vagina to the os uteri;
sometimes, by drawing doAvn the band again slowdy, the back of it being
pressed strongly against the posterior wall of the vagina and the perineum,
the uterus is excited to contract and expel the placenta into the vagina,
from whence it may be removed.
  if not, draw down the funis to its full extent, as far as it wdll go, and let
the hand in the vagina, guided by it, press forward into the uterus.  The
fingers  formed into a cone will  readily dilate the  os  uteri  sufficiently to
admit the hand ;  and here, again, it sometimes  happens that the act of
dilatation will excite a sufficient contraction to expel the placenta; if not,
you must proceed ; but, as a precaution, it would be  well to give the
patient a full dose of opium previous to entering the cavity of the uterus ;
when the placenta is reached, do not at once seize it in order to draw it
down, rather seek  to pass the hand above it, toward the surface of the
cavity of the uterus.  This portion of the uterus is now placed  between
the introduced hand and that which compresses it externally through the
abdomen ; by increasing this pressure, the irritation very seldom fails  in
causing the uterus to contract;  the moment this is observed, let the hand
be slowly withdrawn, having the whole  placenta wdthin it, and let a strong
pressure be made on the fundus uteri externally.  Thus,  the placenta may
be  sately withdrawn, and if the uterus be  properly secured, no further
hemorrhage  will take place.  Our next  object is, therefore, to do this, and
  3dly. To prevent, as far as possible, any subsequent relaxation.—It is
necessary to press very firmly wdth both hands on the fundus, and to con-
tinue this pressure for  some time; if fatigued, an assistant may continue
it;  but you must be particularly careful that be understands your object.
In  order to insure this effect, by the  continuance of  the  pressure, the
abdomen must be very carefully bandaged.
  Hemorrhage after the separation of the placenta  may  depend upon
inertia of the uterus, an over-excited circulation in  a plethoric patient, or
upon  mismanagement.  The last is by far the  most frequent cause; the
patient may be too  soon disturbed after her delivery, for the purpose of
changing the dress or bed-clothes,  or her friends may keep  her in a con-
stant  state of excitement by their kind, but too officious, congratulations.
The result is flooding.  Again, if she escape these dangers immediately
after delivery, your  patient may be alloived  perhaps  on the third or fourth
day to get out of bed ; the circulation is again excited in the uterus, still very
large and easily distended, and hemorrhage is  the consequence.  You are
not even safe on the tenth or fourteenth day.  One of the most alarming
hemorrhages I ever had to treat occurred on the tenth day after delivery.
                                                     Part xix., p. 254.

  Method of plugging the Vagina icith a Caoutchouc Bladder.—M. Diday,
having a case of metrorrhagia,  in  which the patient had become reduced
to almost the lowest point of exhaustion, resolved to avail himself of one
of Dr. Gariel's ingenious   appfications  of  vulcanized  caoutchouc. The
apparatus consists of a small bladder of caoutchouc, to which is attached a
long tube.  Rolled  up  so as not to exceed the little finger in  size, it Avas
passed as deeply into the vagina as possible, and kept there  by the end of
the  finger;  it was teen inflated through the  tube, until the small body,
which had been  introduced almost imperceptibly, acquired a volume con- 
804
UTERINE  HEMORRHAGE.
 stituting a  sphere of about 33  centimetres in diameter.  The air was
 retained by tying the tube.  No means of retaining it in  situ  Avere
 required, and the hemorrhage entirely ceasing, it  was removed  sixty-four
 hours after, as easily as introduced, by allowing the air to escape through
 the tube.                                            Part xxi., p. 202.
    Uterine Hemorrhage.—In a most  dangerous case of this nature, Dr.
 Sweeting gave  five grains of  acetate of lead  every  hour  for forty-eight
 hours.  As the  hemorrhage returned on the suspension of the medicine,
 the same dose was given every four hours, and continued for a fortnight
 with complete recovery;  the patient having taken in sixteen consecutive
 days 576 grains.                                    Part xxiv., p. 114.
   Indian Hemp.—Dr. Christison  considers  Indian hemp exceedingly
 valuable in restraining uterine hemorrhage.   The tincture of the hemp is
 the most efficacious preparation; it may be given in doses of five to fifteen
 or twenty minims, three times  a day in water.         Part xxiv., p. 321.
   Post-partum Hemorrhage.—Dr. Thos. Elliott recommends the follow-
 ing plan of treatment with a view of inducing uterine contraction, it being,
 in his experience, an " unfailing remedy."
   Inject into the  rectum 4 oz. of turpentine, 4 oz. of cold water, and a
 handful of common salt, forcibly retaining this by pressure from a folded
 napkin, until violent tenesmus  is induced ; this will invariably be attended
 with contraction of the womb.  Turpentine is used because it is a power-
 ful stimulant and restorative to the whole system, and, moreover, possesses
 considerable anti-hemorrhagic  properties.            Part  xxxvii., p. 205.
   Opium in Uterine Hemorrhage.—Dr. Gabb, of BeAvdley, states that
 opium has a very different effect in large and in moderate doses on the uterus.
 In large doses it relaxes and favors hemorrhage ; in small or moderate doses,
 as 25 minims, it stimulates and  causes contraction.   It is especially applica-
 ble in cases of deficient poiver from  exhaustion or fatigue, being  here,
 perhaps, the best remedy ivhich  can be employed.
   Utility of Galvanism in  accidental Hemorrhage.—Dr. Stafford, of Bir-
 mingham Lying-in Hospital, recommends, if you have a case of accidental
 hemorrhage  during labor, and the os be pretty well dilated, to apply gal-
 vanism to the abdomen, ivhich will probably soon bring on uterine con-
 tractions, and the head  of the  child  will  descend low enough to
 admit of the forceps being applied.   This is  especially valuable, as in
 these cases ergot of rye often entirely fails to induce contraction.
                                                  Part xxxvii., p. 208.
   Post-partum Hemorrhage.—Dr. W. Thomas, F.  R.  C. S., says: In  these
 alarming and dangerous cases,  where the countenance is blanched and the
 pulse imperceptible, do not, as  is  too often taught, hesitate to give stimu-
 lants freely ; their revivifying influence once seen can hardly be forgotten.
 The great thing to stop the hemorrhage is to empty the uterus; introduce
 the  hand at once  and remove  the placenta, keeping up the pressure
 externally with the other hand  ; this should always be done half an  hour
 after delivery, if the placenta be not then expelled.
                                                 Part xxxviii., p. 210
   Hemorrhage from  Carcinoma Uterri.—Tn  cauliflower excrescence of
 the uterus, says Prof.  Simpson, the hemorrhage is  occasionally  most vio-
lent and alarming.  Simply plugging the vagina does not suffice  to check 
UTERUS.                           805
it, and the use of some powerful styptic means becomes necessary.  Of
these  the simplest  and  surest is the  perchloride of iron dissolved in
glycerine.  It may be applied by a sponge  or piece of lint.   Tannin also is
very useful; it may be apphed in  the form of a medicated pessary;  it
rapidly coagulates the effused blood,  and thus prevents the further flow.
                                                     Part xl, p. 234.
                            UTERUS.
  Diagnosis of Diseases of the  Uterus—Simpson's Uterine Sound.—To
assist in the diagnosis of diseases of the  womb  and its appendages, Dr.
Simpson has been in the habit of using a metallic  uterine sound or bougie,
of nearly the size and shape of a small male catheter, which  is to be intro-
duced into the Avomb and manipulated in the way which we will describe.
  In diseases of these parts, we have only been able  hitherto to extend our
physical examination to the neck and lower  portion of the body.  If the
womb  were very large, we  might,  perhaps,  feel  the fundus through the
walls of the abdomen, but from  its mobility and low situation, this would
be of little service; in short, we  are constantly in doubt when examining
any tumor in this region, whether it be an enlargement of the whole mass
of the womb or a distention of its cavity, or a morbid grow'th ; and, if the
latter, Avhether the groAvth be seated in the  ivomb  itself, or in one of the
ovaries or other neighboring parts.
  It is particularly  useful when we want to ascertain the  state of the
fundus, body, and cavity of the womb, and also when any particular solid
tumor or fluid cyst is connected with that organ.   It is provided, like the
common male sound, wdth a flat handle, and terminates in a rounded knob
or bulb.  Its stem is thicker at its upper part, and  tapers gradually from
the knob to the handle.  By being  thin next the handle, it allows of more
extensive movement in the mouth and neck of the womb, and its increased
thickness at the other end gives  it strength.   The stem is about nine
inches long, and graduated so as  to enable us to measure the depth of the
parts.   In introducing this bougie,  the patient may be placed on her back
or left side, and having felt the os uteri, the practitioner can easily glide
the instrument  into  the womb, the internal surface of ivhich, when in a
healthy state, is not more sensible than that of the  vagina, so that when any
severe pain is felt, it may be considered as indicative of some morbid con-
dition.   When the instrument is in the womb, the practitioner can give
that organ sufficient  resistance for  its exploration  by the fingers, and he
can alter its position as he pleases.   He can thus  fix the fundus, and even
move it about, so as to enable him, with his other  hand on the abdomen,
to examine its external surface and walls, and to ascertain what connections
any other tumor may have wdth it.  The great mobility of the uterus  is
well known.  Its position is changed by many of  the  movements of the
bladder and rectum; it may be drawn down by instruments till the cervix
reach the external parts; and therefore the  uterine sound will enable us
to move it about in rather a startting manner.  The instrument being
metallic, can be  bent to any shape, so that when  ive want to bring the
fundus uteri  more  immediately under our fingers in our  hypogastric
examinations, the extremity shoujd be  bent upon  its stem at as  nearly a
right angle as the conformation of the genital canals admit, and, after being 
806
UTERUS*
introduced, its handle should be well retracted toward the perineum.  By
this proceeding, the body and fundus of the womb will be more easily and
fully turned forward.
  This mode of examination will also be particularly valuable in the early
stages of ovarian tumors.   The ovary lies behind the womb, so that if the
sound shows the tumor to lie on the anterior surface of the uterus, or, in
other Avords, if the uterine cavity runs up the posterior surface of the mor-
bid mass, the disease may be considered as certainly not ovarian.  This
remark will only apply to those cases in ivhich  the tumor is  still not so
large as to have passed out of the  pelvic cavity and become abdominal.
                                                     Part  viii., p. 106.

  Excision of the Os Uteri.—[Excision of the os uteri was, on account of
the marvellous cures said to have been frequently performed by it, in cases
of cancer of the  uterus, very sIoav in establishing itself as a legitimate prac-
tice in this country.  Cancer of the uterus is in reality  of very rare occur-
rence, and  removal of the diseased part presents even  less chance of
recovery than of any other part in which this  disease  may exist.  Cauli
flow*er excrescence, as Dr. Clarke  named it, is, however, very much more
common than was formerly supposed, and it has been ascertained that the re-
moval of this by the knife or scissors, is an operation perfectly safe and effec-
tual.  Dr. Clarke, when  he Wrote, had little to offer as regards treatment.]
   Professor Syme says:  A great  step in advance has been made through
the establishment of the important fact—for ivhich we are  chiefly indebted
to the surgeons of France—that  excision of the os  uteri,  executed  either
by knives or scissors, is an operation perfectly safe  and effectual when
 employed for the removal of growths not possessing a malignant disposi-
tion.  In performing the operation, it is always  desirable, and, in  general,
 easily practicable, to draw the tumor fairly into view, so that the  excision
 may be effected without  taking  away either more or less than  what is
 requisite, and without injuring the neighboring parts.   The most con-
venient instrument for this purpose is that which Dupuytren  employed—
 the hooked forceps of Muzeux, who invented it  for facilitating the  removal
 of enlarged  tonsils—or " vulsellum," as it has been improperly named by
 some writers.
   By means of the double-hooked  extremities  of this  instrument deeply
 inserted into the morbid  groivth  toward its  base, where the texture is of
 firmest  consistence, the tumor may usually be induced by steady traction
 of moderate force, to descend  and present itself to view, when a bistoury
 or curved  scissors may be used  without any difficulty or danger.  The
 assistance of a  speculum should be taken to insert  the forceps, and if it
 seems  necessary, in order to obtain complete command over  the  excres-
 cence, additional instruments of the same kind are to be fixed into different
 parts of its substance.  If the tumor cannot be  made to protrude without
 resorting to an unsafe degree of violence, it may at all events be  brought
 down in this way, so as to be within reach  of the fingers, ivhich will then
 form a safe  guide for the  scissors.  The hemorrhage is seldom more than
 very trivial, and when at all considerable, may be suppressed by filling the
 vagina with lint. In a case ivhich happened fourteen years ago, and was,
 I believe, the first of the kind subjected to operation in Edinburgh, I visited
 the patient about an  hour after cutting off the  excrescence, and to  my no
 small alarm, found the blood dropping from her bed upon the floor.   As 
UTERUS.
807
there had been frequent and profuse hemorrhage from the disease, I con-
sidered  it necessary to use the most efficient means for  preventing  any
further flow, and therefore pulled the bleeding surface into  view, transfixed
its base with a needle, conveying a double ligature, and tied both the threads
firmly.  Recovery was accomplished ivithout any untoward symptom.
  In removing polypus of the uterus, evulsion, excision and ligature have
been employed, and each of-these modes of operation may be rendered the
most  eligible  by  peculiar  circumstances  of particular  cases.   But, in
general, the combination of tying and cutting certainly seems to be  the
best plan of proceeding.  It has the recommendation of facility, efficiency,
and safety.  It accurately determines the limit of destruction, prevents the
possibility of hemorrhage,  and  relieves  the patient from the  fetor,  and
other unpleasant consequences, wdiich attend the slow separation effected
by ligature.  Finally, it has the testimony  of experience in its favor.
                                                      Part  xii., p. 286.

   Uterus—Diseases of.—Dr. Kennedy, of the Dublin Lying-in  Hospital,
directs,  in first examinations, to use t.he four-bladed speculum.  If the os
is not readily caught, ascertain  carefully its  position Avith  the  finger, pass
the instrument well up, and if, on ivithdrawing the  plug, the  os  is  not
seen, withdraw' the speculum slowly, expanding it at the same time.
 ■ When making applications in the os or the vagina, use Ferguson's glass
speculum.
   Congestion.—Apply three to six leeches directly to the uterus, or scarify,
injecting Avarm Avater through the speculum  for some  time after.   Repeat
this several times,  and then make a caustic issue over the pelvis or sacrum.
Inject cold or tepid w*ater into the vagina thrice a day; also mild  astrin-
gent lotions.   Give alteratives—Pullna water, sarza, iodine, pil. plum,  and
taraxacum.  Be cautious about using tonics.  If the menses are interrupted,
use the  hip-bath, and apply a feAv leeches to the uterus, at the period.
   Chronic Catarrh.—Dilate the os  internum by  gutta percha bougies,
and  apply nitrate of stiver by a porte-caustique, or nitrate of mercury by a
camel-hair  brush Avith a graduated handle introduced through a gum tube.
After cauterizing  three  or four times, at intervals of eight or ten days,
use,  every three or four days, lotions of nitrate of silver or  copper, ten
grains to the ounce, and  afterward milder lotions  ivith lead  or zinc.
Apply leeches ; use counter-irritation by sinapisms, tartar-emetic ointment,
or an issue; and give cubebs, or mild tonics and alteratives.
  Inflammation.—Use general and local depletion, antiphlogistic regimen,
mercury and counter-irritation, the warm bath and soothing injections, and
perfect  quiet.
   Ulceration—Mild.—If it is not easily  detected, brush over with a ten
grain solution of nitrate of silver, which will mark its outline ; then  use,
for ten  days, a lotion with  plumb, acet. gr.  j. ad aq. dest. 5j-  In applying
lotions,  lay the shoulders  lower than  the hips, and  inject a continuous
stream,  for some minutes, by a "gum-elastic siphon."
   Granular.—Get rid  of  or relieve the inflammation by depletion, etc.,
then apply caustic, at intervals of seven or ten days, three or four times,
using in the interim  mild astringent or  emollient lotions, according to the
symptoms.
   Cock's Comb Ulcer.—Apply caustic  more freely, using the nitrate of
mercury, so as *o form a slough. 
808
UTERUS.
  Bleeding Ulcer.—Lay a piece of lint carefully round the margin of the
ulcers, then apply caustic freely; apply it also to the interior of the uterus,
if the lining membrane is diseased, taking care to have the caustic melted
into a porte-caustique, to prevent its  breaking ; afterward wash out the
vagina with a stream of water.  Continue the application at intervals, till
the muco-purulent discharge ceases, and the mucous membrane ceases  to
bleed on being touched.
  If aphtha appear when an ulcer is nearly healed, apply a stream of borax
or weak nitrate of silver lotion.                         Part xv., p. 283.
   Ulceration  of the Cervix  Uteri in Virgins.—Dr.  Henry Bennet has
found that inflammatory affections of the os and cervix  uteri do  occur in
the virgin, and that, too, not  very unfrequently; being a cause of those
cases of severe dysmenorrhasa, and leucorrhasa, which so invcterately resist
treatment.
  [Dr. Bennet remarks that from what we know of the diseases of mucous
membranes generally, we cannot suppose that a  mere increase of secretion
from  the mucous  membranes of the  female genitals, should produce that
excessive debility  and anasmia which we frequently see accompanying it;
but ive can readily understand that the assimilating processes should be
affected by ulcerative inflammation in  an organ wdth such extensive  sym-
pathetic affections as the  uterus.  Very marked general debility (in the
absence of any decided cachexia) should  lead us to suspect lesion of the
cervix or os uteri—in this  case,  palliatives, as rest, injections, etc., may
be tried ; but if they fail, or the  case do  not admit of  delay, we must  at
once resort to a digital examination.  Dr. Bennet observes, that,]
  A satisfactorily  digital examination of  the uterus may be nearly ahvays
made in a virgin, Avithout injury to the hymen, especially when the vagina
and external genital organs have been  relaxed by long continued conges-
tion and inflammation.  The hymen is nearly ahvays sufficiently dilatable
to admit the index, introduced slowly and Avith proper care.   Generally
speaking, the os and cervix are reached with  ease, the cervix not being
retroverted, as it  is when  inflamed  in most married  females; and Avhen
once the finger has reached the os nearly all doubts may be solved.  If the
cervix is free from disease, it is soft, and  the os is closed;  if it is inflamed
and ulcerated, the cervix is enlarged, swollen, and the  os  is more or less
open and fungous.  This open and soft  state of the os may also exist from
mere inflammation of the cavity of the  cervix.
  If possible, we must introduce the speculum ivithout dividing the hymen.
The existence of the disease once ascertained, it  is to be treated secundum
artem.                                               Part xvi, p. 278.
  Varicose Ulcer of tfie Os and  Cervix  Uteri.—Dr. Whitehead, of Man-
chester and Salford Lying-in Hospital, treats such cases as follows :  Bleed
from  the arm, and cup, or apply leeches; confine the patient strictly to
the recumbent posture, and give three  to five grains of calomel,  with
hyoscyamus or opium, followed by a saline  aperient.   Apply to the ulcer
at first a strong solution of nitrate of silver, and afterward the solid caustic,
and if there is  much discharge of blood, apply strong solution of sulphate
of zinc with vin. opii and tincture of matico.  (Or gallic or tannic acid, in
the form of solution or ointment.)                      Part xvii., p. 259.
  Preternatural Elongation of the Cervix  Uteri.—Dr. Coley, of Pindico
Dispensary, says that at first, when consisting chiefly in passive congestion, 
UTERUS.
809
it may be relieved by rest in the horizontal position, and the introduction of
a soft sponge to support the parts, and the internal use  of iodide of iron,
or of mercury.  But if permanent hypertrophy remains, excise  the part;
the operation is perfectly safe and easy, in the absence of specific disease.
                                                     Part xvii., p. 260.
  Retroflexion of the  Uterus.—In recent  cases, replace the organ by the
uterine sound, and let  the woman  lie for a length of time on the side or
face: at the same time prevent accumulation in the rectum or bladder, and
restore the tone of the  parts by astringent injections.  In more chronic
cases, besides  the above means, such treatment  must be adopted as will
relieve other co-existing disease, as congestion or chronic inflammation  of
the uterus or  ovaries;  and  after the uterus has been restored to its posi-
tion, it must be  retained  there by wearing one  of Dr. Simpson's  Avire
pessaries.— (Drs. Simpson,  Beat tie and Hensley.)
  Dr. Braithwaite considers  the best plan of proceeding, in the introduc-
tion of the sound or uterine pessary for retroflexion, is to place the female
on  her knees and  elbows, with her face on a pillow*.  Then placing the
forefinger of the left hand upon the os uteri, the point of the sound is very
easily passed into the cervix, and by gently depressing the handle, as with
the male  catheter, the sound passes to the fundus uteri.    Part xvii., p. 265.
  Treatment of Ulceration of the Osand Cervix  Uteri with Collodion.—
Dr. Mitchell adopts the following method :  The patient being placed up-
on her left side, and the  speculum introduced, the ulcerated surface is to
be wiped dry with a succession of pieces of soft lint until the  adherent mu-
cus is -removed; a camel's-hair pencil dipped in the solution is then to  be
rapidly applied to the ulcerated surface, and  allowed to dry, which will
occupy a couple of minutes—a second, third, and fourth  coating, if neces-
sary, can thus be applied ;  the first coating is followed by a slight burning
sensation caused  by the ether, followed by a sensation  of coldness from
its evaporation.  The application  requires  to  be renewed  at  the end of
forty-eight hours, as the secretion collects  underneath the varnish, and de-
taches  it.  In cases of simple abrasion, three  dressings  have proved suc-
cessful : in more obstinate  cases, and where large granulations have  been
present, I have used nitrate of silver, acid nitrate of mercury, and potassa
fusa first, and then applied  a varnish of the gun  cotton over  the eschar,
and have succeeded in curing extensive ulcers of the cock's-comb variety in
half the time I have been able to  succeed without the solution.
  In cases of vaginitis without ulceration, I have found the painting of the
walls of the vagina with the solution most beneficial.  The difficulty, how-
ever, is to dry it well, ivhich requires time  and trouble,  but  in my mind,
the result amply repays both, the friction of the surfaces is prevented, and
the amount of suffering, pain and  inflammation consequently much dimi-
nished.                                              Part xviii., p. 270.
  Uterus—Hypertrophy and Induration of the.—Dr. Oldham advises  to
reduce the size of the uterus  by the application  of four  or six leeches  to
the  upper and back part of the vagina once or twice a week.  Blister the
sacrum or inguinal region, when  these parts are the seat  of continuous
pain ; or rub them well with a liniment composed of tinct. aconit. (Flem-
ing) 3iv.;  ext.  belladon.  5ss.; tin. sapon. co. |iss.; M. Internally give
the  solution of bichloride of mercury, in doses of one or two drachms twice
in the day, combined with  vegetable tonics, or chalybeates,  and occasion- 
810
UTERUS.
ally, if the boivels are torpid, with a little tinct.  rhei.  Let the colon and
the rectum be cleared out  daily by a tepid or cold  milk-and-water  injec-
tion ; long continued exercise or standing to be  avoided ;  and sexual inter-
course abandoned or nearly so.  The application  of potassa  fusa, and
other escharotics, to the uterus, is much to be deprecated unless  there  be
fungoid granulations about the os and cervix.  But with a view of strength-
ening the structures beloiv the  uterus, cold hip  baths  may be  used, and
astringent injections efficiently given, such as  decoction  of oak  bark  or
tormentilla, solution of sulphate of zinc, etc., or vaginal suppositories, made
often or twelve grains of tannin mixed up wdth honey.  A mechanical sup-
port should be afforded  by means of a perineal pad, attached to a firm,
elastic, abdominal belt.                                Part xviii., p. 293.
   Uterine Catarrh.—Prof. Strohl, of Strasbourg, recommends the use of
injections of liq. plumbi acetatis, or of a solution of 3j. of iodide of iron in
§xij. of distilled  water.  Inject the fluid very slowly, through a caoutchouc
tube introduced about three lines into the os uteri, and of such  diameter
as not completely to fill the orifice of the uterus.        Part xix., p. 270.
   Ulceration of Os Uteri.—The best way to apply Vienna paste to the os
uteri, for the purpose of changing the morbid action wdiich  gives rise to
congestion of that part, says  Dr. Mitchell, is  to  use a glass rod, expanded
at the end into a circular  disc.   The paste is  spread  upon  this  disc, and
the rod introduced through the  speculum, and pressed against the part we
wish to act upon.                                    Part x\x.,p>. 270.
   Inversio Uteri.—When the organ is not affected with malignant disease,
and no other special contra-indication  exists, and the patient's  health is
suffering, Dr. Higgins believes that  extirpation  of the womb is a proper
proceeding.  In performing the operation, tie a flat tape, half-an-inch wide,
round the inverted vagina, as high up as possible.   This, when tightened,
acts as a tourniquet, ivithout injuriously pressing  on the  parts—it allows
sutures to be easily inserted—and, if retained on for some time  after the
operation, it keeps the parts closely in  apposition, and prevents  dragging
upon the sutures.                                      Part xx., p. 223.
   Climacteric Disease  in Women.—Dr. W. Tyler Smith directs  to remove
any obvious  cause of uterine  irritation,  by appropriate  treatment.  Use
moderate depletion from  the  uterus, by  incisions  made into the os, or,
still better, by  the application of three or four leeches  to  the  os.  And
use cold hip-baths, or cold injections into the vagina or rectum.   If there
are any dysmenorrhea]  symptoms, use injections with decoction of poppies
and laudanum, into the rectum  and  vagina ; if  there  is menorrhagia,  let
alum baths (§xvj. of alum to each gallon of water, at temp. 98°) be used
in the intervals betiveen the periods.  Keep the boivels  lax, but avoid
drastics, and especially  aloes ; and promote the alvine, renal, hepatic, and
cutaneous secretions.  Let the diet be light and nutritious, with  very little
wine and no malt liquor or spirits.  Let the clothing be ivarm, and in win-
ter let flannel jackets and drawers be worn.  And for the severe symptoms
of nervous irritation, give moderate  doses of sulphuric ether  and valerian.
Sulphuric ether is at this  period a more decided sedative  upon the female
constitution, than either morphia, opium, or hyo&cyamus.  Part xx., p. 232.
   Cauliflower Excrescence of the Os Uteri.—According to Dr. Watson of
 Glasgow, as this disease is, in all probability, not of ?. malignant; nature we
 may hope by its removal  to effect a peimo;ieat cure.  It h, necessary, how- 
UTERUS.
811
ever, that the removal should he complete ; and the  safest and most effi-
cacious mode of accomplishing this end is by free excision of the affected
lip, or, if necessary, cf the entire neck of the uterus.      Partxx.,p. 242.
  Rupture of the Uterus.—Dr. J. C. W. Lever recommends full doses oi
opium at intervals during several days.  A case so treated has  recovered,
though the rupture was so extensive that the hand could be passed  into
the cavity of the abdomen.                             Part xxi, p. 305.
  Erectile Engorgement of'the Cervix Uteri.—Dr. Tilt gives the  follow-
in"- case:  A few months since I was consulted by a lady, aged twenty-
five, who had menstruated  for the first time at  the age of fourteen yeais,
and who did so regularly till she married, three years ago.  . Since then she
had suffered from dysmenorrhcea, and latterly from backache and leucor-
rhoea.  After adopting  the usually employed method  of treatment by
injections and tonics for three w*eeks, I made an  examination,  and found
the vagina hotter and more irritable than usual; and on applying the specu-
lum, its field was filled by a lvell circumscribed substance of a  bright red
color, and yielding to pressure.  On enlarging the aperture of  the  specu-
lum (Coxeter's), it was easy to see that the whole mass  was  formed  by a
swollen lip of the os uteri, ivhich  on being carefully dilated, did not pre-
sent any erosion or ulceration, either on its external portion or in its cavity.
The internal mucous membrane was redder than usual, and there  Was an
increased floiv of the normal glutinous secretion.   I  scarified the  swollen
surface, and ordered tepid injections, mild purgatives, and repose.   A few-
days after the tumor was smaller, more livid, less painful, less tense on
pressure, and I wdiitened it by rapidly passing the nitrate of silver over its
surface.  I ordered injections with cold solution of alum.  I repeated the ap-
plication of the nitrate of silver every five days for  a month ; and finding
that the swelling did but  slowly decrease, I applied iodide of iron to it
 every four  days with a large camel-hair pencil, and in three  iveeks the
 swelling disappeared.  The patient was  under treatment for three months ;
 and never during repeated speculum examinations could I find any other
 lesion of the neck of the womb, except an increased intensity of color.
   Sometimes both lips are  swollen, but  generally only one is so.  Out of
 twenty well-marked cases  of this  description  which I have observed, in
 two the swelling was general; in eight the posterior lip was swollen ; and
 in ten the interior.  Most  of my twenty patients were of a lymphatico-
 sanguine temperament; they were  all married, and  in  five  the complaint
 came on within the six months which  folloived marriage.  In almost  all
 the cases intercourse ivas painful.
   I never employ potassa fusa in this form of uterine disease; I principally
 make use of nitrate of silver, and I have with advantage alternated its use
 with that of the solid sulphate of copper, or a strong solution  of diacetate
 of lead, or of the iodide of iron.                        Part xxii.,_p. 278.
    Uterine Neuralgia.—M. Valleix has pointed out a class of cases in  which
 the cervix uteri, usually insensible,  becomes the  seat  of the  most  acute
 suffering of a neuralgic nature, and has pointed out  the diagnostic distinc-
 tions betiveen these and cases of painful inflammatory congestion of that
 organ.
   In all the cases which have come under M. Valleix's notice,  the affection
 has been accompanied by  pain following the course of the lumbo-abdonn-
 nal nerves.  He therefore regards the neuralgia of the cervix as part of 
812
UTERUS.
the more extensive lumbo-abdominal neuralgia.  This feature is of impor-
tance in reference to the diagnosis of neuralgic from other pains of the
cervix uteri.
  The subjects of this neuralgic affection  present all the characters of
sufferers from chronic uterine congestion, Aiith ivhich disease the former is
almost always confounded.  The pain is much augmented at the menstrual
period producing dysmenorrhcea.  The vaginal discharge which occurs in
these cases is analogous to the increased secretion from the mucous mem-
brane of the eyelids in certain affections of the trifacial  nerve.  They are
both functional disturbances originating in disordered nervous influence.
  Careful exploration is of the first importance to its detection.   The neck
of the uterus will be  found tender to the touch, often so to a great degree,
the tenderness being most acute at the sides of the  cervix, Avhile the ante-
rior and posterior surfaces are free.  The cervix is of its ordinary form
and size.
  On examining the  abdomen and loins, a neuralgic pain will be  detected
in the hypogastrium  a little  beyond the middle line on one side, most fre-
quently the left only.   Along the course of the first pair of lumbar nerves
will be discovered other points, more or less acutely painful, and more or
less isolated.   The painful point ahvays corresponds with the seat of pain
in the uterus.
  The chief diagnostic features are, the degree and  isolation of the tender-
ness, the intermittent character of the pain, and the oo  irrence of the neu-
ralgia of the abdomen and loins.
  Apply blisters to  the hypogastric  region,  cauterization of the cervix,
narcotic injections, with absolute rest and general treatment.
                                                     Part xxii., p. 307.

  Purulent Discharges from the Uterus.—Dr. Lloyd uses an injection of
a solution of chloride of zinc, gr. j. to the §j. every eight hours.
                                                    Part xxiii., p. 210.

  Diversion  of the  Uterus.—Drs. Denman, Burns, and Merriman  advise
the uterus with the attached placenta to be returned ; but the latter men-
tions an instance in which he first detached the placenta, and the patient
did well.                                             Part xxiv., p. 278.

  Carcinoma Uteri.—To relieve the excruciating  pain, apply the  vapor
of chloroform  to  the os uteri  by means  of Dr.  Hardy's "anaesthetic
douche."
  The apparatus for  applying  it consists of a  small metallic chamber; to
one end of this a gum-elastic bottle is attached, to  the other, a pipe fur-
nished with a valve.   On  the end of the chamber  there is also  a  second
valve to admit atmospheric air  for the working  of the instrument.  In
order to charge it  with chloroform it  is necessary to unscrew the stopper
in the side of the chamber, within wdiich a piece of sponge is placed for
holding the fluid.
  The quantity poured in  should  not be more  than  the sponge will absorb,
otherwise, instead of vapor, fluid chloroform  will  be thrown against the
affected part.   When charged, the vapor  may be conveyed to the part re-
quiring its application by any convenient pipe, if closely fitted to the one
on  the  instrument, pressure being made  on  the elastic  bag  to produce
expulsion of the vapor.                               Part xxix., p. 279. 
UTERUS.
813
   Uterine Catarrh and Internal Metritis.—It may be stated with a great
 degree of confidence, that the general opinion of medical men with regard
 to the seat of leucorrhoeal  discharges, is, that they depend  upon organic
 lesions of the  os uteri and  its vicinity.  In  these cases the treatment is
 effective and satisfactory.   But in some cases the lesions may be in  the
 mucous membrane lining the womb, and it is in these cases especially that
 there is the greatest uncertainty, both as regards the  diagnosis and treat-
 ment.
   A sound symptom to judge by in this  disease, is,  that lateral pressure
 all down to the neck of the womb gives considerable pain.  Dr. E. J. Tilt
 recommends the application of the tincture of iodine to the inside and out-
 side of the neck of the womb in such case.   The second application  may
 take place ten days  after  the first, and then repeat  it  every four or five
 days, if necessary, for three months.  The uterine mucus should be  first
 cleared away.  The best injection in such case is 3j. of the acetate of lead
 and one pint of decoction of poppy heads.   As a remedy, five to ten grains
 of ergot of rye, given three or four times, proved as useful as any.
                                                    Part  xxix., p.  285.
   Intra- Uterine Speculum.—For the  exploration of  the cervix uteri and
 using various applications, an ingenious  speculum is used by M. Jobert; a
 very small instrument with a long handks—sufficiently small  to be  passed
 up the common vaginal speculum.                     Part xxx., p.  203.
   Uterine Affections.— Vide Selections from Favorite Prescriptions, Art.
 " Medicine."
   Inflammation of the  Os  and  Cervix  Uteri.—[Besides  arising from
 general unhealthy conditions of the system, it may be induced by causes of a
 mere  local nature, as exposure, violent  horse exercise, improper irritation
 of the part, but especially by the too frequent  application of caustic to the
 os uteri, with such short intervals that the eschar produced by one applica-
 tion could not have healed before the next was made, and this  continued for
 such a length of time as to produce the most serious mischief, both local
 and constitutional.  Dr. Rigby says:]
  This form of inflammation  of the os and cervix presents features which
 distinguish it from the ordinary species I have been describing.  It would,
 perhaps, be correct to call  it a highly irritable  condition of the uterus
 (wdiich not only involves the ovaries, but frequently implicates the spinal
 cord to a serious extent), were it not for the actual alteration of structure
 and permanent injury of the part which has  suffered more  immediately
 from the  treatment.
  The patient complains of constant pain in the uterine region, but generally
 more behind the  symphysis  pubis than is  usually the  case in  ordinary
 inflammation  of the cervix, extending from hip to hip, and in aggravated
 cases darting up the  spine  with neuralgic  severity.   It is  increased by
 standing  or by any exercise whatever.   Sitting down upon a  hard seat, or
 the passage down the rectum of solid fieces, produces great suffering, inas-
 much as when once the pain is brought on, it will continue severely for
 some time after.  The moment she assumes the  erect posture  she has a
 sensation  of  weight, bearing down, and burning heat in the  pelvis, ivhich
 are quickly followed by the pain itself.
  The catamenial  periods usually follow  each other too  quickly;   are
almost always very profuse,  and  invariably attended with great suffering. 
S14
UTERUS.
If the ovaries are involved, the symptoms of ovarian dysmenorrhea will
also  be present.   She has  a  constant  ichorous watery discharge, ivhich
is sometimes very profuse.   The bowels are unhealthy ; the urine thick;
the  tongue pale, dry,-and  rough, with red papillae; the face  sallow and
wan; the spirits  depressed ; ttie  pulse  feeble and very irritable;  and she
has lost strength  and flesh.
  On  examination, per vaginam, this  canal  is found  soaked in the  thin,
watery discharge already mentioned.  On gently touching the os  and cer-
vix uteri with the finger, the patient feels as if the parts ivere raw*,  from
the aggravated sensibility which noAV exists in them ; firmer  pressure with
the finger brings  on the neuralgic pain already described.   The  os  uteri
is usually sivollen, uneven,  and knobby—it is frequently  dragged forward,
or to one side, without any corresponding displacement of the organ itself.
Whether this  alteration  of  shape is oiving to cicatrization  in the part
itself and surrounding vagina ; or whether it depends on different  portions
being affected with different degrees of induration, it is  not  easy to deter-
mine ; at any rate, the cervix  usually has a strong degree of hardness, and
the uterus  above  it feels large, hard, and very tender to  the touch.
  Seen through the speculum, the os uteri does not  present  the dark red
tinge, more or less mottled ivith patches of a brighter color,  as in  cases of
ordinary inflammation, but has a pale ashy hue, much injected wdth vessels,
just as is occasionally seen in the irritable throat and tonsils of an unhealthy
person wdio has been suffering from repeated attacks of quinsy.
  The discharge  is evidently uterine, and is constantly oozing from the os
uteri in considerable quantities.  If the  uterine  sound be passed, it gene-
rally penetrates half an inch, or even a ivhole inch, beyond the usual dis-
tance, showing that  the uterine  cavity is  enlarged; and intense pain  is
produced the  instant it touches the internal surface of the uterus, indicat-
ing  great irritability of that organ, and probably inflammation of its lining
membrane.
  The treatment of this affection will necessarily differ a good deal from
the ordinary forms of inflammation of the os and cervix ; the indications, it
is true, will to a  certain  extent be the  same, but the local as  ivell as the
general  condition of the patient is very different.   The inflammation of
the os and cervix in these cases is seldom of such a  nature  as to require
the  application of leeches  to  the part itself, and the extreme  irritation
which they not unfrequently produce contra-indicates any local applications
but  those of a soothing character; wtiiile the enfeebled state of the  patient's
health renders any depletion very questionable.
  The general treatment  is by no  means so simple  or so  easy  as in the
other case.  The  health has been so much deranged by the long-continued
effects of  severe  uterine irritation, and the strength so broken down by
frequent attacks  of menorrhagia, and profuse leucorrhoea during the in-
tervals, that it is difficult  to adopt any distinct line of treatment at first
starting, beyond  the attempt to regulate the liver and bowels,  by the mild-
est remedies, and soothe the irritable system by gentle sedatives.
  A course of taraxacum,  with decoct, sarsas comp. and liq.  calcis, is valu-
able in the early  stages of treatment, as it obviates the necessity of mercu-
rial  alteratives, ivhich are usually contra-indicated by the mucous irritation
of the intestinal canal.  It  is of great importance to allay this  condition as
quickly as possible, not only because ive thereby remove a fruitful source
of uterine irritation, but because  it also enables us to employ  remedies 
UTERUS.
815
which ive could not otherwise do.   When this has been arrested, ive  may
generally pass at once to the use of mineral acids and tonics, and, if neces-
sary, these will pave the ivay to a course of cod-liver oil.   If the season of
the year permit, a residence  for some months at the sea-side will be most
desirable.  The patient should use sea-water in her morning ablutions, and
if her health be sufficiently improved, and the weather ivarm enough, she
may bathe in the sea ivith advantage.
  The local  treatment, as I have  before stated, must be  essentially of  a
soothing character.   Liq. plumbi diacet. in decoct, papaveris forms one of
the best injections where there is any amount  of heat, swelling, or dis-
charge ; in other cases, the plain poppy decoction appears to be the  only
local application which will give relief.  As it  is desirable she should retain
injections of this sort for fifteen or twenty minutes, she ought to lie upon
her back, wdth her heels draivn up to the nates,  and thus give  the vagina
such a direction that the injection ivill remain in it as long as she preserves
this position.  The suppositories of diacetate of lead and extract of conium
are also very valuable in these cases, and by being in a more concentrated
form, and capable of being retained much longer, produce  a much greater
effect.  The warm hip-bath is, very useful, and with some patients  appears
to be the only thing ivbich gives relief.   If, hoivever,the weather be mild,
the sooner she can gradually come to the use  of cold ivater  the better; and
she may always be looked upon as having made  good progress, when, dur-
ing her residence at the sea-side, she is able to bear cold sponging w ith sea-
water, and bathing in the  open sea.  For those who are  able to  enjoy
these advantages, the salt tow*el which I have before recommended Avill be  _
an excellent adjunct to the cold sponging.  But  it will be needless to enter
into  further details ; they will vary more or less  with every patient, or
with the same patient  at  different times, and will be naturally suggested
by the peculiar features, etc., of each case.   The indications of treatment
are to allay irritation and restore tone, but the treatment itself must neces-
sarily be modified by the circumstances of each particular case.
                                                   Part xxxiii., p. 248,
   Uterine Neuralgia.—This  is often conjoined wdth uterine deviations,
says Dr. Tilt, and may be alleviated or removed  by sedative injections into
the  bowels—say from fifteen to thirty minims of Battley's solution, with
a drachm of tincture of henbane in a teacupful of warm milk.   No remedy
is so valuable in neuralgia as beat (cauterization with a red-hot iron), but
as this  is so very objectionable, apply to the  most  painful  part a  hammer
previously plunged in boiling water.                 Part xxxiv., p. 239.
   Carbonic  Acid  as a  Local Anaesthetic in Uterine  Disease.—Prof.
Simpson has used carbonic acid gas applied as a local anassthetic very suc-
cessfully in neuralgia of the uterus and vagina, and in various morbid states
of  the pelvic organs, accompanied with pain and spasm.   It may be very
conveniently generated in a common wine bottle,  by mixing six drachms
of crystallized tartaric acid wdth a solution of eight drachms of bicarbonate
of soda, in six or seven ounces of ivater.  A long flexible caoutchouc tube
tightly fixed to the cork, conducts the gas from the bottle into the vagina
                                                    Part xxxiv., p. 251
   Uterus— Cancer of.—Dr. West remarked at St. Bartholomew's that hem.
orrhage is an almost constant  symptom of commencing  cancer of the  os
uteri, quite as valuable as hemoptysis is in respect to tubercle in ttie lungs. 
816
UTERUS.
It is peculiarly valuable when the subject of the affection  has previously
ceased to menstruate.                               Part xxxv., p. 254.
   Uterus  and Bladdei—Reciprocal  Sympathies  between.—Dr.  Mont-
gomery communicates as follows : in the human female, there is an intimate
reciprocal sympathy between the uterus and  bladder, and other parts of
the urinary apparatus; so that, under a variety of circumstances, when the
former organ is the seat of any anomalous  action, or brought into a state
of exalted sensibility, whether from natural or morbid causes, the latter
is not only liable, but very apt to sympathize, and suffer correspondingly.
  This is constantly exemplified in the increased urinary irritation so often
accompanjting  ordinary healthy menstruation,  and still more remarkably,
when the latter function  happens  to  be painfully performed.  Again, in
early pregnancy, the same thing is observed; and the remark is trite, that
morbid actions in the uterus, whether benign or otherwise, often have the
earliest announcement of their invasion in symptoms of disturbance first
noticed in the functions of the bladder.
  Thus, congestion or slight ulceration of the cervix uteri, and still more
strikingly, malignant affections of that part, frequently excite, in the first
instance, in the patient's mind, only apprehensions of gravel, or some vesi-
cal disease, for ivhich alone she is induced to seek advice; but woe  betide
us, in this and many other  circumstances, if we let ourselves be beguiled
into the belief that  because a particular organ or locality  is affected  with
certain anomalous symptoms, it is therefore the seat of some disease, of
which these symptoms are to be taken as  indications; and  so  prescribe.
Could ive, for instance, expect to cure the itching of the nose and angle of
the eye ivhich accompanies the presence of intestinal worms, by applications
to the Schneiderian,  or conjunctival membrane ?
   Mrs. C. had, for a long time, intense, intolerable, distracting itching of
the  perineum and anus, ivhich really rendered  her life miserable, and for
which she had consulted many, and used a multiplicity of remedies:  many
of them, no doubt, very appropriate for pruritus, but not for her.  When
she came under my  care, I also, at first adopted the ivrong course; I pre-
scribed for the symptom, and not for its cause.   But fortunately, after see-
ing her a few times, something led me to suspect the existence of intestinal
worms.  I gave her  a dose of the Kousso, which caused the expulsion of
some very large lumbrici, and all her troubles  were forthwith at an end.
  Mrs.  M. consulted me for pruritus  of the  pudendum, from ivhich  she
suffered to such a degree, and  it was  accompanied with other symptoms
of so distressing a kind, that she declared she loathed herself, and felt her
tife an intolerable burden  to her.   She had used gallons of lotions, and all
ports of ointments, without  the slightest relief.  Examination showed an
intense  congestion of the cervix uteri; this  was made the  object of treat-
ment, and on  its removal, the pruritus and all  its miserable  concomitants
totally ceased.
  I have already called the consent betiveen the uterus and  bladder  a re-
ciprocal sympathy, because  it equally acts in the reverse direction, irrita-
tions of the bladder  being frequently found to influence and disturb the
functions of the uterus—a fact ivhich  should not be forgotten in practice,
and especially in the  treatment of the disease of pregnancy, when the ad-
ministration of the more  irritating diuretics should  be avoided, lest  they
should excite contraction of the fibres of the uterus, and so induce prema-
ture expulsion of its  contents. 
UYULA—VACCINATION.                     817
  And again, ive must remember that vesical  disturbances may produce a
group of symptoms so closely resembling those arising from disease of the
uterus, as to be mistaken for them.
  Several years ago, the wife of a general officer, at that time holding the
highest military command in this  country, began to complain of distress-
ing symptoms, having -all the characters of those produced by uterine dis-
ease.  Such was her own conviction, and on her consulting an accoucheur,
he pronounced the affection to be cancer uteri, and could only promise pallia-
tion.  But she had many friends,  and some of them urged upon her the
necessity of having another opinion; to this she at last consented, and the
gentleman called in pronounced the case to be one of stone in the bladder;
the stone was extracted, and the lady passed at once from a  state of pain
and misery to one of comfort and happiness.
  A few years since, a patient came to consult me, stating that, to gratify
her friends, she had come to town  for my advice, although quite aware she
could  not be cured.  She also handed me a written statement of her  case,
which set forth that she  had had seven labors of terrible severity, owdng
to contracted pelvis, always requiring instrumental delivery; that for some
months she had exhibited unequivocal symptoms of the existence of cancer
uteri; and I  confess, that from this account, and the woman's  own des-
cription  of her symptoms, I thought there was little room to doubt as to
the nature of her malady.
   Hoivever. I instituted a careful  examination ; on doing so, I could dis-
cover no disease of the uterus, but the neck of the bladder wras distended
and felt  very hard.  I passed a sound into it, which at once struck against
a stone of considerable size.  Mr.  Fleming now saw the case  with me, the
stone  was removed, and the woman  soou  returned  home well, and con-
tinued so.                                         Part xxxvii., p. 229.
   Uterine Excitement.—Bromide of potassium has a decidedly sedative
effect upon the generative  system.   Dr. Simpson  recommends its use in
spurious pregnancy.   Some  time  since, Dr. Locock advocated its use in
cases  of epilepsy in females apparently having a monthly return.
                                                     Part x\.,p. 181.
                           UVULA.
Vide Arts. "Palate"—"Throat"—" Chronic Phthisis."
                        VACCINATION.
  Vaccine Crusts, the most Effectual Packages for Vaccine Virus.—[The
following is from Dr. Epps' Medical Director of the Royal Jennerian and
London Vaccine Institution, who states:]
  The indurated pock, the scab or crust of the vaccine pock, contains the
dried matter in its cells, wdiich, being broken down, and moistened with
the wetted point of the lancet, has been found effective in hot climates,
when attempts  to preserve the vaccine ichor in other forms have failed.
The crusts or scabs we have  been able to collect in this country, we leam
by letters from the East and West Indies, have withstoood the  heat of
    VOL. ii.—52 
  818                        VACCEffATTON.

  their vertical sun, and spread protection through the plantations and the
  surrounding districts.
    N.B.—These crusts, when  levigated and moistened, and ivorked into a
  fine pulp, have  been used by many practitioners in  tropical climates with
  the most signal success.                                 Part iii., p. 54.

    Dr.  Gregory's Lecture on.—The surgery of vaccination, simple as it may
  appear, has  been  a fruitful theme of controversy.   Differences  of  opinion
  have existed witti  respect to the selection of lymph, the mode  of making
  the incisions, and the number of incisions necessary to insure a full effect.
  Each of these points merits attention.
    Dr.  Gregory observes, that one  of the earliest and most important dis-
  putes ivhich chequered the career of vaccination (inasmuch as it led to the
  secession of Jenner, in 1807,  from  the original  Jennerian Institution) had
  reference to the mode of taking the lymph.  Dr. Walker adopted the plan
„ of  detaching the  epidermis  from  the vesicle, and vaccination with the
  lymph (or fluid) which exuded from the abraded floor of the vesicle. Jen-
  ner objected strongly to this, and employed only the superficial  lymph.
  Dr. Walker persevered in his plan; and it is but fair to confess that his
  vaccinations have stood the test of time fully as Avell as those  conducted
  according to the Jennerian method.
    The proper  time at which lymph may be taken so as to obtain it in the
  most efficient state for propagating the disease, has also been a subject of
  discussion.  Some have  objected to the employment of very early lymph,
  others have scruples in taking lymph after the first appearance of areola,
  and all parties  have concurred in  condemning  the  use of lymph taken on,
  or  after the tenth day.   The facts bearing  on this question are  as  folloAvs:
  The younger the  lymph is, the greater  is its intensity.  The  lymph of a
  fifth-day vesicle,  when it can  be  obtained, never fails.  It is, however,
  equally powerful up to the eighth  day, at which time also it is  most  abun-
  dant.   After the  formation of areola, the  true specific matter of  cowpox
  becomes mixed with variable proportions of serum, the result  of common
  inflammation, and diluted lymph is always less efficacious than  the concen-
  trated virus.  After the tenth  day the lymph  becomes  mucilaginous, and
  scarcely fluid, in which state it is not at all to be depended on. Out of a
  dozen incisions made ivith such viscid lymph, not more than one ivill prove
  effective.  The scabs of cowpox,  ground to poivder, and  moistened with
  lukcivarm water to the consistence of mucilage, ivill sometimes reproduce
  the disease  in all its purity—a satisfactory proof that the alteration ivhich
  the lymph undergoes in its progress  to  maturity is not of a specific kind,
  liable  to influence the result of  the  subsequent vaccination,  but simply
  dilution.
     Cowpox  matter differs in intensity according to the source from which
  it has  been  obtained.  Very pure lymph,  of great intensity, wdll  often prove
  efficacious when taken from the arm on the ninth and even on the tenth days.
  Experience teaches  that all vesicles are not equally fitted  to produce  the
  disease in purity ; but it requires a practised eye to detect  these minutias.
  Irritable  sores are  often produced by  draining  the  vesicle  too much.
  Infantile lymph is more to  be  depended  upon than the lymph obtained
  from adults. The matter of primary vaccinations is  more  energetic than
  that of secondary vaccinations.  These statements may serve as a  guide in
   the selection of lymph wherewith  to vaccinate.  The number  of incisions 
VACC [NATION.                         Si 9
which it is requisite to make in order to produce a full constitutional effect,
has been always a disputed point.   At an early period  of vaccination one
vesicle was held to be  sufficient.   Then three, four, or six, were recom-
mended.  In Germany, great importance is attached to the  raising of
numerous vesicles, it being a received doctrine in that country that, unless
some decided constitutional effect be produced, little reliance can be placed
on the process as a security in after-life.  Common sense dictates  that the
greater the number of vesicles, the greater will be the  local inflammation,
and, on this theory, the greater the probability of constitutional  sympathy.
Some of the German  inoculators have been  in the habit  of  raising from
twenty to thirty vesicles in each subject.   In forming a just judgment on
this matter, the nature and  quality of the lymph  must always be taken
into account.  Lymph recently derived from the cow  possesses so much
intensity, and fixes itself with so  much more of a poisonous character upon
the skin of the arm than lymph long humanized or habituated to the human
constitution, that a single incision  made with it is  equivalent  to six or
eight made with lymph of minor energy.
  Dr. Gregory recommends, that ivith lymph of ordinary intensity five
vesicles should be raised, and. that these should be at such distances from
each other as not  to  become confluent in their  advance to maturation.
Vaccine lymph should ahvays be used in a fluid state, and direct from the
arm, ivherever practicable,  for  it is  a very delicate secretion, and very
slight changes in it are capable of materially altering its qualities.  Lymph
which has been retained fluid for four or five days, is very apt to occasion
that irritable vesicle described as the most frequent of all the  anomalous
appearances.
  When lymph fresh from the arm cannot be obtained, other  means must
be had recourse to.   Vaccine virus may be  preserved fluid and effective
for  two or three days in small bottles, with  projecting ground stoppers,
fitted to retain the matter.  It may be preserved for a like time in  small
capillary tubes having a central  bulb.  This is the  mode usually  adopted
in France for the  transmission  of  vaccine lymph to the  Provinces, and
ivhich proves very  effectual; but if we attempt in this manner to transmit
lymph to the East or  West Indies, we fail utterly.  Most  surgeons have
seen Avhat are called ivory points.   These, wdien ivell armed and carefully
dried, are very effective.   They will retain their activity in this climate for
many months, and  they are found to be the most certain mode of  sending
lymph to our colonies.  Some practitioners  prefer glasses to points, but
they are less  certain.  The employment of scabs for the propagation of
cowpox was first recommended  in 1802.   It  is a very excellent mode  of
transmitting vaccine matter to distant countries, but some nicety  is required
in operating with scabs, which experience alone can teach.
                                                     Part viii., p. 204.

  Value of Vaccination and Re- Vaccinedion.—[M. Serres presented to
the Academy of Sciences,  in the name  of the committee appointed to
decide on the merits of a number of treatises on this subject, a report, from
which the following is taken :]
  Vaccination preserves the human species from variola, but its preserva-
tive power is not absolute.   Variola itself, either spontaneous, or produced
by inoculation, does not preserve absolutely from fu'ure attacks, therefore
it is not extra rdinary that vaccination should not.   Thus Mead mentions 
820                         VACCINATION.
having seen three variolous eruptions take place  successively on the same
woman ;  the son of Forestus was twtice attacked with variola, and Dehaen
states that one of his patients was attacked six times by v*ariola with impu-
nity, but died of a seventh invasion of the disease.   Although, however,
vaccination is  sometimes powerless to preserve us from  variola, it always
diminishes the gravity of the malady.  This property, which Jenner and
his first  successors did not  even suspect,  is thoroughly proved  by  the
various facts ivhich have been recently accumulated.   In one of the most
terrible epidemics of variola that has taken  place in Europe since the  dis-
covery of vaccination—that of Marseilles, in 1828—more than ten thousand
persons were attacked.  Of these, two thousand only had been vaccinated,
and of that number forty-five only died, ivhereas, one thousand five hundred
of the eight thousand who had not been vaccinated, were  carried off by
the pestilence.  Vaccine matter evidently loses part of its  efficacy in passing
from arm to arm ; it is therefore desirable to renew it as  often as possible.
A remarkable fact mentioned by  one of the competitors,  supplies us with a
means of  renewing it, as  it  ivere,  at ivill.  A cow was vaccinated with
matter taken from a child.   Not only did the pustules rise, but they ivere
communicated to other cow s, so that cow pox ivas  observed  nearly in its
natural state.  The pustules were identical in  both  cases.  The propriety
of re-vaccination is noiv fully established.  In Germany, the various govern-
ments have been  induced to pay great attention to re-vaccination, owing
to the circumstance  of epidemics of variola  having latterly manifested
themselves Avith a severity to which we bad become quite  unaccustomed,
 since the  introduction of vaccination.  Re-vaccination  has, consequently,
 been resorted to on a very extended scale,.and has had the effct of arrest-
 ing the epidemics.  Thus, in  Wurteinburg, forty-two  thousand persons
 who have been re-vaccinated, have only presented eight cases of varioloid,
 whereas, one-third Of the cases of variola have  latterly occurred on  persons
 who have been vaccinated.   It is principally betiveen the ages of fourteen
 and thirty-five that  vaccinated persons are  exposed to be  attacked by
 variola.   When  there is an  epidemic, the  danger commences earlier, and
 children of nine years of age may be seized. Prudence,  therefore, requires
 that, under ordinary  circumstances, re-vaccination should be  performed at
 the age  of fourteen or fifteen, and four years earlier if within the radius of
 an epidemic of variola.                                 Part x'i\.,p. 126.
   Instrument for Vaccinating.—[Dr. Weir introduced to the Edinburgh
 Obstetrical Society a new instrument for vaccinating.]
   It consists of a small handle of ivory, ivith four needle-points projecting
 from one extremity, and a small curved knife for collecting and separating
 the vaccine matter at the other.  The skin is  opened by a-crucial  scratch
 wdth the needle-points, which are  held vertically, and' are  lightly applied,
 so as merely to remove the  cuticle.  The advantages  of this instrument
 over the lancet are, that the operation is done more speedily, and that it
 opposes a larger surface for the  absorption of the lymph, which is less lia-
 ble to be washed away by too great an effusion  of blood.
   Soak  a piece of sugar with the lymph, pound it wdien  dry, and keep it in
 a well-closed  bottle.   Apply this poivder by sprinkling it on the exposed
 surface ivith a hair-pencil.                               Part xvi., p. 230.

    Vaccination.—Dr. W. S. Oke directs to make  at least  six  punctures, each
 produced by  carrying the point  of a lancet, held flat to  the arm, obliquely 
VAGIXA.
821
downward through the cuticle into the surface of the cute.  If possible,
use fresh lymph ;  and never take lymph from a vesicle after the eighth
day.   Let the  instrument used to apply the lymph remain  inserted a feiv
seconds, and then  be Aidped upon the orifice of  the puncture.  Lastly, if
the development of the vesicle is not satisfactory, or if there is only one
vesicle, use Bryce's test to try the efficacy of the vaccination.  It consists
in inserting fresh lymph on the evening of the fifth, or morning of the sixth
day; then, if the second vesicle progresses rapidly, and overtake the first,
it will show that the vaccination has been successful.      Part xxi, p. 36.
                           VAGINA.
  Adhesions and Strictures in the Vagina during Pregnancy and Labor.
—Adhesions and strictures of the A*aginamay, no doubt, frequently exist hi
the virgin subject, as ivell as in one who has been previously impregnated
and undergone  parturition.  When it  occurs in the latter subject, it will
generally be the result of pressure or injury during labor.  The walls of
the vagina may become  glued together either at one point or throughout
the  ivhole surface, or bridles of lymph may be found in  different parts.
The formation of  these  cicatrices somewhat  resembles  the same process
from burns.
  u The most usual complication is a falciform  band encroaching  on the
area of the vagina, or one  or more rings of cartilaginous  hardness either
traversing its  ivhole circumference, or only contracting a segment of it;
and ivith these there is too frequently found a vesical fistula."  If the con-
striction is slight, it will not be  necessary for the practitioner to interfere
much during labor.
  The relaxation of the  parts will almost invariably be sufficiently accom-
plished by the  judicious use of tartar emetic, given in nauseating doses.
In most instances, this practice will entirely supersede the use of the lancet.
Cases of the greatest rigidity,  almost resembling a " cylinder of  iron"
round the finger, have been relaxed by this medicine in less than six hours.
Sometimes, hoivever, a perfect  occlusion  exists, and in this case, we  must
have recourse to an operation, wdiich  must at all  times be dangerous on
account of the proximity of the bladder on one side, and the rectum on the
other.
  "The best instrument," says Dr. Doherty, " which we can employ, is  a
straight bistoury, covered throughout  wdth sticking plaster, except over  a
small portion of its extent.   It can be safely introduced by carrying its flat
surface along the  finger, passed  into the vagina.  In making our incisions
we should never allow them to go beyond the sixteenth of an inch in depth
at once, and ive should  frequently wtithdraw the knife and make a careful
examination of the progress we have made.  A pair of flat wooden spatu-
las, introduced one on either side, will,  by keeping the parts asunder,  facili-
tate the operation.   It will also be found a useful precaution  to pass the
finger of the left hand up the rectum, in order that wre may judge hoiv for
our incisions may be carried without endangering that intestine ; and it is
a matter  of prudence to avoid as much  as possible, cutting toward the
bladder, lest, from its close proximity and intimate connection with che
vagina, Ave open into its cavity.  Having thus, step by step, and Avith the
utmost circumspection, separ vted the adhesions as far as ive think prudent, 
822                            TAGINA.
we should w*ait until the opening has had an opportunity of dilating under
the pressure of the presenting part, w hen if the  head be still prevented
from descending, we may endeavor, in the same cautious manner, to enlarge
the canal a little more."
   [The next question is, hoiv long are we to wait  before operating, Avhen
only a severe  constriction  exists, and when the  child's  head  must of
necessity tear through the parts, if those parts are not artificially liberated.
   We must remember that in all severe constrictions of the vagina, its
parietes are not the only parts implicated.  The neighboring viscera will
frequently be too adherent,  and therefore any laceration of the vagina will
also lacerate those viscera ;  hence the necessity of timely interference with
the knife or other instrument, when we feel convinced that the head will
not pass wtithout this.  The  constriction should, therefore, be nicked in tAvo
or three places, the incisions never exceeding the sixteenth part of an inch
in depth, and being directed  laterally or backward rather than forivard,
and the finger of the left hand at  the same  time being kept in the rectum
as a guide.  Dr. Rigby recommends that this  should be done  during a
pain,  when the patient will  probably be unconscious of the  act; but the
correctness of  this practice is  certainly  questionable,  as few patients can
be sufficiently  quiet on such an occasion for the  surgeon to be particular
in the depth and extent of his incisions";  and moreover the incisions might
be very suddenly enlarged if made during a pain.   On all these  occasions
we are not warranted in resorting to an  operation, till we feel convinced
that relaxation of the parts has been carried to the utmost, and that any
further dehiy might produce laceration.]                  Part v., p. 148.
   Vagina and Urethra—Disease of.—The value of the speculum is incal-
culable in all cases where there is  reason to suspect disease of the neck of
the uterus.
   Local Treatment.—In vulvular inflammation,  Dr. Mitchell, of Dublin,
recommends the hip-bath and poppy fomentations.  For the itching, nitrate
of silver 5j-, aq. dest. §j., applied three or four times a-day ; or tincture of
matico.  Both may be applied either ivith a  camel-hair, pencil or with a
stick, to which a piece of sponge is tied.   Lotions of the soluble  salts of
lead, zinc, mercury, narcotic preparations, borax, hydrocyanic acid, bread
crumb soaked  with liquor plumbi  diacet., gelatine and bran baths.
   General Treatment.—Mild saline purgatives, rest, sea-bathing,  alterative
doses of mercury, as Plummer's pill, gr. v. nocte  maneque.  Brandishe's
alkafine solution, twenty drops in  an ounce  of any bitter infusion ; balsam
copaiba.  For  pain in the back apply cautery to the sacrum.
                                                      Part xiv., p. 306.
   Vaginitis.—Dr. Mitchell recommends to paint the walls of the vagina
with  several coats of collodion, taking care to allow the first  coat to dry
well (which requires tivo or three minutes at  least) before the second  re-
applied.                                             Part xviii., p. 210.
   Vagina—Plugging  the.—The vagina may be easily and  efficiently
plugged by means of a little  bladder  of  caoutchouc, of suitable form,
introduced  in a collapsed state, as recommended by  M. Diday, and then
inflated by means of a long tube attached to it.           Part xxi., p. 302.

   Vaginal Cystocele, or Prolapsus  of the Anterior Wall of the Vag'na
and Bladder—Operation for its cure.—[The case  was so aggravated ,h„t 
VAGINA.
823
 with the least exertion the anterior wall of the vagina became so prolapsed
 that  a tumor was  produced by it of the size of a man's  fist, producing
 several ulcerated patches from the friction of the parts.   All  means of
 relief ivhich had  been suggested, having done no good, Dr. I. B. Brown,
 of London, determined to try to effect this by means of operation.]
   The patient having been prepared for the operation, by  emptying the
 bowels, was placed under the influence of chloroform, and then put in
 position for lithotomy, each leg being held by an assistant and well bent
 back on the abdomen, a third assistant holding up the tumor with Jobert's
 bent speculum, and pressing it under the pubes in its natural position.  A
 piece of mucous  membrane, about one inch and a quarter long, and three
 quarters of an inch broad, was dissected off  longitudinally, just within the
 lips of the vagina.  The upper edge of the denuded part  being on a level
 wdth the meatus urinarius, the edges were drawn together by three inter-
 rupted sutures, this being repeated on the other side of the vagina.  The
 next stage of the operation consisted in dissecting off the mucous mem-
 brane laterally and posteriorly in the shape of a horse-shoe, the upper edge
 of the shoe commencing half an inch below the lateral points of denudation,
 taking care to remove all the  mucous membrane up  to the edge of the
 vagina, where  the  skin joins it.  Two deep  sutures of twine were then
 introduced about an inch from the margin of the  left side of the vagina,
 and brought out  at the inner edge of the denuded  surfaces of one side,
 and introduced at the inner edge of the other denuded side, and brought
 out an inch from  the margin of the right  side of the vagina, thus bringing
 the two denuded surfaces together and keeping them so, by means of
 quills, as in the operation for ruptured perineum.  The edges of this new
 perineum were then  brought  together  by  interrupted sutures, and  the
 patient placed  in bed on a lvater-cushion.   Tavo grains  of opium given
 directly, and one grain every six hours ; simple water-dressing applied to
 the  parts ; beef tea and wine  for diet.  A  bent  metallic  catheter was
 introduced in the bladder, to which was  attached an elastic bag to catch
 the urine ; by this  means the  bladder w*as constantly kept  empty.  This
 patient progressed  satisfactorily from day to day, without  a single unfa-
 vorable symptom.  It is scarcely possible to imagine a more satisfactory
 result from any operative procedure.  The benefits from this operation for
 vaginal cystocele will be equally, if not more, applicable to vaginal recto-
 cele,  as well  as to  prolapsus of the entire  vagina, and  also, with some
 slight modifications as to denudation of the mucous membrane, to  prolap-
 sus uteri.                                           Part xxviii., p. 279.

   Vaginitis.—M. Demarquay  has found  a  composition, consisting  of
 eighty parts of glycerine and twenty of tannin, of great service.   Copious
 injections of ivarm  water should be previously used, and the  part freed
 from  mucus, etc., by lint; then a plug should be introduced, saturated with
 this composition,  and alloived to remain to the next day.
                                                  Part xxxiv., p. 254.

   Vaginitis, with  Superficial Inflamma'ion  of the Cervix  Uteri.—M.
Foucher introduces every morning, with the  assistance of the speculum,
a good-sized  pledget of cotton  avooI, Avell smeared over ivith tannin oint-
ment, into  the  vagina, bringing the pledget in contact ivith  the  cervix.
By means of a thread attached to it, this  may  be  withdrawn  by  the
patient, either in the evening or next morning, and the parts baiting been 
82£                      TAGITCS rTEKINTJS.
ivell washed out with cold water or weak alum water, a fresh pledget may
be introduced.  By a little practice, patients soon learn to apply the cotton
wool for themselves.                •                  Part  xh, p. 214

                             ---»-•-•---

                    VAG-ITUS  UTERINUS.
   Case of—Its Medico-Legal beciring.—Cases of vagitus uterinus are  by
no means common, and man} alleged instances of this kind, reported in med-
ico-legal works, are unworthy of credit.  Any authentic  or well-observed
case is, therefore, acceptable.  The folloiving has been communicated  to
Dr. A. S. Taylor, by  Dr. Crothers, who says :  I  was called  upon  to
attend Mrs.  W., in labor of her sixth child ; her former labors had been
quick.  On my arrival  I found her suffering from very strong  pains ; and
on examination the membranes ivere tense, and protruding through  the
os uteri.
  The  labor  not progressing as rapidly  I expected, I ruptured  the
membranes,  found  the  face  presenting,  and   apparently  arrested
at the brim. I  endeavored to move it into a more favorable position, when
happening to introduce a finger into the child's mouth,  I ivas very much
surprised  to hear a distinct cry, which'was  repeated two or three times,
and  so loud as to  alarm the mother  and attendants.  The  former was
quite frightened, so that I had a good  deal of trouble to compose her.   I
do  not now remember if the child cried afterward, ivithout  the fingers
being introduced ; but several times it did so, and so audibly that I think
the lungs must have been pretty well filled with air.  I ivas obliged  to
complete  the delivery by the forceps.  The child is now a  fine healthy
boy.
  Remarks.—The possibility of a child in utero, having its lungs so filled
with  air,  as to be able to utter an audible  cry, has  been doubted.  The
above case, wdth a few others of a similar kind, reported in medical peri-
odicals, removes all doubt on the subject.
  In  all the authentic instances  that  have been hitherto published, the
uterine cry has been heard only where the face has presented, and the
accoucheur has by any accident introduced  bis fingers into the  mouth of
the child.   The air thus finds a passage  to the lungs.
  The only case in  legal medicine on ivhich  the  production of  a uterine
cry has any bearing, is in  the application of the lung-tests  in  cases  of
infanticide.  The air found in the lungs of a child may have been received
into them before birth.  Thus the fact  that these organs floated  on water,
either entire, or when  divided into small portions, would not furnish con-
clusive evidence, that the child had been born alive. It would merely prove
the establishment of respiration, and not the fact of birth.  The uterine
cry has less  interest, in a practical view, than vaginal  respiration  during
tne passage of the head; because in a case of unassisted labor, it  is not
easy to perceive hoiv it could possibly occur; and if an accoucheur ivere
present, then the case ivould  not be likely to come before a medical prac-
titioner as one  of infanticide.                         Part xxii.,/). 315 
VARICOCELE.
825
                          VARICOCELE.
  Radical cure  of Varicocele  by Invagination  and  Shortening of the
Scrotum.—The mode of operating here  recommended  by Dr. Lekinan, is
very similar to that ivhich has been adopted  successfully for the radical
cure of hernia.  A portion of the relaxed and elongated' scrotum is to be
pushed up on the forefinger of the left hand, and invaginated into the part
above it, till the  finger reaches the external abdominal ring.  Holding the
parts in this position, a broad curved needle, with a double thread passed
through an eye near its point, is to be carried along the left finger, through
the bottom of the inverted portion of the scrotum, and to be made to pene-
trate it and the integuments immediately over the external ring. The thread
is then to be removed from the eye, and the needle drawn back  and again
carried through the inverted portion of the scrotum and the integuments at
a distance of about half an inch from the parts previously penetrated.  The
threads passed through the two apertures being now drawn, the invag-
inated portion of scrotum may be pulled up to any desired height; in gen-
eral, it must be drawn very nearly to the external ring ; for  in the subse-
quent progress of the cure,  the relaxation of the parts is so great that the
folds and wrinkles thus produced are  almost entirely obliterated.  The
threads then having been drawn must be knotted, and  the parts thus tied
up must be left for eight or nine days, under a soothing and cooling regi-
men, by which time adhesion will have  taken place  between them at the
cut edges, and, by the excoriation ivhich the discharge produces betiveen
the oppos-'d surfaces of the inverted portion of the scrotum  and that into
which it is pushed.                                     Part iii., p. 108.

  Treatment of  Varicocele.—[This disease, ivhich consists  in a dilatation
of the veins of the chord, is treated in various ways by different surgeons,
and very much according to  the peculiar treatment of varix, which each
surgeon adopts.   Cumano employed the ligature and  extirpation at the
same time;  Mr. Warren  excised or tied the varicose  veins of the
scrotum;  M. Moulinie combined excision ivith ligature ; Delpech divided
the scrotum, exposed the  cord, and tied  or  in.ds'd the veins; in some
cases, he passed a small bit  of sponge under the dilated veins and fixed it
with strips of sticking plaster—it is said he cured six out of seven patients
in this  way.  Bell has tied  the spermatic arteries  for  this  affection.
Within the last  ten years several neiv  methods  of treating this disease
have been tried, all based on the results obtained  from  M.  Velpeau's
experiments on the acupuncture of vessels.  This eminent surgeon adopts
the following method:]
  The  patient is  placed on his back,  the scrotum shave*!, and the vas
deferens held aside.  I then seize the scrotum from behind, and with the
thumb and index finger of the other hand I  bring the  mass of varicose
veins forivard toward the integuments, and fix them in a fold of skin ; an
assistant holds one end of this fold, ivhile I support the  other.  I then pass
a needle under the veins, in the way described for varix, and bring  a liga-
ture round it; a  second needle  is passed within about  an inch of the first
one.  You must avoid inserting the needles too low or  too high, and sepa-
rating them too  far from each other.  If the loiver needle, for example, be
placed too low down, you may wound the tunica vaginalis ;  if the superior
needle  be inserted too high up, you will have difficulty in separating the 
826
VARICOCELE.
veins of the cord ; finally, if the needles are placed too close to each other,
the two wounds may unite and  form one.   The needles  being placed, the
hgatures are wound circularly round them, in the same way  as for varix
of the loiver extremities.   When the eschars are detached, the needles are
withdrawn from the tenth to the twentieth day.  Unless the inflammation
which supervenes be severe, the patients are not confined, and a cure takes
place in about a month.  I have never seen phlebitis occur after this ope-
ration ;  in two  cases, however,  where the inferior needle was inserted  too
low down, inflammation  of the tunica vaginalis  came on.  The ivhole of
my patients, then, were cured in a short time; and, of those whom I have
since met, not one lias suffered  a relapse.                 Part v., p. 136.

   Varicocele treated by the  Needles and the Twisted Suture.—It seems
pretty well understood that all  cases of varicocele do not require operative
interference, proper and well-regulated support  generally affording suffi-
cient relief where  the affection is not of a severe  description.  The  dis-
tended veins of the cord, however, may cause such painful dragging and
disturbance of the general health, as to call for some remedial means.  M.
Boyer advises an incision to  be made over the external ring, to lay open
the fibrous sheath of the spermatic cord, and to tie everything contained in
it  but the vas  deferens and  the artery.  Though  hazardous, the author
prefers this method to the ligature as advised by M. Ricord, cauterization,
or to the rolling up of the varicose plexus, as advocated by M. Vidal.   In
one case, Mr. Fergusson  passed three needles under the scrotal veins,  and
twisted strong  silk round them, as in the hare-lip operation.  After a few
days the needles were removed, which ivere  very nearly out, and in  five
days afterward the sores were rapidly heating, and the patient ivas soon dis-
charged cured.                                     Part xxiv., p. 242.

   Treatment of Varicocele by  Gutta Percha  dissolved in Chloroform.—
Dr. Carey says:  After  having used gutta percha considerably for other
purposes, a knowdedge of its properties forcibly suggested  it in  solution,
as admirably fitted to fulfill the desired objects sought in the treatment ol
varicocele.  In order to  apply it, the patient is placed upon  his back,  and
by means of cold, the scrotum  is corrugated until it is drawn firmly over
the root of the penis, compressing the testes  firmly in the upper  portion
of the  inguinal pouches ; then, by means of a camel-hair pencil, after the
hair has been  removed, apply  the  solution freely  over  the  site  of  the
scrotum, allowing it to extend on all sides some distance by a thin attach-
ment ; but over the scrotum proper lay on a succession of coats, until a
thickness of a  line uniform  throughout is obtained, ivhich will  be suffi-
ciently strong to form an  artificial  pouch of the  nature and  character
desired.  This thickness will be so yielding and pliable as not to afford the
wearer any considerable  inconvenience.  Soon after the solution is applied
to  this  sensitive part, the  patient will complain bitterly of the burning
sensation  experienced, depending  upon the presence of the chloroform ;
but this temporary inconvenience will soon pass off.  The  constitutional
indications, if there be any,  must not, of course, be neglected.
                                                     Part xxv., p.  245. 
VARICOSE  VEINS.
827
                  VARICOSE   VEINS.
  Varicose Veins cured by the Formation of Small Eschars.—Mr. Skey,
of St. Bartholomew's Hospital, treats these cases by forming small eschars
a littie larger than the diameter of a split pea, the number being regulated
bY the extent and complication of the disease.  This is effected by apply-
in «■ a small portion of the caustic paste through an opening made in three
ordbur thicknesses of adhesive plaster.  Apiece  of plaster maybe laid,
then over each quantity, and may be removed in from twenty minutes to-
half an hour. Rest in the horizontal  position is desirable, but not essential.
The healina-'of the ulcers, which are sometimes  slow and  tedious, should
be nushed by bark, wine, good diet,  and stimulants, if necessary.
   v       J                                        Part xxiii., p. 151.
   Varicose  Veins and Ulcers.—These obstinate and disagreeable  affec-
tions, have lately been  treated  by the application of a convoluted  spiral
strap of vulcanized india-rubber, instead of the ordinary uniform elastic
apparatus used.  If there are ulcers along with  the varicose  veins-first
wet with a solution of glycerine. 5ss.  to 3viiss. medicated with a little nitric
acid, a  little common  blotting paper, and  apply it over the wound and
over this a pledget of  lint  or linen wet  with  the same solution,    ihese
may be secured by a turn  or two of the calico  roller and over this is
placed the convoluted spiral bandage.   Mr. Startin, the  author  of this
mode of treatment, states that great success has  resulted from its employ-
     .                                               Part xxni.,p. 276.
 ment.                                                       .        ,
   Treatment of Varicose Veins by Needles and Sutures.—It is an  estab-
lished rule in surgery that as long as varicose veins of the lower extremity,
 or varicocele, do not create much inconvenience, this abnormal  state  ot
vessels  should not be interfered with ; but when  the dilated veins become
very troublesome, or threaten to give way, it is  urgent that relief should
be afforded.                                          .      .       ..,
   Mr  Fergusson has operated with  much success on various patients with
 the needlestand sutures, in cases of varicose veins of the lower extremity; and
 as  some surgeons are rather timid on this subject, we mention the following
 case :   The patient, twenty-six years of age, a  servant, has always enjoyed
 good health, but having had much standing work in her situation, and many
 pairs of stairs to ascend in the day,  has  lately found the veins of  her leg
 enlarging considerably.  When admitted the  pain and inconvenience had
 much increased, the left saphena  vein being large, tense, and tortuous.
   Mr. Fergusson transfixed the vein with needles, and applied the twisted
 suture, as in hare-lip  cases; the  patient was enjoined perfect rest;  some
 pain and  tenderness arose  in the vein ; this was, hoivever, soon  subdued
 by fomentations,  and  the  patient was  discharged m a few  weeks with
 complete obliteration of the vessel.                     Part xxv-» P- iJi-
    Varicose Veins— On the Obliteration of.-Mr. Henry Lee operates upon
 these cases in  the following manner :   He first  introduces a needle under
 the vein to be obliterated, and leaves it there for a few days.  2nd, attei
 that time, when the blood on either side of the  needle has become  coagu-
 lated, the operation is completed by dividing the vein by a subcut-ineous
 incision.  The vein must  be blocked up before incision is pertoi med and
 then we know that no abnormal product, as pus, can pass into hcun  t
 of the circulation from the division of the coats. Hence  the blood must 
828
VARICOSE  VEINS.
be kept at rest for a certain time in the vein.  By this plan we are assured
that the coagulum so formed consists of blood alone, and no other vitiated
fluid.                                              Part xxvii., p. 124.
   Varicose  Veins cured by Injection of the Perchloride of Iron.—In a case
of large varicosity of the saphena vein, under the care of M. Follin, injection
of the perchloride of iron produced coagulation and effected a cure.
                                                    Part xxix., p. 208.
   Varicose  Veins.—Compressing  the vessel  at various points, by passing
a hare-lip pin beneath, and applying  the twisted suture, is insufficient to
cut off all channels of communication, excepting it excites subacute inflam-
mation throughout the veins in the neighborhood, and this end is far more
safely attained by the  application  of caustic issues, which  Mr.  Skey has
shown to be superior to any other mode  of treatment at present known.
The caustic recommended  is composed of three parts  of quicklime and
two of caustic potash,  made  into a paste with spirits of wine.   In apply-
ing it, cut a small hole about the size of a split-pea, or a fourpenny-piece,
in adhesive plaster, put  this exactly  over the part, then apply the paste ;
in from ten to  tiventy minutes the pain will have ceased, and the paste
must be removed.   The issues must not  be applied too closely one to
another, for they approximate afterward by the contraction of the skin.
                                                     Part xxxv., p. 91.
   Varicose Veins treated  by Needles and  Subcutaneous  Section.—Mr.
Erichsen's  practice is  to  pass  pins under these  veins, generally in  three
places, for ivhich purpose the vein must be lifted  up, and the pins passed
well under  them, so as  to avoid  puncturing them ; over each of these a
figure of 8 suture must be  applied. In about three or four days, he with-
draws the pins, and divides the veins subcutaneously. In no instance have
any bad effects followed this plan of treatment.          Part xxxv., p. 91.
   Varicose Veins—Ligature of in Pregnancy.—It has been shoAvn by
the results of a case of Mr. Erichsen's at University College Hospital, that
even during pregnancy (should such a procedure be necessary from danger-
ous  hemorrhage) varicose  veins may be safely ligatured.  Mr. Erichsen's
method, it  will be recollected, consists  of placing  pins  under  the  veins,
and tying them  over a piece of gum elastic bougie.   Part xxxvi., p. 169.
   Varicose Veins.—A case  presented  to Prof. Erichsen, at University
College Hospital, where a mass  of enlarged veins, the  size of half an
orange, was situated in the popliteal space.   A pin was  passed  under the
upper  extremity of the  tumor, and tied in  the  usual way, and the parts
below  were injected with a solution of the perchloride of* iron, by means
of a small  French syringe, the piston  of ivhich works  wdth a  regulating
screw, and  the  point  of ivhich is made sharp, and intended to penetrate
the integuments. The intention of this operation is to coagulate the blood
in the large vessels, and thus cause their obliteration.   Part xxxix., p. 162.
   Varicose Veins and Ulcers.—For some time past the folloiving method
has  been followed  at  the Great  Northern Hospital by Mr. Price, in the
treatment of varicose veins of the legs, whether associated with  ulceration
or not. The leg is firmly  incased in a bandage which is saturated with a
mixture of  starchy and glue;  a uniform  support  is thus afforded to the
swollen vessels.   This bandage, w*hen Avell applied, can be worn for  iveeks
or months; but the rapid  subsidence of the swelling of the leg, in some 
VEINS.
829
instances, may require a recasing of the limb  at  an earlier period.  This
plan  of treatment, in many cases, has proved as effectual as obliteration
of the vessels by the  twdsted suture, and it moreover possesses the advan-
tage  of being available in almost ei*ery instance of varicose enlargement
of the superficial veins of  the extremities.   When there is also ulceration,
a window must be  cut somewhat larger than the circumference of the sore
or sores, to admit of  ttie treatment of the sore  ivithout disturbing the case.
                                                   Part xxxix., p. 232.
                              VEINS.
  Treatment Required  after  the Sp>ontaneous Introduction of Air  into
the Veins.— [The possibility of the introduction of air into the veins
during surgical operations is noiv generally acknowledged, as ivell as the
situation in  wdiich only it  can happen,  accurately pointed  out.   Mr.
Erichsen in this interesting paper confines his remarks to the spontaneous
introduction of air into the system, that is to say, when  it  is not  pur-
posely injected into the heart, but when it gains admittance into  that
organ either in consequence of one of the large veins in its vicinity being
opened at a  point where the flux  and reflux of  blood  are naturally ob-
served, or, during operations, under such  circumstances, Avhether of dis-
ease of the coats of the  vessel, of traction in the removal of tumors, or of
contraction of surrounding muscles, that it  forms  an unyielding, uncollaps-
ing tube, into which the air is apt to be sucked in to supply the vacuum,
which the action of inspiration has a tendency to occasion Avithin the thorax.
  Mr.  Erichsen, before  giving his  own  views of the cause of death in
these cases, sums up those of  previous  writers on the  subject, which he
arranges in four classes, viz.:   1st. That death ensues  from over-disten-
tion of the right cavities of the heart.   Of this  opinion are Xysten, Du-
puytren, Cormack, Amussat, and Bouillaud (partly.)  2d.  That death en-
sues from the irritation occasioned by the passage of the air through the
vessels of the brain.—Bichat.   3d. That the heart's action is arrested in
consequence  of  the deleterious influence  of the carbonic acid which is
eliminated from the venous blood.—Marshall de Calvi.  4th. That the cir-
culation is arrested in the lungs, either, as Piedagnel and Leroy have sup-
posed, in consequence of these organs becoming emphysematous, or, as
Bouillaud and Mercier (partly) think from obstruction of their capillaries,
or, as the reviewer in Dr. Forbes'  Journal is  of opinion, in consequence
of the respiratory changes being interfered wdth.
  Mr.  Erichsen states  his  oivn  opinion  to be: 1st. That the primary
arrest of the circulation that takes place in the capillaries of the lungs, or
in the terminal branches of  the pulmonary artery, in consequence  of in-
ability in the right ventricle to overcome the mechanical obstacle  pre-
sented by air-bubbles in the vessels of those organs.  2d.  That respira-
tion  and animal life cease in consequence of a deficient  supply of arterial
blood to the central organs of the nervous system.  Mr. Erichsen  then
proceeds to that part of the subject wtiiich is the most interesting to the
practitioner, namely, the plan  of treatment to be  adopted.]
  And first of all, as most important, let us take into consideration the best
way  of preventing the  occurrence of the accident in question.  Before
doing so, hoivever, it may be better, in order to understand the principles on
which we should act, to'give a brief summary of  those circumstances that 
830
VEINS.
are peculiarly apt to occasion the introduction of air into the circulating
system during operations.  Now it is well known that what is called by
the French writers the " canalisation "  of  a vein, or its conversion into a
rigid uncollapsing tube, is the condition of all  others ivhich is most favor-
able to the introduction of the air  into it.  Indeed, except in those situ-
ations in which there is a natural movement of  flux  and reflux of the
blood in the veins, this accident cannot occur unless these vessels be canal-
ized, or, in other words, prevented from collapsing.  This canalization of
the vessel may be occasioned in a variety of  ways.   Either the cut vein
may be surrounded by indurated cellular  tissue, wdiich wtill not allow it
to retract upon itself, but keeps it  open like the hepatic veins ; or the
coats of the vessel may have acquired, as  a consequence of inflammation
or hypertrophy, such a degree  of thickness as to prevent  their falling to-
gether when divided.  Again, the principal veins at the root of the neck
have, as Berard has pointed out, such intimate  connections with the neigh-
boring aponeurotic structures  that they are constantly kept in a state of
tension, so that their sides are held  apart when they are cut across.  The
contractions of the platysma and other muscles of the neck may likewise,
as Mr. Shaw has shown, have a similar effect.   In  removing a tumor also
that is situated about the neck, the  traction exerted  upon its pedicle may,
if this contain a vein, cause  it to become temporarily canalized.
  The introduction of air into a vein will be favored by the vessel being
divided in the angle of a wound, the vein being, when the flaps  that form
that angle are lifted up, rendered openmouthed and gaping.
  [In looking over all those cases in  ivhich the wounded vein is particu-
larized,  Mr.  Erichsen found that  the wounded vessels were  always in
one  or other of the abovementioned conditions] and consequently, what
the  surgeon should peculiarly guard against  in the removal of tumors
about the neck and shoulders, viz., incomplete  division of the veins and em-
ployment of forcible traction  on the diseased mass at the moment of using
the scalpel.
  If this be necessary, the chest should, for reasons that will immediately
be pointed out, be tightly compressed, that no deep inspirations may be
made at the moment  that the knife is being  used, or before a divided or
wounded vein can be effectually secured.
  But  although it be necessary for  the spontaneous  introduction  of  air
into the circulating system, that the  vein be  either canalized in one or
other of the ways that has just been mentioned, or else that it be opened
where the venous pulse exists,  yet it is only during the act of inspiration
that air can gain admittance into the vessel;  and it is the more ready to
do this the deeper the inspiratory efforts are.  If a vein be opened at the
root of a dog's neck, it will be found that it is  only during inspiration that
air  rushes  in; that  none gains  admittance  during expiration, and but
tittle, if any, when the inspirations  are  shallow, as when the chest is
forcibly compressed by the  hands ;  and that  the rapidity  of the spon-
taneous  introduction of air is, cmteris paribus in proportion to the depth
of the inspirations.
  This depends  upon  the  tendency that  there is to the formation of a
vacuum within the thorax, more particulary in the pericardium, durino- in-
spiration ; at which time the  blood  is carried with  increased velocity
along the veins in the neighborhood of the heart;  and when expiration
takes place  a temporary retardation occurs.   This is particularly evident 
VEINS.
831
during excited  respiration.  Now,  during operations the state of the
breathing is such as to dispose the patient peculiarly to the entrance of air
into the veins.   When a patient is under  the knife, the respirations are
generally shallow and restrained, the breath being held,  Avhilst every now
and then there  is a deep gasping inspiration, at ivhich moment, if a vein
be opened in which the pulse is perceptible, or that is canalized, air must
necessarily be sucked in; and, as has already been  said, in quantity and
force proportioned to the depth of the inspiration.  This, then, being the
case, the mode  of guarding against the introduction  of  air into the veins
is  obvious.  The chest and abdomen should be  so tightly bandaged with
broad flannel rollers or  laced napkins, as to prevent  the  deep gasping in-
spirations, and  to  keep the breathing as shallow as possible, consistently
ivith the comfort of the patient.
  The surgeon  must be careful  not to remove the compression  until the
operation be completed and the wound dressed, for  if this precaution be
not attended to, as  the patient will most probably, on the bandage being
loosened, make a deep inspiration, air may be sucked in at the very mo-
ment that all appeared safe.
  It has been fully proved from the experiments of Nysten, Cormack,
and Amussat, as well as from recorded cases of recovery in man, that it is
necessary that a certain quantity of air be introduced before death can take
place, in confirmation of the observations made long since  by Nysten,
that a few bubbles of air would not occasion death.  Magendie states, that
he has several times, whilst injecting medicinal saline solutions into the veins
of patients, seen air introduced without any bad consequences  ensuing.
In order, then,  that the accident prove fatal, it is necessary that a certain
quantity of air be introduced into the venous system.  This quantity it is
impossible to determine accurately, for obvious reasons.
  What, then,  are the measures that a surgeon  should adopt in order to
prevent the occurrence of  a fatal termination  in those cases in which air
has accidentally been  introduced  into  the veins during an operation ?
Beyond a doubt, the first thing  to be done is to prevent the  further in-
gress  of air, by compressing the wounded vein with the finger, and,  if
practicable,  securing it by ligature.   At all events, compression ivith the
finger should never be omitted, as it has been shown by Nysten, Amussat,
Magendie and others, that it is only when the air that is introduced ex-
ceeds a certain quantity that death ensues.  All further  entry of air hav-
ing thus  been prevented, our next object should be to keep up a due sup-
ply of blood to the brain and  nervous  centres, and thus maintain the
integrity of their actions.  The most efficient means of accomplishing this
ivould probably be the plan  recommended  by Mercier, wdio, as it has
already been stated, believing that death ensues in  these cases, as in pro-
longed syncope, from a deficient supply of blood to the brain, recommends
us to  employ compression of  the aorta and axillary arteries,  so  as  to
divert the ivhole of the blood that may be circulating in the arterial sys-
tem to the encephalon.   This appears to me to be a very valuable piece of
advice, and to be the  most effectual way of carrying out the first indica-
tion, that of keeping up a due  supply of blood to the brain and nervous
centres.  The patient should, at the same time that the compression is
being  exercised on his axillary arteries and aorta,  or, if it be preferred,
as more convenient and easier than the last, on his femoral*, be placed in
a recumbent position, as in ordinary fainting, so as to facilitate the afflux 
832
VEIN3.
of blood to the head.  The compression of the axillary and femoral arte-
ries  may readily be made hy the fingers of two of those assistants that are
present at every operation.
  For the fulfillment  of the  second indication, that of maintaining the
action of the heart until ttie obstruction in the capillaries of the lungs can
be overcome or removed, artificial  respiration  should be resorted to, as
the most effectual means of keeping up the action of that organ.  Thus
Sir B. Brodie states that  he  has  seen, in a dog that ivas beheaded, and
whose cervical vessels ivere tied, the contractions of the heart maintained
Joy artificial respiration for tivo hours and a half, at w*hich time there were
thirty-two pulsations in  a minute, and from my own observations, I can
state that, by the  same means, this organ may  easily be  kept in action in
an animal that has been pithed for an hour and  a half.  For the purpose
of keeping up artificial respiration, the Humane Society's bellows, if they
be at hand, might be used, or, if they cannot readily be procured, a split-
sheet might advantageously be employed.  Before inflating the lungs, it
wdll be  necessary to  remove  everything  that can  compress the chest or
interfere in any ivay wdth the free exercise of the respiratory movements.
Friction wdth  the hand over the  precordial region, and the stimulus of
ammonia to the nostrils may at the same  time be resorted to.
  The third indication—that of overcoming the obstruction in the pulmonic
capillaries, would  probably be best fulfilled by the means  adapted for the
accomplishment of the second, viz., artificial inflation of the lungs.   That
the  action of respiration if kept up sufficiently long, would enable the capil-
laries of the lungs to get rid of the air contained in  them, appears to be the
case, for I have several  times observed that, if a  certain quantity of air
be spontaneously introduced  into the jugular vein of a dog, and artificial
respiration be then established and maintained for half or three quarters of
an hour, but a very small  quantity indeed, if any, will be found,  on  killing
the  animal, in the cavities of the heart, or in the branches of the pulmo-
nary vessels.
  If by these means we should succeed in lvarding off an immediately fatal
termination  to the accidental introduction of air into the veins, we must
watch carefully for the  supervention of pneumonia or bronchitis, which
disease Nysten  has shoivn to be very apt to occur in those animals that
recover the immediate effects  of the accident. That the same danger exists
in man is evident  by the two cases that have occurred to MM. Roux and
Malgaigne respectively.   In Roux's case the patient lived seven days after
the accident, at the expiration of which period he died of pneumonia; whilst
Malgaigne's patient died on the fourth day of bronchitis.   In recapitulation,
then, the following are the principal points that it has been endeavored to
establish in this paper:
  1st. That the primary arrest of the circulation takes place in the capillaries
of the lungs, or in the terminal branches of the pulmonary artery, in con-
sequence of inability in the right ventricle to overcome the mechanical ob-
stacle  presented by air-bubles in these vessels.
   2d.  That respiration and animal life ceases in  consequence of a deficient
supply of arterial blood to the central organs of the nervous system.
   3d.  That  as air enters the veins in quantity, in force, and  in rapidity,
proportioned to the depth of the inspirations, the best mode of preventing
the  occurrence  of the accident, or, at all events, of lessening its probable
fatality, would be in all  operations about the dangerous region—the  root 
VENTILATION—VERMIFUGES.                  833
of the neck and summit of the thorax—to bandage the chest tightly with
broad flannel rollers or laced napkins, so as to prevent deep gasping inspi-
rations, and to keep the breathing as shallow as possible, consistently with
the comfort of the patient.
  4th. If the air  have already gained admission, prevent its further entry
by compressing, or, if possible, ligaturing the w*ounded  vein by ivhich i't
entered.
  5th. Keep up a due  supply  of blood to the brain and central organs of
the nervous system, by placing the patient in a recumbent position, and by
compressing his axillary and femoral arteries.
  6th. Maintain the action of the heart, by artificial respiration and friction
on the precordial region, until the obstruction in the capillaries can be over-
come or removed.
  7th. Remove, if possible, the obstructions in the capillaries of the lungs
by artificial respiration.
  8th. If the patient survive the immediate effects of the accident, guard
against the supervention of pneumonia or bronchitis.     Part ix., p. 149.
                      VENTILATION.
  Importance of Ventilation.—According to Mr. Squire, the usual argand
gas-burner consumes above five cubic feet of gas per hour, producing rather
more than five cubic feet of carbonic acid, and nearly half a pint of ivater.
Shops using thirty of these lights, therefore, in an evening of four hours, pro-
duce upward of nine gallons of water, holding in solution the noxious pro-
ducts of the gas.  An argand lamp, burning in a room tivelve feet high and
twelve feet square, containing 1728 cubic inches of air, with closed do'ors
and windows, produces sufficient carbonic acid, in rather more than three
hours, to exceed one  per  cent, which is considered  unfit for respiration,
and when it amounts to ten  per cent, it is fatal to life.  A man makes, on
an average, twenty respirations per minute, and at each respiration inhales
sixteen cubic inches of air; of these 320 cubic inches inhaled, thirty-tivo
cubic inches of oxygen are consumed, and twenty-five cubic inches of car-
bonic acid produced.                                   Part xl,p. 108.
                      VERMIFUGES.
   Observations  on Vermifuge  Medicines.—Dr.  Cazin, of Boulogne-sur-
Mer, states that  he has frequently employed the common spigelia or worm-
grass.   He administers it in the form of decoction, prepared by boiling
two drachms of the herb in a quart of water to one-half.  The decoction
is then expressed, strained,  and  flavored  with a little lemon  juice and a
sufficient quantity of sugar.  The dose for an adult is two wine-glassfuls,
followed by a wine-glassful every six hours until the desired effect  is pro-
duced.  To children and delicate persons a smaller quantity is to be given.
   Wormwood (absinthium) is an excellent indigenous anthelmintic :  it is
also a powerful tonic and stimulant, the use of w hich, continued after the
expulsion of the  ivorms, prevents their reproduction.  M. Cazin often uses
  VOL. n.—53. 
834
VEKMIFUGES.
a wine prepared by digesting an ounce of wormwood, with an equal quan-
tity of garlic, in a bottle of "white wine, of which he gives from one to three
ounces every morning.  This wine is w*ell adapted for poor lymphatic sub-
jects, Avasted  by  wretchedness,   and suffering from  the influence  of a
marshy soil. The absinthium maritimum is likewise a very good anthelmin-
tic.  M. Cazin gives it to the extent of one or two drachms boiled in  four
or five ounces of water, with  the addition of some white sugar, or of any
anthelmintic  sirup.  This is a quite popular remedy in the maritime dis-
tricts, and almost ahvays succeeds with children affected with  ivorms.
  Assafoetida possesses acknowledged "anthelmintic properties, and is suit-
able for cases of sympathetic  nervous affections produced by the existence
of worms.   It thus, like valerian, fulfills a two-fold  indication.  In a case
of nervous affection, ivhich M.  Cazin  believed to be idiopathic, the admi-
nistration of assafoetida both  determined the  disease and revealed its true
cause, by effecting the expulsion of a number of lumbrici.  This result has,
in three cases of chorea and in two of epilepsy, enabled him to  recognize
that sympathetic irritation, depending on the presence of intestinal worms,
was the sole cause of disease in these instances.  Under ordinary circum-
stances, M. Cazin  frequently combines  assafoetida with calomel in pills.
This combination,  of all those that he has employed, succeeds best in expel-
ling  lumbrici.  He has also combined it with black oxide  of iron, particu-
larly in anaemic patients.  Assafoetida may be given in powder, in doses of
from four grains to half a drachm.
  The essential oil of turpentine is not merely useful in  cases of tasnia, but
is also decidedly efficacious in expelling the lumbrici.  M. Cazin has some-
times, in cases of lumbrici and ascarides, administered with advantage tur-
pentine enemata, prepared  by suspending, by means of yolk of egg, from
one drachm to half an ounce  of the oil in decoction  of  tansy, absinthium,
ivorm-seed (semen-contra), or Corsican moss.
  Common salt is  very destructive to ivorms; it is  given alone in large
doses dissolved in water ;  it should be  taken on an empty stomach.  M.
Cazin also frequently administers it in the form of enema, ivith broivn su-
gar, linseed or poppy oil, and a sufficient quantity of ivater.  With children
it almost always succeeds.
  Like all tonics, iron has the advantage of destroying worms, at the same
time that, by imparting tone  to the  intestines, it prevents  their repro-
duction.  From six to eight grains of iron filings,  mixed with an  equal
quantity of rhubarb, and taken  tivo or three times a  day, have often been
sufficient to expel the worms contained in the intestines.
  M. Cazin succeeded in rapidly curing a boy nine years of age, emaciated
and pale, whose sleep was  disturbed, and who was suffering from spas-
modic movements  similar to  those which characterize  . horea, by the ex-
hibition of pills of sulphate  of iron, combined, according to Puller's form-
ula, Avith aloes, senna, etc.,  under which treatment he voided twentv-three
lumbrici in four days.  He  has also used with remarkable success Boson's
mixture, containing extract of black hellebore and  sulphate of iron.   But
what he chiefly gives to children,  as well as to adults, is  the sirup of citrate
of iron (four parts of citrate to  sixty of simple sirup, and one of essence
of lemon,) in  doses of from two drachms to half an ounce to children, and
from half an ounce to two ounces to adults.
  M. Cazin remarks that calomel, so efficacious as an anthelmintic ouo-ht
never to be combinel ivith  an alkaline chloride, as the formation of oorro- 
VOMITING.                           835
sive sublimate would probably ensue from their admixture.   In  like man-
ner, the combination of calomel ivith cherry-laurel water,  or emulsion of
bitter almonds, would give rise to the development of two formidable poi-
sons, corrosive sublimate and cyanide of mercury.
  The effects of the male fern, tin, pomegranate bark, hellebore, etc., re-
quire merely to be noticed ;  and the  properties of the pomegranate root
bark are so well known that they need not be divert  upon.  M. Cazin has
remarked nothing particular respecting other  anthelmintics.  He  merely
says that cod-liver oil has succeeded ivith him in the cases of two females,
one of whom  passed tw*elve lumbrici the same day that she  had  taken in
the morning three table-spoonfuls at intervals of an hour.
  But whatever be the medicine selected, we must not, tike routine prac-
titioners, be content when the ivorms are  killed  and  dislodged, with this
merely palliative cure.  A i*ery important indication remains  to be fulfilled,
viz. to prevent their reproduction.   This object is attained, according to
M. Cazin, by  the adoption of a tonic  and stimulant regimen, wdiich  must
be long continued,  and, above all, by the employment of bitter and chaly-
beate preparations.   He has found the ferruginous chocolate to  be  suffi-
cient, in the case of children, to prevent  the relapses wdiich  are for many
years very apt to occur.  Wine taken while fasting has succeeded  with
the poor inhabitants of the marshes,  accustomed to live  only on vegeta-
bles and milk; and he has also  remarked its efficacy as  a  preventive of
worm affections in other instances.                     Part xxi, p. 154.
                        VOMITING.
   Creasote and Acetate  of Lead in  Vomiting.—Dr.  Cormack, of Edin-
burgh, states that creasote, in medicinal doses, is almost immediately seda-
tive and calming ;  but these effects are of short duration ;  so that it  is a
drug which requires to be given in often repeated small doses.
   Creasote is one of the best medicines ivhich  we  possess  for stopping
vomiting.   In the vomiting of pregnancy, an affection so distressing to the
patient, it seldom fails.   If the  sickness  come -on  regularly after rising in
the morning, Dr. C. prescribes  two or three  drops to be taken five or ten
minutes before  getting out of bed.  This generally  proves effectual; but
if it does not, the patient ought to be directed to repeat the  dose in  tivo
hours.   In more troublesome cases, when the sickness occurs at intervals
during the day, one or two drops should  be given every two, three or
four hours.
   [In a case communicated by  Professor Simpson, the creasote failed to
reheve the distressing sickness,  ivhile  doses of acetate of lead proved suc-
cessful.  In the sickness and vomiting follow ting a drinking debauch, crea-
sote is sometimes very useful.  In such  a case a single dose of four drops
was found  to relieve speedily.  Iu seasickness it will often be found effica-
cious ;  but " it is  worthy of notice  as a  general remark that creasote,
though excellent in allaying vomiting,  often excites it when it does not
exist."]
  In vomiting connected with hysteria,  creasote  proves  a very valuable
remedy, and  so far as Dr. C.'s experience goes, be is inclined to think, that
Dr. Elliotson and others, who have recommended it very strongly ;n this
class of cases, have not done so ivithout sufficient cause.    In at least ten 
836
VOMITING.
cases of this kind, Dr. C. has tried it in doses varying from  two to eight
drops,  and in all excepting one, it proved an admirable medicine, not only-
relieving the vomiting, but also apparently, in most instances, calming the
nervous excitability.   In the case in which it apparently did no  good, the
dose could not be increased beyond six drops  thrice a day, on account ol
the vertigo which it occasioned.  The patient was ultimately much bene-
fited by sponging with cold water, and taking four grains of the  saccha-
rine carbonate of iron three times a day.                 Part xl, p. 12.

  Atonic Vomiting.—Dr. Debregue gives the folloiving :   In the vomit-
ing that may be considered to  be nervous or spasmodic in its nature—i. e.,
when it  is not connected  either with  inflammation or  any bilious dis-
turbance of the stomach—he recommends very highly the use of columba
poivder: it possesses, he says,  a sort of specific virtue in such cases nearly
as great as bark does in agues.  He gives it in  doses  of from 15 to 20
grains  in two or three spoonfuls of red (French) wine, before meals.   The
addition of a few grains of magnesia, or of a minute  dose of opium, may
be necessary, if much acidity  or gastralgia be present; and, should the
patient be feeble and anaemic,  the  subcarbonate  of iron may be very ad-
vantageously combined with it.  Opium is freely used  by Dr. D.  in vari-
ous abdominal affections, after the state of the intestinal  secretions has
been ascertained to be tolerably healthy.                 Part x., p. 27.

   Vomiting of Pregnancy—Strychnia—Recommended in  minute doses,
by Dr. Golding Bird.                                  Part xiv., p. 08.

   Observations on Vomiting.—For sympathetic vomiting occurring  espe-
cially in females, Dr.  Seymour, of St. George's Hospital, uses the following
formula: Carbonate of ammonia, a scruple ; water, an ounce and a half; sirup,
a drachm ; fresh lemon juice half an  ounce; draught to be taken  every 4
hours.   The folloiving draught, according to our author, answers the same
purpose : Sulphate of magnesia, a scruple; carbonate of magnesia,  10 grains ;
mint-water, 10 drachms; laudanum, 3 to G minims; this draught to betaken
every four hours.  The same means, he says, often afford relief for consi-
derable periods of time, even Avhen the vomiting is symptomatic of much
more  serious disease or injuries.  In symptomatic vomiting, a blister or
mustard poultices often put an end to the morbid sympathy. From half a
grain to a grain of opium, made into the smallest size, and as fresh as can
be procured, is often  successful where all has failed.  He has seen equal
parts of milk and lime-Avater succeed where everything else had been tried
in vain.  In hysterical vomiting, he gives his testimony to the value of
creasote, the dose being one or two minims thrice daily.  Aniono- other
means  of checking vomiting, he mentions the successful use of savory meat
—the jelly of meat taken  in  very small quantity regularly thrice a dav.
Against the vomiting of phthisis he recommends four grains of the extract
of conium, to be taken twice  or thrice a day,  followed by  this  draught:
Lime-water, one  ounce ; cinnamon-water, half-an-ounce ; sirup, a drachm.
Our author affirms that vomiting occurring almost ahvays  after couoh in
phthisis at an early period, marks a severe and rapid form of it; and at a
late period that large collections of matter are locked up in the luros.  In
the vomiting attending what was formerly termed the iliac passion in aVonn^
woman, after the case had become hopeless, he succeeded by administer-
ing two grains of calomel, made up with a grain of the soft and recent extract 
VOMITING.
83?
of opium*; and when  the endeavor to vomit returned, by forcing the pa-
tient to siyallow half a bottle of soda-water in astute of effervescence ; "the
expansibility of the gas, and the dowmvard impression in swalloAiing, had
the  desired effect."  Such cases as this, marked by feculent vomiting, he
regards as the idiopathic iliac passion, being plainly unconnected either with
hernia or intus-susception.
  [In the vomiting of Asiatic cholera, one of the best remedies consisted
of a scruple of Epsom salts, ivith five grains of magnesia, and tivo or three
minims of laudanum in a tablespoonful of Avater every three or four hours,
or oftener.]                                           Part xvi, p. 151.
  Vomiting during Pregnancy.—According to Dr. Churchill, if all other
means fail hi its relief, premature labor must be induced.
                                                    Part xvii., p. 208.
  Vomiting.—In obstinate  vomiting, try  Sir James  Murray's new  salt,
"the bisulphate of iron and alumina," given in doses of five or ten grains,
every two or three hours.         ,                    Part xix., p. 312.
  Use of Sub-nitrate of Bismuth.—Vomiting may depend upon a simple
gastric neurosis, and then M. Monneret thinks the bismuth can  be very
usefully employed. It is also useful in the vomiting of pregnancy, and that
accompanying dysmenorrhcea ; but its efficacy is less certain than in affec-
tions of the gastro-intestinal tube, and is never so great as when diarrhoea,
colic, and  flatus are present. From  whatever cause pain manifests itself
during digestion, ive may relieve it by mixing the  sub-nitrate  freely with
the  articles, of food.                                     Part xx., p. 92.
  Vomiting—Sympathetic.—Dr. Selkirk  advises  iodide of potassium in
combination wdth infusion of quassia; a wineglassful of the  infusion with
three or four grains of the iodide three times a day.     Part xxi, p. 152.
  Vomiting— Obstinate.—In a case treated by Dr.  Heath of Newcastle-on-
Tyne, wdiere all the usual remedies had been tried in vain, a small quantity
of chloroform  was inhaled to quiet the stomach, but not to produce insen-
sibility.  Half a  grain of morphia  was  then  given  and the inhalation
reneAved.  The patient was kept fully  under its influence for a feiv minutes,
and when consciousness returned he  was free from  all feeling  of sickness.
The inhalation was  kept  up slightly for an hour and a quarter.  He had
no  return  of  the sickness  for  twenty-four hours.  A slight  return was
checked afterward in the  same way.                  Part xxviii., p. 310.
  Treatment of Vomiting.—Dr. Lees, of Meath Hospital, says: If vomit-
ing be caused  by some structural disease of stomach, as ulcer, scirrhus, etc.,
give a drop of creasote, or five or ten  drops of medicinal naphtha, or a com-
bination of bismuth with gallic  acid  and opium, as recommended by Dr.
Turnbull.   If caused by a morbid state Of the blood,  as in scarlatina, ery-
sipelas, cholera, etc., our treatment must be  chiefly directed to eliminate
the "materies  morbi" from  the  system by means of the  skin and boivels.
Vomiting may be from a mechanical cause, as from the violence of an
habitual cough, or  a stooping occupation.   If  vomiting be from a sympa-
thetic cause, as disease in the ivomb  or brain, or calculus in the gall duct,
kidney, or ureter, we must endeavor to  remove  this, the  origin of the
vomiting.  Thus it  has been necessary in some cases to produce abortion,
the life of the  patient having been in danger from  the long continuance of
this distressing symptom. If caused by the passage  of a calculus, either from 
838
VULVA.
the gall-bladder or kidney, large doses of opium are required, the first dose
combined Avith aloes and carbonate  of soda.  In some cases chloroform
may be given wdth good effect.  For the cure of nervous vomiting, that is,
vomiting induced by some modification of innervation of the stomach, un-
connected with  any  change of structure,  a proper regulation of the mind
is essential.   A slight but continuous  action must be kept up by some mild
aperient medicine.  In some cases, effervescing draughts, with prussic acid
or laudanum, will succeed ; and in hysterical cases, assalietida, valerian, and
creasote will be found useful.  When the patients are anamiic, give iron
with bitter tonics.  External counter-irritation is often of much use.  The
diet must be very simple and easily digestible.        Part xxxvi., p. 275.
   Vomiting of Pregnancy—Oxalate of Cerium.—Prof. Simpson  states
that cerium has a peculiar sedative and tonic  action on the stomach, re-
sembling in some degree the action of the salts of silver and bismuth.  It
is of all remedies the most generally useful in cases of obstinate vomit
ing from pregnancy.   It  does not  invariably nor certainly act thus in
these cases, but it is more certain than any of the remedies previously in
use.   The oxalate is the  salt  most readily procured.  It may be given in
doses of one or two  grains three times a day, or oftener. Part x\.,p. 185.
   Curdled Vomitings of Children.— Vide " Marasmus."
                             VULVA.
  Inflammation of  the  Mucous  Follicles  of the  Vulva.—M. Robert
believes  this affection frequently accompanies Menorrhagia, or  occurs in
women liable to inflammatory affections in  these parts, from pregnancy,
abortion, etc.  The chief  seat of the inflammation is in those two large
mucous follicles at the entrance of the vagina.  Its cure consists in intro-
ducing one of Anel's  stylets  into  the  follicle, and  then laying  its cavity
open by means of a pair of probe-pointed scissors, and cauterzing its inter-
nal surface with nitrate of silver.                          Part v., p. 143.
  Treatment of Pruritus Vulvae.—Having been  a great many times con-
sulted  for  the relief of pruritus vulvas, and most frequently in  pregnant
women, says  Dr. Meigs, I  have rarely had occasion to order anything more
than the folloiving formula, viz.: R Sodae borat.,  gss. ; morphias sulphat.,
gr.  vj.; aq. rosa destillat., gviij. M.  F. sec. art. mist.  I  direct the person
to apply it thrice a day to the affected parts by means of a bit of sponge,
or a piece of linen, taking the precaution first to wash the surfaces with
tepid ivater and soap, and. to dry them before applying the lotion.  I can
confidently recommend the prescription  as suitable in most  cases of this
most annoying malady.                                part x\\^ jK 297.
  Follicular  Disease  of  the  Vulva.—Mr. Oldham  has met with several
cases of a form of disease  attacking the follicles ivhich are freely  scattered
over the mucous membrane of the  vulva.  It is  a  painful affection, very
difficult of cure, and is attended with leucorrhceal  discharge.  In its treat-
ment arg. nit. and nitric  acid  are of no use.  Hydrocyanic acid lotion is
serviceable, or  an ointment made of two drachms of  prussic acid  and a
scruple of diacetate of lead, with two ounces  of cocoanut oil. The parts
are to  be first washed with infusion of roses, and the ointment applied two
or three times a day on lint. 
WAETS.
830
  Or try a lotion of  hmc-ivater ivith opium ; or make a poultice of bread,
 saturated with decoction of conium leaves, to a pint of which add two
 drachms of the liq. plumbi diacet.
  When irritation is excessive,  prescribe  vapor-baths, either simple or
 medicated with sulphur.  Attend to general health, order a nutritious but
 unstimulating  diet; avoid wine  and  porter ;  give  milk with lime water;
 keep  the  patient  at  rest; forbid sexual intercourse.   There  should be
 change of air.  Give the vegetable tonics, as cascarilla, columba, cinchona,
 sarsaparilla, etc.; keep the boAvels open  with small doses of magnes. sulph.
 in infusion^of cascarilla or chamomile.  When the symptoms are decidedly
 abating, give a mild mercurial course with sarsaparilla.  Part xiv., p. 30V.
   Vulva—Prurigo of the.—Prof. Simpson recommends in severe cases of
 prurigo of the vulva, vagina, or  cervix  uteri,  to  brush  the affected parts
 OA*er with hydrocyanic acid, the  strength of that of the Edinburgh Phar-
 macopoeia.                                            Part xxi., p. 289.
  Blenorrhagia of the Vulva.—Mr. Acton would enforce cleanliness.  A
 soothing plan should be  first employed,  and separation of the surfaces at-
 tempted ; then lotions of nitrate of silver, 3j. to §ij. of distilled Avater, with
 the addition of warm baths.  If the  inflammation has gained  the deeper
 structures, leeches may  be employed in addition, to the groins; and if
 abscess should form, it  must be opened immediately, though  we should
 pause when the inflammation occurs round an already-formed cyst.
                                                    Part xxiv., p. 345.
  Prurigo of the  Vulva.—Prof. Simpson  believes this may be relieved,
 and  generally  cured by  the assiduous  and persevering application of a
 solution of borax, five or  ten grains  to the ounce of ivater, or in a little
 infusion of tobacco.  An ointment of the iodide of lead, or of bismuth  and
 morphia, is very useful.  Chloroform, applied locally in the form of vapor,
 is one of the  most certain means ivhich can be employed.  These remedies
 should be  alternated.  In the more  obstinate cases  astringents ivill  be
 found of much use : alum, or aluminated iron, or tannin.   Of  course the
 general health of the patient must be attended to.  Arsenic, aqua potassa,
 and other alterative medicines of that class may be required.
                                                      Part x\,p. 214.

                               ---•-*-•---

                            WARTS.
  Ti'eatment of Venereal Warts.—If  they are pedunculated, Bransby B.
Cooper recommends the ligature; in other cases, caustic or  poAvdered.
savine.  If these means are  insufficient, excise the warts with the knife,
and apply caustic to the cut surfaces.   When there is phimosis with Avarts,
the prepuce must ahvays be laid open immediately.  Vide "Condylomata."
                                                     Part xxi., p. 270.

  Warty Excrescences.—Mr. T. W. Nunn,  acting on the principle of  Dr.
Arnott, of using congelation as an anaesthetic agent, has recently applied
little Avedged-shaped  pieces of ice to  the necks  of large warty groivths
depending^from the labia minora,  till they became  blanched and  cold ; and
he then removed a great many of them  wdth a single stroke of the knife,
without causing the patient any but very slight pain.  Part xxii., p. 314. 
840
WATER—WHET.
  Non-Specific Affections.—These,  ivhich consist  of warts, vegetations,
herpes preputialis, eczema, and excoriations, may be  treated with strong
acetic acid.  Mr. Acton recommends  the powder of oxide of  zinc in the
more simple forms, and in the obstinate a poAvder composed of etpial parts
of aerugo and pulvis sabinae.                          Part xxiv., p. ->4Q.
  Unexpected Effects of the Employment  cf Carbonate of Magnesia in
Case  of  Warts.—In the case of a girl affected with gastralgia, whose
hands were covered with warts, Dr. Lambert gave carbonate of magnesia.
Two months after, though the stomach affection was unaltered, the warts
had disappeared.   In another case, the same dose, a teaspoonful night and
morning, produced a similar effect in five weeks.      Part xxvii., p. 161.
                           WATER.
  Artificial Harrogate  Water.—Where the  genuine Harrogate w*ater
cannot well be procured, the following will be found a good substitute:
                    ARTIFICIAL HAEROGATE WATER.
  R Sulphatis potassas  cum sulphure, 3j-5 potassae bitartratis, 3ss.; mag-
nes. Sulphat., 3aj.; aquas destillat. Ibij.
  Solve.—Capiat dimidium p. r. n
   The above is sufficient for a quart, and ought to be taken early in the
morning  before breakfast,  and be followed by a  walk,  to produce the
desired aperient effect.                                   Part v., p. 85.
   Waters of Vichy and Carlsbad.—Dr. Cahill considers the waters of
Vichy and Carlsbad very valuable in gout, rheumatism, gravel, and affec-
tions of  the liver and  spleen, owing to their  strong alkaline character,
which is  principally due to the large quantity of bicarbonate of soda which
they contain ; they are very mild  and gentle in their operation, and not
like  the  waters of Homburg,  Weisbaden, and  Kissengen, which  contain
chloride  of sodium, and are severely purgative.      Part xxxiii.,^. 295.
  Kreuznach  Waters.—Dr. Prieger thinks  there  is no reason to believe
that these waters, whether employed on  the spot, or elsewhere, have any
power in removing undoubted fibrous tumors of the womb, although Ave
may speak with the greatest  confidence of their  efficacy in diminishing
general hypertrophies of the uterus,  not  having an isolated form, or inde-
pendent growth.                                    Part xxxv ,p. 30S.
                            WHEY.
  Different Kinds of Whey.—The  following is a translation of the direc-
tions given in the " Pharmacopoeia Borussica" of 1829, for the preparation
of five different kinds of whey :
  1. Serum lactis dulce, Sweet  Whey.—Take  an ounce of the dried
stomach of a calf, infuse Avith six  fluid ounces of cold ivater for ten or
twelve hours, add an ounce of this liquor to  nine pounds of fresh cow's
milk, warm gently, and after coagulation is effected, decant and strain the
liquid.
  2. Serum lactis dulcificcdum,  Sweetened Whey.—Take  three pounds of 
WnTTLOAV  OR FELON.
841
coav's milk, boil, and at the commencement of ebullition add one drachm
of bitartrate of potash; wdien a coagulation is effected, and the Avhole has
become cool, strain, and boil with a sufficient  quantity  of Avhite  of  egg
beaten up into a froth, until the albumen is coagulated ; strain, and  add
as much  prepared chalk (or shells) as is required to neutralize the acid,
and filter.
  3. Serum lactis acidum, Sour Whey.—The former without addition of
the chalk.
  4. Serum lactis aluminatum, Alum Whey.—5.  Serum lactis tamarind-
inatum,  Tamarind  Whey.—In  these  respectively  a  drachm  of crude
poAvdered  alum,  or one  ounce of  the pulp of tamarinds,  is employed
instead of the bitartrate of potash.                   Part xxviii., p  321.
             WHITLOW   OR   FELON.
  Use of Potassa Fusa.—Whitlow, paronychia, or felon, may be removed,
according  to Dr. Barnes, of St. Louis, U. S., in the early stages, and  in
the  later stages may be much relieved, by applying potassa fusa. Slightly
moisten the end of a stick of this caustic, and rub it over the surface  ot
the  diseased and adjacent parts for a few* seconds, until  the patient com-
plains of much pain.  If this pain or  burning sensation lasts for a few
minutes, the application  has been sufficient; if it subsides more quickly,
reapplv the caustic for a short time.  Be very careful not to destroy the
Bkin7 •                                               Part xv,., ;>.320.

  Wliitlow—Deep-seated.—Dr. Hamilton, of Ptichmond Hospital, Dublin,
gives the case of a man forty years  old, who was seized with a deep-seated
whitlow.  Deep incisions were made in  the front of the fu>t phalanx,^out
of which matter gushed, to the man's great relief.   Incisions were after-
ward made in the palm and dorsum  of the hand, but  still  the linger was
obliged to be removed at the metacarpal articulation.
  The symptoms  are usually as follows:   The  affected finger becomes
painful, the pain increasing  to the greatest degree, so as to  prevent sleep,
and often to cause the patient to spend the night walking about his room
in torture   This will be at first accompanied by little  swelling, and little
redness, more especially in  front, although the greatest suffering is com-
plained of there.   The finger will be kept bent, any attempt to straighten
it increasing  the  pain, as  does also  pressure over the affected part,   by
keeping the finger flexed, the skin in front  is relaxed as well as the tendon,
relieving the painful  tension, and the pressure of the tendon on the inside
 of the inflamed sheath.  The back of the finger next becomes red, swollen,
 and shining, pitting on pressure.  You  might be misled by this  and think
 it was the place to make your incisions in search of matter, but it wi  I be
 found that pressure on this part  can  be borne, whereas m front, where
 Boyer says this whitlow always occurs, it cannot;  and when the nnger is
 attempted to be straightened, the suffering is at once referred to the front.
 After the third or fourth day, this part will be found swollen and prominent,
 particularly on a side view, but no fluctuation is discernible  Ii no treat-
 ment  is adopted, the disease will often proceed ^m*J^^
 which becomes red, swollen, and. tender, the back ot the hand paiti.ulaily 
842
WHITLOW OR FELON.
so, of a deep shining red, pitting on pressure, and fluctuation is soon appa-
rent either over the knuckle of the affected finger,  or in the  iveb between
the fingers.  In the  palm of the hand Ave often observe that the matter,
after having made its way out through a small opening in the skin, does
not pierce through the cuticle, which in the laboring classes is excessively
thick, but separates it extensively, and you have a considerable collection
of pus only covered by cuticle, before you come to real abscess ; as the
palm becomes  engaged, other fingers get flexed, and cannot bear exten-
sion, and the pain shoots up the arm to the shoulder; in a woman, I kneAv
it extend to the breast of the affected side.  In most instances the inflam-
mation with suppuration stops at the finger and palm, particularly when
treatment has been resorted to;  but if not,  it may  go up the front of the
wrist to the  forearm, in which  case the patient recovers after weeks of
suffering, worn  out by sleepless nights and profuse suppuration, wdth benti
emaciated fingers, and a stiff wrist, and a nearly  useless hand.  Should
the  disease not extend  so high, or not  be so violent, it may end with a
stiff, bent finger.  I should say when there has been suppuration the finger
is  invariably stiff, and  usually bent, from adhesion of the integuments to
the sheath of the tendons, and of the tendons to the inside of  the sheath,
while in the  state of  flexion.  If the inflammation is  very intense,  the
tendons die and  protrude through the natural or artificial opening that
has  let out the matter, and  throw off greyish white  sloughs;  wdiere a
portion of the flexor  profundus is totally destroyed,  the finger may be
quite straight, being kept so by the extensor tendon.   Such is the case in
the man noiv in the house, who came to the hospital after having suffered
from ivhitloAv six weeks. I took away a dead portion of the flexor tendon,
one  and-a-half  inch  long, from  the  sheath.  I  am going to  remove his
finger, as he presents a further step in the disease, viz.,  the periosteum is
stripped from the bone of the first phalanx by effusion of pus, and the bone
is killed.
  The death of the bone is most common in the last phalanx, particularly
of the thumb.  In such a case you will find, though the matter has been
let out by a free opening, the disease lingers,  the  part  continues red  and
swollen, the opening discharges abundance  of thin matter, they are large
flabby granulations around  it, and if you feel the end of the finger, there
is a pseudo-fluctuating feel,  as if it was extensively undermined ; a probe
passed in removes every doubt, by grating  against the  rough bone.  It is
best not to wait till it separates of itself, but  enlarge the opening, and seiz-
ing the dead bone with a forceps, divide  any ligamentous  connections at
the joint, while they are on the stretch.  The  parts soon  heal, the finger
shortened, bent forivard, and  clubbed at  the  end, the  nail  irregular, but
still a useful finger.
  The fever, in deep-seated whitlow, often  runs high, and  I have known
delirium at night,  but  I  never met with a fatal termination, except in one
case, a man  who crushed  his  thumb while  intoxicated ; deep-seated
paronychia followed, inflammation of the veins up the arm,  and death.
   On looking over the notes of  many cases, I find the most frequent  seat
of deep-seated  whitlow's to  be the middle finger, next the rino-, and then
the index finger, all before the thumb.  This agrees with Boyer's experi-
ence; it  differs from what we perceive  in  the superficial paronychia in
wdiich the index finger and  the thumb are so  much the oftenest  affected
and at their extremities. The part of the finger in the deep-seated parony- 
WHITLOW  OK FELON.
813
chia most commonly engaged is  the sheath of the flexor tendon over the
first phalanx;  this sheath is not  only the longest, but the strongest, and
most complete.  A feAv cases, when suppuration was threatened, subside
and terminate  by resolution.   The majority run rapidly into suppuration,
which is more  or less extensive, according to  the  intensity of the inflam-
mation.  Such is an outline of the symptoms and pathology of deep-seated
whitloAV.   You see that it  is an  inflammation  of the inside of the sheath
of the  tendons, that nature makes vain efforts to get out the matter con-
fined in the strong fibrous envelope ; you have witnessed the disastrous
effects  of the unrelieved diseased action, the periosteum, the tendon, the
bone, all  at last  engaged, and the finger, or even  the hand, permanently
injured or even lost.  You  ivill at once naturally arrive  at the conclusion,
that a free incision into the sheath, early performed, is the only treatment.
Yet hoAv is it that so many come to the hospital, where this has never
been done, and all  the destructive consequences allowed ivithout an inci-
sion ever having been made ?
  I believe it arises from timidity, a fear of wounding  bloodwessels,  par-
ticularly  when  the disease  approaches the palm ;  there the  palmar arch
becomes  a kind of bugbear.  Some years ago, I made careful dissections
of the band, with a view of  furnishing myself with precise rules for making
incisions in deep-seated whitlow's.  Permit  me to  call your attention to a
few practical conclusions I  arrived at:
  "There are two  principal wrinkles or lines  running across the palm of
the hand; one, nearly transverse, corresponds to  the joints  between the
metacarpal bones and first phalanges, and is situated about an inch behind
the first transverse lines on the fingers.  The second begins from the first,
at the  articulation  of the index phalanx with its corresponding metacarpal
bone, and goes in an oblique direction across the palm toward the pitiform
bone at the inside  of the wrist; it answers pretty nearly to the course of
the ulnar or superficial or palmar arch.   These tivo lines, which are very
regular, Avill be found to serve as excellent guides  in making  our incisions
in paronychia with confidence.
  " On the fingers  there are three bundles of transverse lines;  the tAvo from
the tip correspond to the articulations, that next the palm does not corres-
pond to any joint,  but is situated about the centre of the first phalanx end
of the sheath of the flexor tendon.
  "The palmar fascia goes  about  as far as the transverse palmar line before
it sends  off its  four  processes ivhich go  between the fingers,  and are
attached  to the sides along with  the  tendinous insertions of the extensor
muscles and the lumbricales.
  " The web betAveen the fingers contains the digital  artery from the pal-
mar ach and its  division, and is filled up with  loose cellular  tissue, allow-
ing matter easily to go from the  palm to the  back of the hand.  As the
superficial palmar arch, the only one likely to be wounded, corresponds to
the oblique line  which is behind the  transverse line, the distance increas-
ing as it  approaches ihe inside of the wrist, you  can, in all the  fingers,
safely  make your incision as far as the transverse  line ; nay,  in all fingers
but the middle, you can cut beyond  this as far as  the centre  of the hand,
and in  the index finger even further.  But it is worse than useless ever to
carry your  incision from the finger further than the transverse line, so as
to endanger the arterial arch at all, as alter  going so  far it is quite suffi-
cient to pass a director  under the palmar fascia,  which alone confines the 
844
WORMS.
matter, if it has gone into the band.  On the director, you could, if desira-
ble, cut out through the fascia, and even the annular ligament.  Whereas,
if you cut down without a director to the palm, through ah the parts to
the bone (ivbich in the palm is unnecessary, as there is nothing below  tl.e
palmar fascia or annular ligament to  confine matter), you could scarcely
avoid w*ounding the arteries or large nerves.  In the same way in the  fin-
gers after the sheaths of the tendons are divided, nothing remains to con-
fine matter.   These sheaths extend from the tip  of  the  fingers to  the
transverse palmar line or metacarpal  phalangeal articulation ;  they  are
thick and strong  betiveen the joints, thhteopposite  to them; you should
avoid over the joints, and confine your incisions to  the strong part of  the
sheaths betiveen them, cutting to the bone if you choose, or what is  gene-
rally enough, down to the tendon, taking  care  to  open the sheath well,
and always keeping in  the  centre to avoid the digital arteries running
along-the sides of the fingers.  In the thumb it is particularly necessary to
observe this last  rule, as otherwise, after cutting beyond the first joints,
you would be very likely to wound the superficialis volas.
  " Bearing these facts in mind, you  will have no hesitation in making
sufficiently free and  deep  incisions.   I repeat,  take care  that  your
cut is long  enough  to open the sheath freely ; a  mere deep  puncture
through it may let out matter, and give ease for the time*; but not allow-
ing free vent, will cause the pus to seek another outlet, and much mischief
ensue."
  In spite of free incisions the diseased action is not always stopped.  In
such cases, though there is at first much relief, the  unpleasant sensations
return ; the  next night the patient will  be kept awake by deep-seated,
throbbing pain, and you may be sure  that  the matter is working its way
out in some other direction, and is not getting free exit,  and  you  will
probably discover some swollen, tender spot,  to repeat the incision.  If
the disease presents  itself in a more advanced and  aggravated form, not
only engaging the finger, but extending to  the palm, back of the hand, or
even the wrist, wdiich last is very rare, you will have to follow the matter,
regulating your incisions by the rules I have mentioned.  Some authors
have made a separate division of paronychia, which they name paronychia
periostei, from supposing the disease in this form to commence in the peri-
osteum   covering some part of the  phalanges, with suppuration betiveen
the periosteum ar.d bone, death of the bone, etc.  I regard the affection
of the periosteum rather as a secondary effect of the  deep-seated parony-
chia, whose seat we have seen to  be the sheaths of the tendons, but
when neglected, to engage finally all  the  tissues, the periosteum among
the  rest, and the bone.  When the first or second phalanges are stripped
of periosteum, and dead, it is best to remove the ivhole finger at the meta-
carpal articulation.
  If it is the last phalanx, it can be removed alone, and as I have already
said, a useful finger will remain after the opening is healed.
                                                   Part xxxi, p. 183.
                              ---»•-•—

                            WORMS.
   Tape-worm—Treatment of.—In 206 cases of tape-worm,  Dr. Wawruch
found the following tieatment the mo,4 efficacious :  As a preparatory step 
WORMS.
845
all the patients took a laxative decoction with sal ammoniac, for three, four,
or five days, and ate nothing but iveak soup, thrice a-day.   In 8 cases the
worm was expelled  by the mere effect of continued abstinence.  The an-
thelmintic remedies employed were castor oil and the powdered root of
the male fern.  From one to two tablespoonfuls of the oil were given as a
dose, alternately with one or  two  drachms of the powder twice or thrice
a day.
   Enemata of oil and milk were frequently thrown up, to attract the worm
toward the  large intestine, and it was  observed, that the effect of the
drastic was always most sure when given a certain time after the last dose
of fern, than at once. The drastic purge employed was composed of equal
parts of calomel, gamboge, and sugar, two to eight grains of each for a dose.
In many cases a single dose brought the worm aivay, but in others three
to six doses  were required.  The period at ivhich the worm was discharged
ivas  very various.   The tasnia is  not exclusively a solitary worm,  for in
nine cases there were two worms, of different ages  and development;  in
two  cases, three  ivorms.  In one very remarkable case, four worms ivere
discharged,  and this patient still suffers from the complaint.
   Generally speaking, the patient  may expect to be entirely free from his
disease, if he pass ten or twelve weeks without discharging any remnants
of the worm.                                          Part iv., p. 26.

   Tape-worm—Mode of giving Turpentine.—Dr.  Bellingham does  not
 think it necessary to administer this remedy in the large doses which were
 formerly given.  He states that it will be equally effectual if the system be
 kept for some time under its influence by giving it in moderate doses, two
 or three times in the twenty-four  hours, occasionally exhibiting a larger
 dose • and if no cathartic effect folloivs, he combines it or follows it up with
 castor oil.                                              Part vl, p.  14.
   Oleum Santonicee, or Chenopodii as an Anthelmintic—[Dr. Monsarret
 made use of this medicine when some obstinate cases, supposed to be owing -
 to intestinal worms, came under bis notice.  He began with four to eight
 or ten drops on lump sugar or milk to a child, and so on in  proportion.

   Its'1 effects surprise me, not having had much previous  faith.  In almost
 every case, I could observe innumerable  quantities  of lumbrici  were dis-
 charged   In adult cases I have used it to the extent of half a drachm, or
 more, for several days, with success ; then, as a precaution, prescribing the
 following draught:
   R 01. ricini, 3vj.; ol. terebinth., 3y.; spts. lavand., 3j.; ess. m. pip., gtt.
 xx. M. Ft.  haust.                                       Part lx-> P- 1S'
   Santonine—A  Tasteless Worm Medicine.—This  is now recommended
  on  good authority as a remedy for worms,  especially lumbricales,  in  this

   Pantonine, one  drachm ;  sugar, five ounces ; gum tragacanth, half a
  drachm.  Make into 144 lozenges; of these a child may take  from five
  to ten daily, or santonine may be given in powder with sugar.

   Lumbricoides—Pulmonary Disease arising from the Presence of-Dr.
  Chanman <tives the following cise : I w is e.ilie 1 into emsiitatioa witli Ur
  Mou -es to a boy who, with most of  the sympto ns of pteis.s, particularly 
816
WORMS.
the copiousness  of purulent expectoration, was so much  reduced that
the portions of the bones on which he rested, had protruded through the
integuments in several places.   Discovering that his abdomen was tumid,
bis tongue  furred, his appetite  capricious  and depraved, and that he was
subject  occasionally to convulsions, I was  led to suspect the existence of
worms,  and under such an impression,  anthelmintics  were  administered.
In less than one week,  sixty-eight lumbricoides ivere evacuated, and from
that moment he became convalescent and rapidly got well. Part xl, f>- 55.
  Ascarides—Of the Rectum.—An anonymous correspondent of "Amer.
Jour,  of Med.  Sc." recommends to give an  enema with five grains of Prus-
sian blue, rubbed up in two ounces of rain water or  mucilage, and let it be
retained until the next  regular stool.  Repeat this daily, gradually increas-
ing the  qantity of the salt.                            Part xvi., p. 155.
  Ascarides.—Give camphor in three  or  five-grain doses ;  a  convenient
form is  Sir  James Murray's solution of camphor in his fluid magnesia.  Or
the same preparation maybe given in  the form of enema.  Part xvii., p. 18.
  Treatment of  Worms in Children.—The symptoms said to indicate the
presence of worms, are most of them, Dr. West remarks, of small value ;
and nothing short of seeing the worms can be regarded as affording con-
clusive evidence  of their existence.  The general treatment is, to regulate
the diet, and, give alteratives and ferruginous preparations, with  occasion-
ally a brisk cathartic.   The  special  treatment for ascarides  consists in
giving a lime-water enema, with or without  tAvo  drachms of miniated
tincture of iron ; if they have  occasioned much diarrhoea and tenesmus,
the lime-water injection should be  given daily  for tAvo or three  days
together, and  small doses of castor oil  mixture given  every six or eight
hours.  For taenia give decoction  of  the bark of pomegranate root, in
doses of §j. thrice a  day,  to  a child  seven  years old, interrupting its
administration tAvice in the week, in order to give a purge of calomel and
Rcammony.                                         Part xviii.,/). 128.
  Tape-worm  treated  by " Kousso."—The "kousso," or  bray era  an-
thelmintica (a plant of the natural order Rosacea?), Avas introduced into
notice by  a pharmacien of Paris, and  its properties  as an anthelmintic
were investigated by the Academy of Medicine so long ago as  1847.  The
report of the above-named body, as also of the Academy of  Sciences, was
extremely favorable.
  The parts of the plants used  are the  flowers, wdiich, being reduced to a
fine poAvder, are  macerated  in  lukewarm  ivater for fifteen minutes.  The
infusion, with  the powder suspended in it,  is taken either in one,  two, or
three doses, quickly following each other.   It is recommended  that lemon
juice  should be  taken freely before  and  after the  kousso.  The  patient
must be prepared by low* diet for a day previously, and the medicine taken
on an empty stomach before breakfast.  The clear  infusion  has the color,
and  a somewhat similar taste, to very weak senna tea.   It rarely causes
any annoyance or uneasiness, except  a  slight nausea, and this but seldom.
                                                     Part xxi., p. 153.
  Lumbrici.—A  combination  of assafoetida with calomel, in the form of
pills, says  Dr. Cazin,  has  succeeded better than anything in  expelling
lumbrici.   The dose of assafoetida is from  four grains to half a drachm.
The administration of three tablespoonfuls of cod oil,  at intervals of an hour
has also been followed by the expulsion of lumbrici.     Part xxi, p.  154. 
WORMS.
817
   Schmidrs Remedy for  Tape-worm.—By  the  process  of Schmidt, the
 tape-worm is said to be expelled in from three to five days, ivithout injury
 to the patient.  A trial of it was made, under the authority of government,
 in the Berlin hospital, when the results were found to be so favorable, that
 the King of Prussia  purchased the  secret through a pension of several
 hundred dollars  bestOAved  upon  the originator.   The  plan substantiates
 the purely empirical fact, that \-ermifuge  medicines, when  exhibited sepa-
 rately, are less efficacious than wdien combined in complex formulae.  The
 patient commences  by  taking, in the morning,  the  folloiving mixture :
 ft. Pulv. rad. valer. min., 3vj.; fob senn., 3ij.; aq. ferv.,  §vj.; infunde et
 cola;  adde sal. glauber. crystalb, 3iij.; syr. mannas,  §ij.; elaeosacch. tanaceti.
 3ij., M.S.  Two tablespoonfuls  every two hours, drinking freely at inter-
 vals of sweetened coffee.  With this he perseveres  till seven in the
 evening.  At noon he takes a thin gruel;  and. in the afternoon one or two
 herrings with the milt.  At eight  in  the evening the patient has a herring
 salad, with  minced raw ham, and oil, siveetened with  sugar,  plentifully
 added. Frequently portions of the tape-worm begin now to be  discharged.
 At six in  the ensuing morning,  he  commences the following pills, every
 hour :  ft.  Assafostidas, extr. graminis, aa., 3tij,; gambog., pulv.  rhei, jalap.
 aa., 3ij-; pulv. pecac, digit, purp.,  sulph.  antim.  aurat.  aa.,  9ss.; sub.
 muriat. hydr., Bij. ; ol. tanacet., aether, anisi,  aa., gt. xv.  M. Divide  into
 pills of tivo grains each, ivhich are to be placed in  a well-stoppered bottle ;
 of these, six pills are to be administered every hour with a teaspoonful of
 common sirup.    Half an  hour after the first dose, a tablespoonful  of
 castor oil is also given.  Siveetened coffee is again to be taken freely at
 intervals during  the  day.  At two in the afternoon, the  worm is usually
 wholly expelled, when the pills are to be  discontinued.   Should only sepa-
 rate portions  be voided, hoivever, the remedies are persisted  with, and a
 second dose  of castor oil  becomes  requisite.   Meat soup is  allowed at
 dinner, and in the evening.   On the succeeding day, as  an additional pre-
 caution, six pills  are  again exhibited at three different times—morning,
 noon, and evening.                                   Part xxiii., p. 124.

   Vermicularis (maw-ioorm.)—Dr. Merel uses injections of an infusion ot
 red onion, mixed wdth half a grain of extract  of aloes.    Part xxvi., p. 90.

   Tape-worm.—Prof. Osborne, of College of Physicians, Ireland, suggests
 tannic acid.  This Ave might infer from analogy Avould be beneficial from its
 action on gelatine and albumen, both of which these parasites contain.
  The seeds of the pumpkin contain a fixed oil; Prof. Paterson, Philadel-
 phia, recommends half an ounce of this given  twice a day,  followed  by an
 ounce of castor oil.                                   Part xxix.,]).  120.

  Tcpnifuge Medicines.—Prof. Strohl says :  The fruits call tcdze and zareh
are the produce of a shrub of the family of the myrsinaceas, the " myrsina
Africana."
  This plant is found  in Abyssinia, in moist, rocky places  at the Cape  of
Good  Hope, in the Azores, in Algeria, and other parts of Africa.
  Tatze is a powerful tasnifuge, Avhich has succeeded in all the six cases  in
which  it was administered.  This  number is too small to draiv any con-
clusion as regards the  constancy of its action,  but  it is  quite sufficient  to
assure us that it at least  deserves  to be  placed among the resourc -s  of
materia medica.   Tatze is less gentle in its action  than saoria. 
848
WORMS.
  As to its mode of administration, it should be given in doses  of about
half an ounce, reduced to poivder,  and blended in a ptisan or aromatic in-
fusion ; if after three hours it has not caused a motion from the bowels, or
if in stools which have followed no traces of the worm are to be discovered,
a dose of castor oil should be administered.              Part xxx, p. 65.
  Tape-worm.—Professor Bennett has found this  to be the best remedy
for  tape-worm.  Give  9ij. of the ethereal extract of the male shield fern in
the evening,  and follow this in the morning by §j. of castor oil.  Unne-
cessary, give another scruple of the extract the next ei'ening, and another
dose of castor oil the following morning.   These doses may  be  repeated
according to circumstances.                           Part xxxi., p. 94.

  Santonin as an Anthelmintic.—For round and thread-worms, Dr Perry
gives to a child two years old, three grains  of crystallized santonine,  and
about tivo hours after it a dose of calomel  and  jalap ;  in the  course of
twelve or twenty-four  hours the worms will be expelled.  Santonine  is a
medicine ivhich may be given with perfect safety, and its  effects are  cer-
tain and satisfactory                                Part xxxiv., p.  103
   Tape-worm.—The folloiving mode of administration  of male  fern is re-
commended by Dr. Jenner, University College Hospital. You must first pre-
pare the patient by clearing out the bowels and keeping on low diet.  For
an adult give two calomel and colocynth pills at night, and a dose of castor
oil in the morning ; when the bowels have  acted  well  give  one drachm
and a half of ttie oil of male fern  on some aromatic water,  and repeat in
six  hours if necessary.   The dose of the oil must be the  same for a child
as an adult.  No unpleasant results ever follow its use.  Part xxxiv., p.  105.
   Use ofKameela as an Anthelmintic.—Kameela, a native plant of India,
is said to  be much more  efficacious than kousso, and is certainly much
cheaper.   It produces  only the ordinary effect of a  purging  medicine and
little or no griping.  Dr. Gordon (surgeon to the 10th foot  regiment) has
never known it fail.  A drachm may be given mixed with a little ivater,
and repeated in  about  three hours—from one to  five doses may be neces-
sary.  A  spirituous tincture is more convenient, §iv. of the powder to Oj.
of alcohol, and filtered.  Only about  §vj.  will be  obtained  in  this way.
The dose  necessary will be from 3j. to 3uj.—3ij. being in most cases suffi-
cient.                                               Part xxxv., p.  263.
  Nitrate of Silver in Ascarides.—Dr. Schultz states that he has employed
enemata of this substance with great success for the removal of the oxyu-
ris  vermicularis which so frequently infest the anus in such large numbers.
The clyster is formed of argent, nitrat. gr. x. acl xv. to aq. dest. §iv. Two,
or at most three, of these suffice to effect a complete cure.   The first  one
does not usually remain up long, and ivorms, some living and others dead,
are returned with it.  The  next clyster remains  from six to twenty-four
hours, and the great mass of the dead ivorms are discharged with it.
                                                   Part xxxviii., jo. 91.
  Tcenia.—Dr. Peacock, of St. Thomas' Hospital, considers  kameela more
efficient than kousso, but prefers the oil of male fern to either.  The res-
inous principle of the oil is apt to be deposited from the  ethereal solution,
when the supernatant fluid is of course inefficacious.  Part xxxviii.,/?. 334. 
WOUNDS.
S49
                           WOUNDS.
   Hints on the Treatment of Wounds after Operations.—The folloAving
 brief passages are extracted from a letter which M. Phillips, of Liege, a 1-
 dressed to M. Baudens, the chief surgeon of the French army in Africa.
   After an amputation in a joint, the flaps should be  brought and  kept
 together by a few stitches, in order to promote union by the first intention ;
 but as adhesion rarely, or perhaps never, takes place betiveen  the surface
 of a cartilage and the contiguous flesh, ive  should  not only remove  so
 much of it (the cartilage) before closing the wound, but also place a small
 portion of lint upon it, so as to encourage suppuration at this point, while
 the rest is retained in exact contact.  The annals of surgery afford scarcely
 one instance of complete and  perfect union, without  suppuration  of a
 wound, after a disarticulating amputation.  We are of opinion that when-
 ever an  amputation is  performed  at a joint, an  issue or opening should
 ahvays be left opposite to the  cartilage, while  the rest of the wound is
 retained together by sutures.
   Even  after ordinary amputation, where a bone has been  sawn across,
 some surgeons  have recommended  that  the  same   practice  be  pur-
 sued ; but without positively admitting the propriety of so general a rule,
 it is worthy of remark that Avhen  the two ends of a bone are saAvn off in
 cases of  ununited  fractures, not only is there a better chance  of a union
 taking place, but this union is  always much firmer and more solid, when
 suppuration has been established at the point of junction, than when imme-
 diate adhesion of the w*ound has occurred.  Such was the opinion of M.
 Delpech; a high authority certainly on all subjects  of practical surgery.
   The success of M. Percy, after  the battle of Neubourg, deserves to  be
 alluded to, in consequence of certain circumstances.   There ivas such a
 want of  many of the most necessary articles, as lint, ointment, and  ban-
 dages, in the French camp, that all the patients were dressed  indiscrimi-
 nately with merely cold water.  It is probably to  this very circumstance
 that the great success of the  surgeons, in the results of their  operations,
 was attributable on that occasion.   For some years  past, the same practice
 has been adopted by Mr. Liston at the London University Hospital, and
 M. Phillips has  of late universally followed it with very marked  benefit,
 after almost all his operations.  In all severe injuries of, as well as after
 operations of the eye, M. P. always subjects the part to the action of the
 cold water Tor several days.  Also  after  the extirpation of tumors, when
 the lips of the wound have been brought  and kept together by several
 stitches, compresses wetted frequently with cold water, are laid invariably
 upon the part.  M.  Phillips mentions that in such  cases he generally unties
 the ligature at the loiver angle of the wound on the day after  the opera-
 tion, for  the purpose of giving exit to any bloody or  other kind of dis-
 charge, and after removing this, he  again  secures it.   On  the third  or
 fourth day  he removes one ligature, and another on each day successively;
 continuing the  use of the cold application all the time.  M. P. trusts  to
 torsion of the arteries to arrest the hemorrhage, after many such operations.
There is very little doubt  that this simple expedient, if really sutlicient  as
 a hemostatic means, must contribute  very  materially to the  speedy union
 of wounds, as each ligature on a blood-vessel must necessarily give rise  to
 a point of suppuration and to  a  minute sinus or fistula extending from the
tied vessel  to the surface of the  wound.                    Part l,p. 88.
  vol. ii.—54 
850
WOUNDS.
   Wounds after Amputation—Primary and Secondary Union of—Baron
Larrey was a surgeon eminently practical.  In his work on the surgical
cases  of the campaigns of 1815, he takes the opportunity of noticing the
mode of performing amputation in London, and  whilst he admires  the
coolness and dexterity of the surgeons, he condemns their mode of dressing
the stumps.  This condemnation, however, is  only applicable  to those
surgeons Avhose operations he witnessed, and not  to many others who do
not make a practice, as he supposes, of forcibly approximating the divided
surfaces for the purpose of promoting  union by the first intention.  Larrey
denies that the surgeon abridges the labor of nature by this process.  He
states that  as the tissues or organs of the limb  are divided more or leas
perpendicularly to the axis of the bone, there must necessarily remain at
the bottom of the wound a cavity when the superficial parts are forcibly
approximated.  This will  be especially the case when we remember  the
conical way in ivhich the  muscles are generally divided so  as to produce
a good flap to protect the extremity of the bone.  In this cavity there will
continue to accumulate the fluids that for some time are poured out of the
contiguous surfaces, which ivill necessarily  cause  distention, and perhaps
separation  of the flaps or  absorption  of  pus.  The presence of pus in the
veins is no proof of these vessels being inflamed; they may only be con-
veying this secretion from the wounded  surfaces.   Iu all amputations for
chronic diseases of the extremities, he strongly recommends, as indeed is
now adopted by many surgeons in  this country, that  the divided surfaces
be not immediately united and kept together.
   " When the tissues of an injured part are in a state of inflammation, they
are not  at  all in an  apt  condition to unite ; and the only way, in which
they can become degorged, is by the  process of suppuration being estab-
hshed.   When the operation is performed for any chronic  disease of the
extremity, as for caries of the bones,  white-swelling of the joints, or  can-
cerous or other malignant degeneration of the soft parts, 1 consider it to
be quite indispensable, if we hope to  prevent  local engorgement  and
purulent infection, that the divided surfaces be not immediately united and
Kept together;  so that the effused fluids may not be retained or forced
back upon the  system, but may ooze out from the wound as they are
formed."
   He recommends nearly the same practice in those cases ivhere amputa-
tion is adopted in consequence of recent injuries;  and confirms his opinion
by relating the want of success ivhich followed many of the amputations
at the siege of Antwerp, in consequence  of attempting to heal the parts
by the first intention, and the greater success of his own practice.   In the
former cases, the limbs were frequently not healed before  the fiftieth or
fifty-fifth day, whereas this was accomplished three weeks earlier by adopt-
ing his own method.
   Most  of our leading surgeons now adopt this practice to a greater or
less extent—Liston, for example, says, " Surfaces are not disposed to unite
for many hours after the division and separation have occurred.  So long
as oozing continues, there is no  good end  to be  achieved  by their close
•apposition.  It is only when reaction has occurred, when vascular excite-
ment around the  solution of continuity has taken place, when the whole
circulation has been roused, and ivhen plastic matter begins to be secreted
and thrown out,  that the process  can be expected  to commence.  The
edges of a  large wound, as that resulting from amputation of the extremi- 
WOUNDS.                           851
ties, may be approximated in part so soon as bleeding from the  principal
vessels and larger branches has been arrested.   But the close  apposition,
and the application of all the retentive means, had better  be delayed for
six  or  eight hours at least.  In the interval, extreme sensibility of the
injured parts may be  abated, the oozing  moderated, and the chance of
secondary hemorrhage much diminished, by covering the parts wdth  lint
dipped in cold water, and frequently renewed; or a piece of lint may be
placed  on the wound, and a constant irrigation of the exposed surface kept
for  some time hy threads  passing  from  a vessel containing cold water.
This plan is very useful ivhen  the  whole surface of a ivound is exposed.
In cases where there is a deep cavity, ivhere coagulated blood may collect,
as at the bottom of the wound after amputation of the thigh, where  the
flaps, as they always should  he, are  very long, it is much better to change
the lint frequently.'-
  Mr. Fergusson, on the other hand, is an advocate for dressing the stump
early.  On this subject he says, " Whether an  amputation is done by flap
or circular incision, it is almost the invariable practice among British sur-
geons of the present day to promote union by the first intention; and for
this purpose, as soon as the bleeding has been arrested by the application
of ligatures and otherwise, the surfaces of the wound are brought into
apposition, and retained  thus by means of stitches, straps, and bandages.
It is the custom of some to allow  several hours to pass ere the edges or
surfaces are finally adjusted  ; and this is  done with the intention of mak-
ing sure  that  all bleeding has actually ceased, and also under the convic-
tion that union is not retarded by keeping the surfaces so long from each
other.   If the edges of such a wound  are brought together immediately
after the operation, and probably whilst the patient is faint from the shock,
there is a chance of some vessel beginning to bleed after he has got ivarm
in bed; and on this account it may be necessary to undo all the dressings.
In general, hoivever,  if proper care be taken to apply  a sufficient number
of ligatures  at the time of the operation,  there will be no further trouble;
and I do not hesitate to recommend that, as a  common rule, the wound
of an amputation should be dressed whilst the patient is on the operating
table.  I have tried both ways, and have always remarked  the  additional
distress ivhich any interference  Avith the  ivound, four, six  or  eight hours
afterward, has occasioned."
  Larrey is a great enemy to the frequent dressing  of all recent wounds,
whether these be simple  or  complicated  with fracture of bones.  In  the
case of gun-shot wounds, the frequent renewal of the dressings is, we need
scarcely say, often quite impracticable ; it is therefore a matter of serious
importance to know the best mode of proceeding under such circumstances.
The authority of so  experienced a writer will  very properly command
no  ordinary  attention.  The main object of  his  instructions  seems to
be,  to place the wound in such a position  that nature is interfered with as
little as possible in the reparation of the  injury that has been  infiicted.
With this view he seeks  to maintain the part in perfect quietude, guard-
ing it from  exposure to the outivnrd air,  and maintaining a proper  tempe-
rature around it; and effecting these ends, without continiiig the patient
to bed, or even to the house.  He found  by experience  that  in  cold sea-
sons wounds were, on the ivhole, more tardy of healing—especially if they
were frequently exposed to  the air—than in  warm  ones.  He had  too
often occasion to verify the  truth of this  remark in the dreadful campaigns 
852                           wounds.
of Russia, Saxony, and France; especially when contrasted with the mem-
orable one of Egypt.  It was during these wars that the admirable effects
of his " appareil inamovible" were most conspicuous.  We were  retreat-
ing, he says, all the while, and yet unwilling to leave our wounded behind.
Accordingly, most of our patients, after  they  had their  wounds  dressed
according to  my plan, were immediately  dispatched forward, and some
of them even reached their homes in France before the original dressings
of their wounds were removed.  We  give but one instance.  A soldier,
after having his arm amputated, at  the shoulder joint, after the  terrible
battle of Moskowa, was advised to proceed direct on to his native place
in Provence, and do nothing to the wound except keep it clean by spong-
ing away any discharge from the outward dressings, and cover the limb
with a good sheep's skin, to guard it from the cold and damp air.   When
he reached home, and the dressings were removed, the wound was found
to be nearly cicatrized.  This is one of many scores of similar cases, where
the primary dressings were not removed for two, three, or even four weeks
after they had been put on.
  The following are the instructions given by  Larrey how to arrange and
apply his "appareil."  If the fracture of the limb be complicated with a
wound, we should first simplify it, as much as possible, by freely  incising
(debrider) its edges, extracting all foreign substances or pieces of broken
bone, and arresting the  hemorrhage.  When all has been done, Ave should
approximate the edges and keep them in apposition by means of  a piece
of linen  (linge fenetre) on  Avhich some balsamic substance, such as the
Styrax ointment, balsam of Mecca, etc., has  been  spread.   Pledgets  of
lint, carded cotton or tow, are then to be  placed over the  dressing, and
the anfractuosities that correspond to the ivound; also, some square com-
presses dipped in  a glutinous, strengthening  fluid, that  is prepared by
beating up the white of two or three eggs with camphorated wine  or vine-
gar, or, in lieu of these, with salt water.  These compresses should  be care-
fully applied over the whole of the injured part, while an  assistant  is en-
gaged in maintaining the fractured bone or bones in exact apposition by
appropriate extension and counter-extension.   These compresses perform
the service of immediate splints, ivithout their inconvenience.  They are
kept in their place and are moreover  strengthened  by an eighteen-tailed
bandage,  which, when  properly applied, maintains  everything firmly to-
gether.  The foot and ankle joint should previously be enveloped  in long
compresses, that have been wetted in the same fluid.  A pad of tow, of a
pyramidal shape, is to be placed under the tendo Achillis, to make  all level
and even, so that the pressure of the apparatus may be uniform through-
out.  The surgeon is then to take two cylindrical  rolls of new rye straw,
and, wrapping them up  in the  opposite edges of a  towel or small sheet,
which is to be stretched out under the leg, he applies them on each side,
haying previously interposed  two or  three flat cushions  filled with oat
chaff, to prevent the pressure of the straw rolls on the skin.  These are
secured in their place by  a good many broad tapes or  ribbons, which
should be tied over the outer roll of straw, and in such a manner that they
do not press directly upon the  crest of the  tibia.  The advantage of the
straw rolls is that they are so elastic, that, although they give way at first,
to the swelling of the limb, they continue to remain in close contact with it
as the sivelling  subsides., and no void ever exists  between it and  the ap-
paratus—an objection  to the  paste-board  splints, and other substitutes 
WOUNDS.
853
.which have been suggested of late years   As  a substitute for  the  foot-
board, I use a piece of folded sheet placed like  a stirrup under  the  sole,
some tow being previously interposed to fill  up the concavity; the two
ends are  brought up, crossed  over the instep, and then secured to the
straiv rolls with strong pins.
  The loose end of the sheet, stretched  under the leg, which extends be-
low the inferior ends of the straw-rolls,  is to be folded under the foot and
over the  ends  of  the rolls, and then firmly secured by a feAv stitches
or  pins.
  With such a simple, yet so  efficient an apparatus, the reader will  read-
ily  understand how a  patient is able to walk about with the aid of crutches,
the foot being merely suspended by a ribbon passed over the neck.  The
same apparatus is equally  well suited for fractures of the body, or of the
neck of the femur.   We have  only to lengthen the external straw-roll
as  far up as the  pelvis, and secure it  firmly by a belt passed round the
body.   The limb, in such cases, should be kept  in the horizontal position,
until the callus has become consolidated.
  The camphorated albumino-vinous wash, which we have recommended,
has the great  advantage of increasing  the tonic action of injured parts,
and of preserving their natural  heat, without obstructing  the meshes of
the linen or cotton cloth that is used in  making the  apparatus.  The thin-
ner portion of the discharge oozes out, and may be removed with a sponge,
whenever it is necessaiy.                               Part xl, p. 120.

  Punctured Wound and Ligature of the Posterior Tibial Artery.—Take
the wound as a centre, and cut down upon the vessel, and tie it both above
and below the seat of injury.  (Arnott).  If it be a case of secondary hem-
orrhage, and there is  a good deal of coagulum in the parts surrounding
the vessel, it .will be advisable to tie the femoral  artery.  When there is
a wound in the calf of the leg, with sufficient bleeding to warrant a  belief
that the posterior tibial artery  is wounded,  separate the soleus from its
 attachment to the tibia, cutting through the  deep fascia, and secure the
vessel.   (Mr. B. B. Cooper.) '                        Part xiii., p. 216.

    Wounds of the Eyelids.—Diefenbach insists strongly on the advantages
of his fine insect needles in producing union by the first intention.  A suffi-
cient number must be applied to effect exact apposition. If the edges do
not correspond, they must be made to do so by the use of fine scissors.
If  a large piece of skin be lost and the edges cannot be united, subsequent
ectropium is  avoided by making an incision a quarter of an inch from
the edge  of the wound, which allows the edges then to  be united.  Open-
ing of the lids during the healing process to be prevented by a strap of
plaster, carried over them both.  About the third or fourth day the
needles are to be carefully removed, and the  adherent wound supported
by strips of plaster, to  prevent reopening.   If the  needles are  properly
applied, no scar remains.                              Part xni., p. 313.

  Ergotine as a Styptic in Wounds of Arteries.—M. Bonjean has strongly
advised the  use  of ergotine  (ergot of rye) to  arrest  hemorrhage from
wounded arteries.  It is stated  that in a recent experiment, he divided the
right carotid  artery of a horse  by a transverse incision, ivhich comprised
one-third of the circumference of the vessel.  The hemorrhage was speedily
arrested by the application of ergotiv.e.                  Part xix., p. 192. 
854
WOUNDS.
  Severe Wounds of the Throat inflicted for the purpose of Self-Destruc-
tion.—Dr. A. M. McWhinnie arranges them thus :
  1st. Those in which the skin, superficial muscles, and vessels, are divid-
ed, and  which are the most frequent in occurrence ; 2nd, Those in ivhich
an opening  is made either  into the fauces, pharynx, larynx, trachea, or
oesophagus,  and which are next in  point of frequency; and, 3d,  Those in
which blood-vessels of large calibre, or other  parts, have been injured, so
as to cause a sudden or speedy cessation of life, and ivhich are compara-
tively rare in occurrence.
  Treatment.—If the superficial parts are simply divided, and there is no
mischief done  to  the air-passages, etc., a suture or  two,  aided  by the
approximation  of the chin to the sternum, will generally suffice.   Where
the wound has opened the pharynx, larynx, or trachea, our first object
must be to inquire as to the extent of the hemorrhage which may have
taken place, and to spare no pains, even at the risk of enlarging the  wound,
to secure by ligature every divided vessel.  Mr.  John  Bell says, that
" they are often retracted among the cellular tissue, and that ive are saved
all trouble and  care, except that of making our outward suture for  uniting
the external wound."  These observations,  coming from so eminent a
Burgeon, must carry with  them considerable authority ; but I cannot sub-
scribe to so dangerous a proceeding.  With regard to sutures, they should
be  employed only in  superficial  wounds; or, if alloivable  in deep ones,
they must  be  confined to those  cases  in which the  air-passages have
escaped.  In extensive wounds, where the cartilages of the larynx have
been injured or separated from each other, sutures are irritating  and hurt-
ful.  They cannot promote  what  never takes  place in  these parts, viz.,
union by the first intention; and by closing the  outward wound, they will
act in  the  most deleterious manner by confining the  discharge, which
should have as  free an outlet as possible.
  The wound is to be left freely open, and narrowly watched, in the event
of any  recurrence of the bleeding, when reaction has been established.
The patient should  be in a ivell-ventilated room, the liead gently raised
with pillows, and everything is  to be  avoided which may produce any
bodily irritation or mental excitement. An elastic tube is to be introduced
through the nostril, and, if the patient does not  greatly object, should be
allowed to  remain in the oesophagus.   Although it may at first produce
some inconvenience, the patient will generally become.accustomed to its
presence. When the tube is passed, it should be quickly carried  along the
floor of the  right nostril, and the finger of the left hand introduced, either
through the mouth  or wound, to guide its extremity into the pharynx.
This is  very important; for I have frequently seen  the surgeon well-nigh
foiled in his repeated attempts to introduce the instrument, in consequence
of its  hitching against, or passing into the aperture of, the glottis, which
it will be liable to do, if not properly directed by the finger of the operator.
The distress has been so great that every resistance has been offered to its
employment.   Much  of the  comfort to be derived  from our treatment
depends upon its use.  All attempts at deglutition, and even  speaking are
to be avoided, that these  extremely movable  parts  may  be  kept  as tran-
quil as possible.  Every loose portion of cartilage or other  tissue should
be carefully removed, on account of the irritation and inconvenience pro-
duced.   I have seen it necessaiy to take aAvay the epiglottis, when nearly
separated from its connections. 
WOUND8.
855
  The lightest and simplest dressings will be found best adapted to these
cases ; water-dressing, with fine linen or muslin—occasionally a light poul-
tice  placed  over the latter.   The wound should be constantly cleansed;
and if very extensive, and in the neighborhood of the glottis, the introduc-
tion and frequent renewal of soft portions of sponge will  be found very
useful in absorbing the purulent discharge which might otherwise flow into
the larynx.  The only nourishment allowed for some time should be fluids.
The individual who has thus attempted suicide should be carefully watched;
for the melancholy and  deplorable condition  in ivhich  he is placed urges
him  to resort to  every  possible means to  accomplish  his  end ; and the
strictest restraint, during the treatment, is sometimes absolutely necessaiy,
to prevent the  infliction  of  further injuiy.   Great advantage is derived
from the  administration  of opium and other narcotics,  introduced by the
oesophagus tube, or by means of enemata.
  With regard to other internal remedies, these ivill he  few and simple, in
the absence of cerebral and general febrile excitement,  which, if present,
must be combated by suitable treatment; and the great depression, both
mental and physical, often supervening upon the cessation  of the  inflam-
matory symptoms, wdll  demand the judicious employment  of stimuli.
Local and general bleeding, antimony, and mercurials, must be had recourse
to, in the  event of inflammation affecting the lining membrane of the air-
passages and lungs.
   [The plan  suggested by Mr. Liston is now*  generally adopted, of intro-
ducing a tube through the glottis, when there is  an cedematous state of
the mucous membrane ; and in those cases when dyspnasa has supervened
after some time, in consequence of excrescences or granulations encroach-
ing upon the air-tubes, Sir Charles Bell's plan  of performing tracheotomy
must be practised.]
   In general, we may augur favorably of superficial wounds of the throat.
When deep, their danger diminishes in proportion as they are remote from
the aperture  of the glottis.  Thus, wounds entering the  mouth above the
os hyoides, or dividing the larynx below the glottis—i. e., through  the
lower part of the thyroid cartilage, or between it and the cricoid, will (as
also  wounds of the trachea,  generally)  do  well;  but, for  reasons above
mentioned, we should pronounce  very unfavorably of a case where the
incision has  extended through  the thyro-hyoid membrane, through the
centre or upper part  of the  thyroid cartilage, or in any other direction
toward the rima-glottidis, by Avhich that part is exposed or injured.
  Still, however, a  great  deal of comfort may be derived from proper
treatment, and the chances of a favorable termination may  thereby be
much augmented.   These wounds,  from the  great  surface exposed, are
extremely tedious in healing—a process ivhich must  take place almost
wholly by granulations ;  and  it has been shown that the patient must not
be considered safe for a considerable time after the healing  of the external
wound.                                              Part xiv., p.  194.

   Wound of Branches of the Palmar Arch of Arteries —Gallic acid has
proved a most useful addition to our use of astringents.  Both as an ex-
ternal and internal remedy in  hemorrhages its oharacter stands high, and
justly so ; it is now generality alleged to be the active  principle  in Ilus-
pini's  celebrated styptic, which Dr.  Thompson is of opinion consists  of
gallic  acid, sulphate of zinc,  opium,  alcohol,  and  rose-water; the gallic 
856
WOUNDS.
acid evidently  being the active ingredient.  Some time since, says Dr
Hughes, I saw  the power of Ruspini's styptic put to the test in a case of
a gentleman who had some of the branches of the palmar arch of arterie.1
opened by the bursting.of a  bottle of soda water; profuse  hemorrhage
having ensued, and  attempts  to secure the bleeding vessels having been
tried in vain, graduated pressure was applied, but to such  an extent, and
for such a length of time, that sloughing of the palm of the hand ensued,
with  inflammation extending up  the forearm, and  considerable fever,
together with repeated periodical hemorrhages, by ivhich the patient was
considerably reduced; at this stage I saw the case in consultation, when
it was agreed to give a trial to this powerful styptic, and a single applica-
tion of it was followed  by  an immediate arrest of the hemorrhage, and
recovery.                                             Part xx.,p. 143.
  Prevention  of Infection from Dissecting  Wounds.—Dr.  Hargrave
directs to wash the wound (on the fingers or thumb) for a few minutes  in
cold water; then suck it, and immediately tie a ligature on the cardiac
side of the wound, so tightly as to induce numbness, and keep it on for at
least tAvelve hours.   The physiology of such treatment is explained by the
ligature causing a permanent stasis in the fluids of the parts injured on its
distal side, and producing a well-marked plethora in them; the  greater
the amount of it the greater will be the impediment to absorption, admit-
ted by all.  The  constriction caused by the ligature aa till  also oppose a
barrier to the return  of  the venous and lymphatic fluids into the system,
consequently to their being circulated through  it, so that the poison  is
prevented entering into the constitution and destroying it, which will then
be eliminated locally from the parts where it was first applied.
                                                    Part xvi, p. 209.
   Treatment of Dissection  Wounds.—Mr. B. Cooper advises not to apply
caustic, unless infection has been received from a diseased subject.  For an
ordinary dissection wound, wash the part well, wrap np in a poultice, and
keep the arm in a sling ;  take an aperient of calomel, James's poivder, and
rhubarb, followed by a saline, and go into the country for a week.
  As precautionary measures, Dr. T. Cattell would apply sticking plaster
to old abrasions, and anoint the whole surface of the hands, or wear india-
rubber gloves.  If wounded, immediately apply oil of turpentine, nitrate
of silver, strong  solution of  alum, nitric acid with  camphor, chloride of
antimony, chloride of zinc, creasote, or concentrated  solution of chloride
of soda or lime.                                      part xvi., p. 300.
   Wounds of  the Chest.—[Mr. Guthrie recommends the  treatment  of
wounds of the chest in the folloiving manner :]
  1. All incised or penetrating wounds of the chest should  be  closed  as
quickly as possible, by a  continuous suture  through the skin only, and a
compress supported  by  adhesive plasters, the  patient being  afterward
placed on the wounded side.
  2. If blood flows freely.from  a small opening, the wound should be
enlarged, so as  to show whether  it does or does not flow from within the
cavity.  If it evidently proceed from a vessel  external to the cavity  that
vessel must be secured by torsion or by ligature.                   '
  3. If blood flow from within the chest, in  a manner likely to endanger
life, the ivound  should be instantly closed ; bur as the  loss of  a reasonable
quantity  of blood in such cases, say from  two  to three pounds  will  be 
WOUNDS.
857
 beneficial rather than otherwise, this closure may be delayed until syncope
 takes place, or until a further loss of blood appears unadvisable.
  4. If the wound in the chest have ceased to bleed, although a quantity
 of blood is manifestly effused into the cavity of the pleura, the ivound may
 be left open, although covered, for a few hours, if the effused or extrava-
 sated blood should seem  likely to be evacuated from it, when aided by
 position ; but  as soon as this evacuation appears  to have been effected, or
 cannot  be accomplished, the wound should be closed.  It must, be borne
 in mind that the extravasation  which does take place is usually less than is
 generally supposed—a point which auscultation and percussion will here-
 after in all probability disclose.
  5. If auscultation and percussion should indicate that the cavity of the
 pleura is full of blood, and the oppression of breathing  and the distress are
 so great  as to  place the life of the patient in immediate danger, the wound,
 although recent, should be reopened.
  6. As  soon as the presence of even  a serous fluid  in  the chest  is ascer-
 tained to be in sufficient quantity to compress  the lung against the spine,
 and time has been allowed for the  closure of the vessel from which blood
 originally flowed, a counter-opening should be made in  the place of election
 for its evacuation  by the trocar and canula, which  may be afterward en-
 larged, unless  the reopening of the wound should  be thought preferable,
 which will not be the case unless it should be low in the chest.
                                                     Part xvii., p. 149.
  Solutions for Protecting the Skin against Contagion.—Mr. Acton has
 made various experiments with solutions of gun cotton, gutta percha, and
 caoutchouc, with a view of testing their property of protecting the surface
 from the influence, by contact, of contagious poisons, and  the  following
 are the conclusions at which he  arrived:  1. That a  solution of gun cotton,
 when dry, corrugates the  skin too much to be available for the purposes
 required.  2. That gutta percha alone is devoid  of elasticity and sufficient
 adhesive quality—that the solution of caoutchouc wants body and is too
 sticky, but that —3. The compound  solution  of caoutchouc and gutta
 percha possesses the requisite qualities to fulfill the purpose required.   It is
 prepared by adding  a  drachm of gutta  percha to an ounce of benzole,
 (the volatile principle of coal naphtha,) and ten grains of india-rubber to
 the same quantity of benzole, each being  dissolved at a gentle  heat, and
 then mixed in  equal proportions.  The author has employed this compound
 in painting the surface surrounding  a chancre, with  the  solution, and
 found that the acrid secretion had  no effect upon  it when dried, and warm
 or  cold  ivater may be  applied with impunity.  He considers that it may
 be  employed  advantageously in many and various  ways, as in protecting
 the hands during post-mortem examinations, in preserving the cheek from
 excoriation in gonorrhasal ophthalmia, and in  covering the parts contiguous
 to a sore where water-dressing is the application, etc.     Part xix., p. 208.

  Gunshot—Practice  of  " Debridement."—The  question,  as  it  now
 stands in Paris, says Dr. C. Shrimpton, may be  rendered  thus :   Should
large incisions be made to divide the aponeurotic membranes as a preven-
tive means immedately on the receipt of a gunshot wound, or not?
  Larrey, the  illustrious representative of French  military  surgery, and
his  son, the Baron, have, it is true, greatly recommended debridement, but
this practice is not continued at the present da}'. 
858
WOUXDS.
  The potent antiphlogistic remedies, constant cold application, by means
of ice or irrigations of cold water, so generally employed, have now com-
pletely superseded it.
  In most cases, submitted to a proper treatment, the  strangulation does
not take place, and these large incisions may be avoided; but when the
tumefaction does take place beneath the resisting membrane, it is time
enough to open the aponeurosis and liberate the compressed tissues.
                                                     Part xix., p. 307.
  Treatment of the Sting of a Bee.—The immediate application of honey
is good; the use  of indigo is better ; and tobacco juice is  thus  recom-
mended:  " Apply the juice of tobacco as you find it in the mouth end of
a smoked cigar, or in the reservoir of a German pipe.   It not  only imme-
diately relieves the pain, but  prevents  SAvelling."  The substance  recom-
mended is not, it must be remarked, the juice, but the empyreumatic oil
which, according to Dr.  Morris, is a much more energetic poison than the
juice.                                                Part  xx., p. 283.
  Wounds—Union of.—M. Vidal has contrived a number of minute for-
ceps of different shapes,  ivhereby the lips of the wounds, especially after
the operation for  phimosis, being gently kept in  apposition by their self-
applying pressure, the use of sutures is rendered unnecessary, the pressure
exerted not being so great as to perforate the skin. The period  for  their
application does not exceed twenty-four hours.         Part xxii., p. 259.
  Poisoned Wounds.—Dr. Maclagan, having removed the poison as much
as possible by suction, encouraging the  part  to  bleed, or excision of the
whole tract of the  Avound, applies caustic to the surface freely. Venereal
chancre may be regarded as a poisonous ivound, and according to Ricord
and others, if it is  cauterized during the first three or four days, constitu-
tional  symptoms  never follow, as  the  surface  secreting  the poison is
destroyed, and  the virus is  thus prevented getting into the system.
                                                    Part xxii., p. 345.
  Protection of Gramdating Surfaces.—[Professor Miller protects raw
granulating surfaces " from the influence of the  atmosphere,  by imitating
the incrustation of nature."   This he does by  using  " a thick semifluid
aqueous  solution of gum tragacanth."  This is]
  Laid gently and  uniformly on  the raw surface,  so as completely to
protect it ,  and if at any  portion the envelope threaten to become imperfect,
the attendant is directed to effect an immediate  repair.  The application
is productive of no irritation; and, being translucent,  permits a complete
surveillance of the part.  Atmospheric influence is completely excluded;
and the raw surface would  seem to be placed  in  circumstances someivhat
analogous to its normal state, as if still invested by the integument.  Should
inflammation ensue, no harm has  been  done; on  the  contrary, action is
likely to prove less intense  than it otherwise would have been ;  the gum
is loosened  and washed away by the  purulent  secretion ;  and  water-
dressing may then be used, as in ordinary circumstances.
                                                    Part xxiii., p. 288.
  New Forceps for Extraction of Bullets, etc.—These consist in the blades
being separate, so that one  blade at a time can be introduced into a  sinus
or cavity, and when the object is secured the handles  can be  locked lik •
the midwifery forceps.                               Pari xxxi  » 312° 
WOUNDS.
859
   Glycerine as a Dressing for Wounds.—M. Demarquay considers glyce-
rine a capital application to wounds of almost  any description, and espe-
cially if sloughy.   It is very clean, soft and  comfortable to the  patient,
and it promotes cicatrization.   The  manner of applying it  is by simply
dinninff a piece of lint into it, and placing it over the whole of the wound.
  1F  b   r                                          Part xxxiii., p. 238.
  As formulas frequently occur in this work, in ivhich mention is made  of
French weights and measures, a table is here given of the value of those
denominations which most frequently occur in pharmacy.
         FRENCH MEASURES.

MiMlitre  = 16.3 min. Brit. Apoth. Meas.
Centilitre =  2.705 fl. dr3.    Do.
Decilitre =  3.381 fl. oz.      Do.
Litre    =  1.1608 Imp. Pint.


           FRENCH WEIGHTS.

Milligramme  =   .0154 grs. English Troy.
Centigramme =   .1543 grs.    Do.
Decigramme  =  1.5434 grs.    Do.
Gramme     =  15.4340 grs.    Do. 
Dr.  W. S. Wells :
            Dear  Sir : I send you the  following compilation, written several years ago for my own use.  As it may be serviceable to students, it
is at your option to publish.  Yours, respectfully,                                                  Samuel R. Percy,  M.D., NeAV York City.


                                                A   TABLE  OF  THE  MUSCLES,

Showing the Origin,  Insertion, and Action of the Muscles  of one Longitudinal Median Section of the Human Body, not including the three Muscles
   of Hearing, the five of the Larynx, tfie Diaphragm, or Septum  Medium,  the  six  Inter-Spinal, eleven Inter-Transversal of the Neck, the five  of
   the Loins, and the (Jremaster.

                                                  Muscles  of  Facial Expression.

                                                       EPICRANIO-FRONTAL  REGION,  3.
Name.
1. Occipito-frontalis.



2. Corrugator SuperciliL




8. Pyramldalis Nasi.
 From the outer 2-3 of the superior curved line
of the occipital bone,  and from  the mastoid
portion of the temporal.

  From the inner extremity of the  superciliary
ridge.
  Is a pyramidal slip of muscular fibres sent
downward upon the nose by the occipito-
frontalis.
Insertion.
  Into  the orbicularis palpe-
brarum muscle and nasal tu-
berosity of the frontal bone.

  Into the inner  and  inferior
fleshy part  of  the  occipito-
frontalis,  where it joins  with
the orbicularis palpebrarum.

  Into the tendinous  expan-
sion of the compressores nasi.
Use.
  To raise the eyebrows, thereby throwing the integuments of the
forehead into transverse wrinkles.
  To draw the eyebrow of that side toward the other, and make it
project over the inner canthus of fhe eye.  When both act they
pull down the skin of the forehead  and make it wrinkle, particu-
larly between the eyebrows.

  Assists the occipito-frontalis in its action, draws down the inner
angle of the eyebrow, and by its insertion fixes the aponeurosis
of the compressores nasi.
AURICULAR  REGION,  3.
4. Retrahens Aurem (Auricu-
  la rls posticus.)
5. Attollens Aurem.
6. Attrahens Aurem (Aurlcu-
  Urls anticui.)
  By 2, 8, or 4 muscular slips from the mastoid
process immediately above the insertion of the
sterno-cleido mastoid muscle.
  From  the  tendon of the occipito-frontalis
where it covers the aponeurosis of the temporal
muscle.

  Thin  and membranous near the posterior
part of the zygoma at the edge of the aponeu-
rosis of the occipitp-frontalis.
  Into  the back  part  of the
ear,which is opposite to the sep-
tum  that divides the scapha
and concha.

  Into the upper part  of the
concha.
  Into  a small  eminence on
the back of the helix, covering
in the  anterior and posterior
temporal arteries.
To draw the ear back and stretch the concha.
  To draw the ear upward, and make the parts into which It Is
inserted, tense.
To draw this eminence a little forward and upward. 
PALPEBRAL  REGION,  2.
T.  Orbicularis  Palpebrarum
  (Palpebrarls Amicus.)
g. Levator  Palpebral  Supe-
  riorls.
 9.  Rectus  superior  Ocull
    (Attollens.)

10.  Rectus Inferior Ocull (de-
    pressor.)
11.
12.
 Rectus   Internus  Oculi
(Adductor.)

 Rectus   externus  Oculi
(Abductor.)
  Prom the  internal angular process  of the
frontal  bone, from the nasal process of the
superior maxillary, and from a short tendon
(tendo oculi),  which extends from the nasal
process of the superior maxillary bone to the
inner extremities of the tarsal  cartilages of
the eyelids.

  From the  under surface of the lesser wing
of the sphenoid, immediately above the optic
foramen, and  from  the fibrous  sheath of the
optic nerve.
  Into the lower border of the
tendo oculi  and  nasal _ pro-
cess of the superior maxillary
bone.
  Into the upper border  of
the superior tarsal cartilage.
CUBITO-OCULAR  REGION,  6.
18.  Obliquus superior  Ocun
    (trochlearis.)
14. Obliquus Inferior Oculi.
   Prom the margin of the optic foramen, and
 from the fibrous sheath of the optic nerve.

   Prom the inferior margin of the optic fora-
I men, by a tendon, which is common to it,
 and  the internal and external rectus  (liga-
 ment of Zinn), and from the fibrous sheath of
 the optic nerve.

   From the common tendon, .and from the
 fibrous sheath of the optic nerve.

   By two distinct heads, one from the  com-
 mon tendon, and the other with the origin of
 the  superior rectus  from the margin of the
 optic foramen; the  nasal,  third, and  sixth,
 nerves passing between its heads.

   From the margin of the optic foramen, and
 from the fibrous sheath of the optic nerve;  it
 passes forward to the pulley beneath the in-
 ternal angular process of the frontal  bone;
  its tendon is then reflected beneath the superior
  rectus, to  the outer and posterior part of the
  globe of the eye.  The tendon is surrounded
  by a synovial membrane while passing through
  the cartilaginous pulley.

    From the inner margin of the superior max-
  illary bone,  immediately  external  to the
  lachrymal  groove, and passes  beneath the
  rectus inferior.
  To shut the eye by drawing both lids close together, the flbrei
contracting from the outer angle toward the inner, press the eye-
Da™, *q"ee*e the lachrymal gland, and convey the tears toward
the puncta lachrymalla.
  To open the eye by drawing the eyelids upward which it does
completely by being fixed to the tarsus, pulling it below the eye-
brow, and within the orbit.
  Into the upper surface of>
the globe of the eye.

  Into the inferior surface of
the globe of the eye.
  Into the inner surface of the
globe of the eye.

  Into  the  outer  surface of
the globe of the eye.
  Into the tunica sclerotica, \
about half-way between  the
insertion of the attollens oculi
and the  optic nerve.
  Into the outer and posterior
part of the sclerotica at about
two lines  from  the  optic _
nerve.
   The four recti, acting singly, pull the eyeball in the four direc-
 tions of upward, downward, inward, and  outward.  Acting by
 pairs they carry the eyeball in the diagonal of these directions—
■viz  upward and inward, upward and outward, downward and
 inward, downward and outward.  Acting altogether they directly
 retract the globe within the orbit.
  The superior oblique, acting alone, rolls the globe inward and
forward,  and carries the pupil outward and downward to the
lower and outer angle of the orbit.  The inferior oblique act ng
alone rolls the globe  outward and backward,  and carries the
pupil outward and upward to the outer and upper angle of the
eye  Both  muscles acting together, draw the eyeball forward
and give  the pupil that slight degree of eversion which enables it
to admit the largest field of vision.
on 
SUPRA  MAXILLO  NASAL  REGION,   3.
Same.
16.  Compressor Nasi.
16.  Levator labli  superioris
    aUeque nasL
Origin.
17. Depressor labii  inferioris
    al«que nasi (Myrtlformis)
18. Levator  labii superierus
   proprlus.
 19. Levator anguli oris.





20. Zygomaticus major.



91. Zygomaticus minor.
  By its  apex from the canine fossa of the
superior maxillary bone, and spreads out upon
the side of the nose.
  By two distinct origins:  the first from the
external part of the orbitar process of the su-
perior maxillary bone, which forms the lower
part of  the orbit, immediately above  the
foramen infra orbitarium; the  second por-
tion arises from the nasal process of the supe-
rior  maxillary bone,  when it  joins the os
frontis at the inner canthus, descending along
the edge of  the  groove for  the  lachrymal
sac.
Insertion.
  Slightly into the interior ex-
tremity  of the  os nasi, and
nasal process of the superior
maxillary bone, which it meets
with some  of the  fibres  de-
scending from  the  occipito-
frontalis.

  The first and shortest por-
tion into the upper lip  and or-
bicularis labiorum; the second
and longest into the upper lip
and outer part of ala nasi.
Use.
SUPRA  MAXILLO  LABIAL,  4.
  Is seen by drawing upward the upper lip,
and raising the  mucous membrane; it  is a
small oval slip of muscle, situated  on each
side of the fraenum, arising from the incisive
fossa, and passing upward.

  From the lower border of the external part
of the orbitar process of the superior maxil-
lary bone.

  From the canine fossa of the superior max-
illary bone, and passes outward.
  From the os  malaj  near  the zygomatic
suture.
  Prom the upper prominent part of the os
malae above the origin of the former muscle.
  Into the upper lip and ala of
the nose.
  Into the side of  the upper
lip.  It covers in the infra or-
bital nerve and artery.

  Into the angle of the mouth,
intermingling  its fibres  with
those of the orbicularis, zygo-
matici, and  depressa  anguli
oris.

  Into the angle of the mouth,
continuous with the other mus-
cles attached to this part.

  Into the upper lip, near the
corner of  the  mouth, along
with the levator anguli oris.
  To compress the ala toward the septum nasi, particularly when
we want to smell acutely, but if the fibres  of the frontal muscle,
which adhere to it, act, the upper part of this thin muscle assists
to pull the ala outward.  It also corrugates the skin of the nose,
and assists in expressing certain passions.
  To raise the upper lip toward the orbit, and a little outward;
the second portion serves to draw the skin of the nose upward and
outward, by  which the nostril is dilated.
To draw the upper lip and aia nasi downward and backward.
To raise the Upper lip.
To draw the corner of the mouth upward.
  To draw the corner of the mouth and under lip toward the
origin  of the  muscle,  and make the  cheek prominent, as in
laughing.                                             ,

  To draw the corner of the month obliquely outward and up-
ward toward the external canthus of the eye.
on 
[XTER   MAXILLO  LABIAL,  2.
 Buccinator  (the Trum-
peter's Muscle.)
28. Orbicularis oris.
24. Depressor anguli oris (tri-
    angularis oris.)


25 Depressor labii inferioris
    (Quadratus   menti  vel
    genae.

26. Levator labii Inferioris.
27.  Platysma  Myoides  vel
    (Musculus Cutaneus.)
  Into the angle of the mouth
within the orbicularis oris.  It
is pierced opposite the second
molar tooth of the upper jaw*
for the  passage of Stenoni's
duct.
  Prom the lower jaw, as lar DacK as the last
dens molaris and fore-part of the root  of the
coronoid process, from the upper jaw, between
the last dens molaris and pterygoid process of
the sphenoid  bone  continued between both
jaws, to the constrictor pharyngis superior,
with which it joins.

  Is formed by the  muscles that move the lips, the fibres of the superior de-
scending, those of the inferior ascending, and, decussating  each other about
the corner of the mouth, run along the lips to join  those of  the  opposite side.
It is a sphincter muscle.   'Hie upper segment is attached by means of a small
muscular fasciculus (naso-labialfa) to the columna of the nose.
INFRA  MAXILLO   LABIAL,  3.
  By a broad base from the external oblique
ridge of the lower jaw.


  From the depression  by  the  side of the
symphysis of the lower jaw.


  From the incisive fossa of the lower jaw, a
number of separate, slender, fleshy fibres.
  Into the angle of the mouth,
joining with the zygomaticus
major and levator anguli oris.

  Into the orbicularis oris and
integument of the lower lip.
  Into the integuments of the
chin.
THORACO  LABIAL.
  To draw the angle of the mouth backward and outward and to
contract its cavity by pressing the  cheek inward, by which  the
food is thrust between the teeth.
  To shut the  mouth by contracting and drawing both lips to-
gether, and to counteract all the muscles that assist in forming it.
  From the cellular substance that covers the
upper parts of the deltoid and pectoral mus-
cles ; in their ascent they all unite to form a
thin  muscle which  runs  obliquely upward
along the side of the neck, adhering  to the
skin.
  Into the side of the chin, ob-
lique line of the lower jaw,
the angle of the mouth, and
into the cellular tissues of the
face.
To pull down the corner of the mouth.
  To pull the under lip and the skin of the side of the chin down-
ward and a little outward.


  To pull the parts into which it is inserted upward.
  To assist the depressor anguli oris in drawing the  skin of the
cheek downward.
  The  entire muscle is  analogous to the cutaneous muscles or
brutes, the panniculus carnosus.
Masseter.
The   Masticatory   Muscles.
   Is composed of two planes of fibres, superfi-
 cial and deep.  The superficial layer arises by
 a strong  aponeurosis from the tuberosity of
 the superior maxillary bone, and  the  lower
I border of the malar bone and zygoma,  and
1 passes backward.
   The deep layer arises from the posterior part
 of the zygoma, and passes forward.
  Into the ramus and angle of
the inferior maxillary.
  Into the  upper half of the
ramus.
  To pull the lower to the upper jaw, and by means of its oblique
decussation a little forward and backward.  This muscle is crossed
by a duct of the parotid gland, by the transverse facial artery,
and by several branches of the facial nerve.
CO 
29. Temporalis.
TEMPORA  INFRA  MAXILLARY,  2.
Origin.
Insertion.
  By tendinous fibres from the whole length of    Into the apex of the coronoid
the temporal ridge, and by muscular fibres  process,  and for  some way
from the temporal fascia, and from the  entire  down upon its inner surface.
surface of the temporal fossa.  Its fibres con-
verge to a strong and narrow tendon.        \
Use.
  To pull the lower jaw upward and press it against the upper, at
the same time drawing it a little backward.
  This muscle is covered in by a  very dense fascia  (temporal
fascia.)
00
Ci
PTERYGO   INFRA  MAXILLARY,  2.
81.
 Pterygoideus
(minor.)
 Pterygoideua
(major.)
lnternus
  From the pterygoid ridge on the greater ala
of the spheroid, and from the external ptery-
goid plate, and tuberosity of the palate bone.
  From the inner and upper part of the inter-
nal plate of the pterygoid process, filling all
the space between the two plates, and from
the pterygoid process of the os palati between
these plates.
  Into the neck  of the lower
jaw, and inter-articular fibro-
cartilage.


  Into the ramus and angle of
the lower jaw internally.
  To pull the lower jaw forward and to the opposite side, and to
pull the ligament from the joint, that it may not be pinched dur-
ing these motions.  When both external pterygoid muscles act
the fore teeth of the under jaw are pushed forward beyond those
of the upper jaw.

  To draw  the jaw upward  aud obliquely toward the opposite
side.
Muscles of  Deglutition.
PTERYGO  STAPHYLIN,  6.
82. Levator palati (mollis.)
83.  Oircumflexus,  or tensor
    palati.
84.
Azygog  uvulae  (levator
uvulae.)
85 Palato pharyngeus.
   From the extremity of the pars petrosa of
 the temporal bone, where it is perforated by
 the eustachian tube, an4 also from the mem-
 branous part of the same tube.

   From the spinous  process of the sphenoid
 bone behind the foramen ovale; from the eus-
 tachian tube  not far from its  osseous part,
 and then runs down  the pterygoideus inter-
 nus,  passes over the hook of the internal
 plate of the  pterygoid process, by  a round
 tendon, which soon spreads into a broad mem-
 brane.

   Is a  pair of small muscles placed side by
 side  in the middle  line  of the soft palate.
 They arise from the spine of the palate bone.

j   From the  middle  of the velum pendulum
  Into the whole length of the
velum pendulum palati, as far
as the root of the uvula.
  Into  the  velum  pendulum
palati, and the semi lunar edge
of the os palati, and extends
as far- as the suture, which
joins the two bones.
Into the apex of the uvula.



Into the muscular structure
  To draw the velum upward and backward, so as to shut the pas-
sage from the fauces into the mouth and nose.
  To stretch the velum, to draw it downward, and to a side toward
the hook.
Raises the uvula upward and forward, and shorteas it.



Draws the uvula and velum downward and backward, and at 
*1
o
r  86.  Constrictor  isthml fau-
       cium (palato-glossus.)
palati, at the root  of the uvula posteriorly,
and from the tendinous expansion of the cir-
cumflexus palati.


  From the side of the tongue near its root;
runs upward within the anterior arch before
the amygdalia.
of the pharynx and posterior , the• »££- ?^*&"SS^^^J^S^VSt
border of  the thyroid  carti-  «d*^»It >£*£e'ZZ\he nostr?ls.  and, in swallowing, K
"*8e-                         thrusts the food from the fauces into the pharynx.

            ....   #.v„„„i.,m     Draws the velum toward the root of the  tongue, which It raises
  ™tortM*«^^%\^*^*^mi*1»h it, fellow contracts the passage be-
?h\nnvula aPnteriorlV          I tween thTtwo arcies, by whichit shuts the opening into the fauces.
Ot
87. Constrictor pharyngls in-
    ferior.
 Constrictor   pharyngis
medius.
Constrictor pharyngk su-
perior.
40.  Stylo-pharyngeus.






41. Lingua'is.



42. Genio-hyo-glossus.




 43. Hyo-glossus.
PHARYNGEAL,   4.
  From the side of the thyroid cartilage, near
the attachment of the thyroideus and thyreo-
hyoideus muscles; and from the cricoid car-
tilage near the crico-thyroides.

  From the appendix of the os hyoides; from
the cornua of that bone, and from the liga-
ment which connects it to the  thyroid car-
tilage.


   Above from the cuneiform process of the os
occipitis, near the holes where the ninth pair
of nerves pass out, lower down  from the
pterygoid  process of  the  sphenoidal  bone;
from the upper and under jaw near the roots
of the last dentes molares;  and between the
jaws it is continued with the buccenator muscle
 and  with some fibres from  the  root of the
 tongue and from the palate.

   From the root of the styloid process.
  Into the white line in the
middle of the pharynx.
  Into the middle of the cunei-
form process of the os occipi-
tis, and joined to its  fellow at
a white line in the middle back
part of the pharynx.

  Into the middle of the pha-
rynx, where it U  overlapped
interiorly by  the  constrictor
medius.
  Into the side of the pharynx
and back part of the thyroid
cartilage.
  Prom the root of the tongue laterally runs
forward between the  hyo-glossus and genio-
  From a rough protuberance in the inside of
the middle of the lower jaw.  Its fibres run
like a fan, forward, upward, and backward.


  From the base, cornua, and appendix of the
os hyoides.
GLOSSAL,  4.

  Into  the  tip of the tongue
along with  part of  the stylo-
glossus.

  Into  the whole length of the
tongue, from its base to the
apex, and into the base of the
os hyoides,  near its cornua.

  Into the side  of the tongue
between the stylo-glessus and
lingualis.
  To compress that part of the pharynx which it covers, and to
raise it with the larynx a little upward.
  To compress that part of the pharynx which it covers, and to
draw it and the os hyoides upward.
  To compress the upper part of the pharynx, and draw h for-
ward and upward.
To dilate and raise the pharynx and thyroid cartilage upward.
  To contract the substance of the tongue and bring it backward,
and to elevate the point of the tongue.


  Acccording to the direction of its fibres to draw the tip of the
tongue backward  into the mouth, the middle downward, and to
render its dorsum concave, to draw its root and os hyoides for-
ward, and to thrust the tongue out of the mouth.
To pull the tongue inward and downward.
CO 
Name.	Origin.	Insertion.	Use.
44. Stylo-glossus.	From the styloid process and stylo-maxillary ligament.	Into the root of the tongue, runs along its side, and is in-sensibly lost near its apex.	To draw the tongue laterally and backward.
45. Stylo-hyoideus.
46. Digastrlcus.
 47.  Mylo-hyoideus.





 48.  Genio-hyoideus.








 49. Thyro-hyoldeus,



50. Sterno-thyroideus.



51. Sterno-hyoldeus.
SUPRA  HYOIDAL,  4.
  By a round tendon,  from the middle and
Inferior  part  of  the  styloid process  it  is
pierced  by the  tendon  of the  digastricus
muscle.

  From the digastric fossa immediately be-
hind the  mastoid process  of the temporal
bone; it is fleshy  at each extremity, and ten-
dinous in the middle.
  From the molar ridge on the lower jaw, and
proceeds  obliquely inward; it is a broad tri-
angular plane of muscular fibres, forming
with its fellow of the opposite side the inferior
wall or floor of the mouth.

  From a small tubercle upon the inner side
of the symphysis of the lower jaw.
  Into the os hyoides at the
junction  of  the  base  and
cornua.
  Into  a depression  on  the
inner side of the lower jaw,
close to the  symphysis.  The
middle  tendon is held in con-
nection  with the body of the
os hyoides, by an aponeurotic
loop through which it plays as
through a pulley;  the  loop
being lubricated by a synovial
membrane

  Into  the raphe of the two
muscles, and into the base of
the os hyoides.
  Into  the
hyoides.
body of  the  os
To pull the os hyoides to one side and a little upward.
  To open the mouth by  pulling the lower jaw downward and
backward, and when the jaws are shut to raise the  os hyoides,
and consequently the pharynx upward, as in deglutition.
To pull the os hyoides upward, forward, and to a side.
To pull the os hyoides toward the chin.
                      Muscles   of  the   Neck.

HYOIDO-THYROIDAL,  OR  ANTERIOR  SUPERFICIAL  CERVICAL,  4.

  Prom the oblique line on the thyroid carti-
lage.  It is a continuation upward of the sterno-
thyroid.

  From the posterior surface of the upper
bone of the sternum, and from the cartilage of
the first rib.

  From the cartilaginous  extremity  of the
first rib, the upper and inner part of the ster-
num, and from the clavicle where it joins with
the sternum.
  Into the lower border of the
body, and great cornua of the
os hyoides.

  Into the oblique line on the
great ala  of the  thyroid car-
tilage.

  Into the base  of the os hy-
oides.
  To pull the  os hyoides  downward, or the thyroid  cartilage
upward.
To draw the larynx downward.
To pull the os hyoides downward. 
62.  Omo-hyoideus.
  From the upper border of the scapula, and I   Into the base of the os hy-
from  the  transverse Ugament of the supra  oides between its cornua ana
scapular notch.                             the  insertion  of the sterno-
                                          | hyoideus.
To pull the os hyoides obliquely downward.
53.  Rectus anticus major.



64. Rectus anticus minor.


55. Longus colli.
ANTE-TRACHELIAN,  OR  DEEP   ANTERIOR  CERVICAL,  3.
|   From the anterior tubercles of the trans-
i verse processes of the third, fourth, fifth, and
 sixth cervical vertebras.

   From the anterior border of the lateral mass
 of the atlas.
  Into the basilar process of
the occipital bone.


  Into the basilar process.
  The upper portion arises from the anterior    Into the transverse processes
tubercle of the atlas.                       I of the third  fourth and fifth
  The lower portion from the  bodies  of  the  cervical vertebra?, into the bo-
second and third, and  transverse processes of  dies of  the three lower cervi-
the fourth and fifth vertebras.                 cal  and  three  upper  dorsal
                                          | vertebras.
To bend the head forward.



To bend the head forward.


To bend the neck gradually forward and to one side.
66.  Rectus capitis lateralis.
67. Scalenus anticus.
68. Scalenus posticus.
69. Sterno-cleidc-mastoideus.
               LATERO-TRACHELIAN,  OR  LATERAL  CERVICAL,   4

From the transverse process of the atlas
  From  the anterior tubercles of the trans-
verse processes of the third, fourth, fifth, and
sixth cervical vertebras.
i   From the posterior tubercles of all the cer
 vical vertebrae, excepting the first.
  Into the os occipitis opposite I   To bend the head a little to one side.
the  foramen  stylo-mastold
curve of the temporal bone.   J

  Into the tubercles upon the
inner border of the first rib.
The  phrenic  nerve and sub-
clavian vein lie on this muscle,
and the subclavian artery be-
hind it.
                                            By two fleshy strips into the
                                          first and second ribs.  Hence
                                          the scalenius medius and pos-
                                          ticus of some anatomists.

  Arises by two distinct origins : the anterior 1   By a  thick  strong  tendon
from the top of the sternum, near its junction  into the mastoid process which
with the clavicle; the posterior from the upper  it surrounds;  and _ gradually
and anterior part of the clavicle; both unite a  turning  thinner is  inserted as
little  above the anterior articulation of the  far  back  as  the  lambdoid
clavicle, to form one muscle which runs ob- | s
liquely upward and outward.
  The scaleni muscles taking their fixed point from below are
flexors of the vertebral column, and from above elevators of the
ribs, and therefore inspiratory muscles.
  To draw the head to one side, and betid it forward.  This Is the
great anterior muscle of connection between the thorax and the
head   The anterior border of this muscle is the guide for the In-
cisions in ligature of the carotid artery.  It is pieroed at it. upper
third by the spinal accessory nerve.
CO 
POST-TRACHELIAN,  OR  DEEP  POSTERIOR  CERVICAL,  4.
Name.
60.  Reotus  posticus  major
    (capitis.)
61.  Rectus  posticus  minor
    (capitis.)
62. Obliquus superior (capitis)


63. Obliquus inferior.





64, Splenius.
65. Trachelo Mastoldeua.
66. Complexus.
Origin,
From the spinous process of the axis,
From the spinous tubercle of the atlas.
  From the extremity of the transverse pro-
cess of the atlas.

  Prom the spinous process of the axis.
Insertion.
  Into the Inferior curved line
of the os occipitis near the
rectus capitis lateralis, and the
Insertion of the obliquus capi-
tis super.

  Into a rough surface of the
occipital bone, beneath the in-
ferior curved line.

  Into the os occipitis near the
rectus posticus major.

  Into  the  extremity  of the
transverse process of the atlas,
US4.
00
To pull the head backward, and assist a little in IU rotation,





To assist the reotus major.



To draw the head backward.


To give a rotary motion to the head.
POST-TRACHELIAN,  OR  MEDIAN  POSTERIOR  CERVICAL,   3.
  Is single at its origin, but divides soon after
into two portions, which have different inser-
tions.
  Prom the spinous processes of ten vertebras,
the four lower cervical and six upper dorsal,
and divides, as it  ascends the neck into the
S. capitis and S. colli.
  From the transverse processes of the four
upper dorsal and four lower cervical vertebras.

  From the transverse processes of the four
upper dorsal and four lower cervical vertebrae,
It is a large muscle,  and with  the splenius
forms the great bulk of the back  of the neck.
  The splenius capitis into the
rough surface of the occipital
between the two curved lines,
and into the  mastoid portion
of the temporal,
  The S. colli into the posterior
tubercles  of  the  transverse
processes  of  the  four upper
cervical vertebras.

  Into the mastoid process.
  Into the  rough surface  on
the occipital bone between the
two curved lines, and near to
the occipital spine.
  To bring the head and upper vertebras of the  neck baokward
laterally, and when both act to pull the head dkeotly backward.
To assist the complexus, but it pulls the head more to one side.
  To draw the head backward and to one side.
  A portion of the  complexus is named blventer cervicls, from
consisting of a central tendon, with two fleshy bellies.
CT. Peotoralls major.
        Muscles  of  the   Thorax.

ANTE-COSTAL  OR  ANTERIOR  THORACIC,  3.
  From  the sternal 2-8 of the clavicle; from
I the breadth of sternum its whole length;
and from the cartilages of all the true ribs,
except the first.
  By a broad tendon into the
anterior bicipital ridge of the
humerus.
  To move the  arm forward and obliquely upward, toward the
sternum,  That portion of  the  muscle which  arises  from the
clavicle, is separated from that connected with the  sternum, by a
distinct  cellular interspace; hence we speak of the clavicular
portion and sternal portion of the pectoralls major. 
68.  Pectoralls minor.
69.  Subclavius.
  Prom the upper edge of the third, fourth,
and fifth ribs, near where they join with their
cartilages.
  Into the inner and  upper
surface of  the  coracoid pro-
cess of the scapula.
  By a round tendon from the cartilage of the    Into the under surface of the
first rib.                                    clavicle.
  To bring the scapula forward and downward, and to  raise the
ribs upward.


  Draws the clavicle downward and forward, and thereby assists
in steadying the shoulder.  This muscle is concealed by the costo
coracoid membrane, an extension of the deep  cervical  fascia, by
which it is inserted.   These three muscles are agents in forced
respiration, but are unable to act until the shoulders are fixed.
TO. Serratus magnus.
                                     LATERI  COSTAL,  1.

By  fleshy serrations from the nine upper i   Into the whole length of the
ribs, excepting the  first, and extends back-
ward upon the side of the chest.
base of the scapula.
  Is the great external inspiratory muscle, raising the ribs when
the shoulders are fixed, and thereby increasing the cavity of the
chest.  Acting upon the scapula it draws the shoulder forward, as
we see to be the case in diseased  lungs, where  the chest has be-
come  almost fixed, from apprehensions of the expanding action
of the respiratory muscles.
POST  COSTAL,   OR  POSTERIOR  THORACIC,   2.
Tl Serratus posticus superior. I   Prom the spinous processes *>f the two last
                            cervical and two upper dorsal vertebrae.
T8.  Serratus posticus inferior.
  From the spinous processes of the two last
dorsal and two upper lumbar vertebrae.
  By four serrations into the
second, third, fourth, and fifth
ribs.

  By four serrations into the
four lower ribs.
To elevate the ribs and dilate the thorax.
To depress the ribs into which it is inserted.
DEEP   COSTAL,  OR  INTERNAL  THORACIC,  23.
T3. Inter-costale*  extern!, 11
    in number on each side.
T4. inter-costales intend, 11
    on each side.
T5. Triangularis sterol.
  From the Inferior acute edge of each supe-
rior rib, and run obliquely forward, the whole
length  from the spine to near the Joining of
the ribs with their cartilages; from which to
the sternum, there is only a thin membrane
covering the internal lnter-costals.

  In the  same manner as the external; but
they begin at the sternum and run obliquely
backward as far as the angle of the rib; from
that to the spine they are wanting.

  By a thin aponeurosis from the side of the
sternum, cuneiform cartilage, and sternal ex-
tremities of the costal cartilages.
  Into the upper obtuse edge
of each inferior rib, as  far
back as the spine, into which
the posterior portion is fixed.
   To raise the ribs when they act from above, and depress them
. when they take their fixed point from below.  They are, there-
 fore, both inspiratory and respiratory muscles.
  In the same manner as the
external.                   J
  Into  the  cartilages  of the
third, fourth, fifth, and sixth
rlbt, and often into the second,
  To depress these cartilages and the extremities of the ribs, and
consequently to assist In contracting the cavity of the thorax.
00 
       Scapular   Muscles.

SUPRA  AND  INFRA  SCAPULAR,  8.
oo
Name.
76. Trapezius, or (Cucularis.)
77. Rhomboideus, or  inferior
    major.


    Or superior minor.
78. Levator anguli scapulas.
Origin.
Insertion.
  From the superior curved line of the occipi-    Into the scapular third of the
tal  bone;  from  the  ligamentum  nuchas,  clavicle, the acromion process,
supra spinqus ligament, and spinous processes  and  the  whole length of the
of the last cervical and  all the dorsal verte- | upper border  of the spine  of
bras.  The fibres converge from these various I the scapula.
points..

  From the spinous processes of the four, five,    Into the posterior  border of
or six upper dorsal vertebra?, and from the  the scapula, as far as its  infe-
supra spinous ligament.                    . I rior angle below the spine.
  From the spinous processes of the two last
cervical vertebras and ligamentum nuchas.
  By distinct slips from the posterior tubercles
of the transverse processes of the four upper
cervical vertebras, which soon unite.
  Into the  edge of the trian-
gular surface, on the posterior
border of the scapula  above
the spine.

  Into the upper angle  and
the  posterior  border  of  the
scapula as far as the triangu-
lar smooth surface at the root
of its spine.
Use.
  Moves the scapula according to the three different directions of
its fibres.
  To draw the scapula obliquely upward, and directly Inward, or
rotator of the scapula.
To pull the scapula upward and a little forward, and rotate.
SUPERFICIAL  SCAPULAR,  4.
 79.  Supra spinatus.





 60. Infra spinatus.



 81. Teres minor.





82. Teres  major.
  From all that part of the base of the scapula
that is above the spine; also from  the spine
and superior costa; passes under  the acro-
mion, and adheres to the capsular ligament of
the os humeri.

  From all that part of the base of the scapula
that is between its spine and inferior angle.
  From all the round edge of the inferior
border of the scapula.
  From the lower third of the inferior border
of the  scapula, encroaching  a little  upon its
dorsal aspect.
  Into that part of the large
protuberance on the head  of
the os humeri, that is next the
groove for lodging the tendon
of the long head of the biceps.

  Into the  middle depression
upon  the great tuberosity  of
the humerus.

  Into the  back part of the
large protuberance on the head
of the  os humeri, a little be-
hind and below the termina-
tion of the infra spinatus.

  In common with the tendon
of the latissimus dorsi into the
posterior bicipital ridge.
  To raise the arm upward, and at the same time to pull the cap-
sular  ligament  from between the  bones, that it may  not  be
pinched.
  To roll the humerus outward; to assist in raising and supporting
it when raised, and to pull the ligament from between the bones.
  To roll the humerus outward, and draw it backward, and pre-
vent the ligament being pinched.
  To roll the humerus inward, and draw it backward and down
ward. 
83. Sub-ecapolaris.
DEEP  SCAPULAR,  1.
  From the whole' of the under surface of the
scapula, excepting the superior angle.
  The tendon of this muscle  forms a  part of
the capsule of the joint, and communicates
with the synovial membrane of the' articu-
lation.
  Into the lesser tuberosity of
the humerus.
  To roll the humerus inward, and to draw it to the side of the
body, and to prevent the capsular Ugament being pinched.
84. Deltoid.
85. Triceps extensor cublti.
80. Biceps flexor cublti.
Muscles  of   the  Arm.
     SUPRA  HUMERAL,  1.
  Fleshy,  from all the posterior part of the
 clavicle that the pectoralis major  does not
 possess; tendinous and fleshy from  the acro-
 mion, and lower margin of almost the whole
 spine of the scapula opposite to the insertion
I of the trapezius.  The fibres from this broad
| origin converge to the middle of  the outer
 side of the humerus.
  Into a rough protuberance in
the outer side of the os humeri,
near its  middle,  where  the
fibres of this muscle intermix
with some parts of the bra-
chialis externus,
  The Deltoid Is the elevator of the arm In a direct line, and by
means of its extensive origin can carry the arm forward or back-
ward, so as to range with the hand a considerable segment of a
large circle.
POST  HUMERAL,  OR  POSTERIOR BRACHIAL,  1.
                                                     Extensor of the forearw.
   The external head arises from the humerus
 Immediately below the insertion of the teres
 minor.  The  external head (short) from the
 humerus immediately below the insertion of
 the teres major.  The scapular head (long)
I lies between the two others, and arises from
 the upper third of the inferior border of the
 scapula.  The three heads unite and form a
| broad muscle.
  By an  aponeurotic tendon
into the olecranon process of
the ulna; a small bursa is situ-
ated between its tendon ahd
the upper part  of  the ole-
cranon.
ANTE-HUMERAL,  OR  ANTERIOR  BRACHIAL,  3.
  By a strong roundish tendon
into the tubercle on the upper
end of the radius internally.
  By two tendons; the short head from the
coracoid process  of the scapula, in  common
with the  coraco  brachialls;  the  long  head
from the  upper edge of the glenoid cavity of

  ThTione head, a long slender tendon passes through the capsular ligament
of the  shoulder joint, inclosed in a sheath of the  synovial membrane; after
leaving the cavltv of the joint, it is lodged in the deep groove that separates
the two tuberosities of the humerus, the bicipital_ groove.  A small synovial
bursa is interposed between the tendon of insertion and the .tubercle of the
radius   At the bend of the elbow, the tendon of the biceps gives off from its
inner side a broad tendinous band, which protects  the brachial artery, and is
continuous with the fascia of the forearm.
Flexor and supinator of the forearm,
 
          Nam*.

87. Coraco-bracbialis,
88.   Brachial]*  anticus
    ternus).
(in-
89. Supinator Longus.
90.  Extensor carpi  radlalis
    longior.
91. Extensor digitorum com-
   munis.
92.  Extensor  minimi  digit!
    (auricularis).
98. Extensor carpi ulnaris.
                 Origin.

  From  the forepart  of the coracoid process
of the scapula, adhering in its descent to the
short head of  the biceps.
  Fleshy, from the middle  of the os humeri,
at each  side of the insertion of the deltoid,
covering all the inferior and forepart of this
bone, runs over the joint, and adheres firmly
to the ligament.
         Insertion.

  About the middle of the in-
ternal part of the  os humeri,
near the  origin  of  third  head
of the triceps, whence it sends
down a thin tendinous expan.
eion to the internal condyle of
the os humeri

  By a strong tendon Into the
coronoid process of the ulna,
                           Use.

  Draws the humerus Inward and assists in flexing it upon the
scapula.
  Flexor of the forearm.  It is a powerful protection to the elbow
Joint.
00

to
Muscles   of  the   Pore-Arm.
      SUPERFICIAL ANTEBRACHIAL,  10.
   From the external  condyloid ridge of the l   Into the base of the styloid
 humerus, nearly as high as the insertion of the  process of the radius.
 deltoid.

   From the external condyloid ridge below the    Into the base  of the meta-
 preceding.   Its tendon  passes  through  a I carpal bone  of  the   Index
 groove in the radius immediately behind the  finger.
 styloid process.

   From the external condyle.                   Into the second and  third
                                           phalanges of  all the fingers.
  Before it passes under the ligamentum  carpi annulare externum it divides
 Into four tendons.  Opposite the first phalanx each tendon spreads out so as
 to form a broad aponeurosis, which covers the whole of the posterior aspect of
 the finger.  At the first joint the aponeurosis divides into the three slips.   The
 middle slip is inserted into the base of the second phalanx, and the two lateral
portions are continued outward on each side of the joint to  be inserted  into
the last.  Little oblique tendinous slips connect the tendons of this muscle as
they cross the back of  the hand.
  Is an offset from the extensor communis,
It assists in forming the tendinous expansion
on the back of the little finger.
  From the external condyle of the os hu.
merus, and from the upper 2-3 of the border
of the  ulna.  Its tendon passes  through the
posterior groove in the lower extremity of the
ulna.
Into the two last phalanges,
  Into the  base of the meta-
carpal bone of the little finger.
  To roll the radius outward, and  consequently the palm of the
hand upward.


  To extend and bring the hand backward,
  Restores the fingers into the straight position, after being flexed
by the two flexors—sublimis and profundus,
  It is to this muscle that the little finger owes Its power of sepa-
rate extension;  and from being called into action when the point
of the finger is introduced into the meatus of the ear for the pur-
pose of removing unpleasant sensations; the muscle was called
by old writers "Auricularis."

  Assists in extending the hand. 
94.  Anconeus,



95. Plexor carpi ulnarls.




96. Palmaris brevis.


 97. Palmaris Iongus.



 98. Pronator radii teres.
99.  Extensor carpi radialis
    brevlor.
100. Flexor sublimis digitorum
    (perforatus).
  From  the  posterior part of the external
condyle of the os humeri.


  By two heads—one from the inner condyle,
and the other from the olecranon and upper
2-8  of the  inner border  of the ulna.  The
ulnar nerve passes between its two heads.

  From the palmar fascia, and passes  trans-
versely inward.

  From the internal condyle of the os humeri,
and  from the  sheath  of  fascia Which sur-
rounds it.

  By two heads—one from the inner condyle
of the humerus and fascia of the forearm, the
other from  the  coronoid process of the ulna.
The median nerve passes between them.
  Into the olecranon  and tri-
angular surface on the upper
extremity of the ulna.

  Into the pisciforme bone and
base of the metacarpal bone
of the little finger.
  Into the integuments on the
inner border of the hand.

  Into the palmar fascia.
  Tendinous into  the  middle
third of the oblique ridge of
the radius.
MIDDLE   ANTE-BRACHIAL,  2.
  From the external condyle of the humerus.
Its tendon is lodged in the same groove of the
radius, with the extensor carpi radialis longior.

  From the inner condyle, coronoid process of
the ulna, and oblique  line  of the radius.  The
median nerve and ulnar artery pass between
its origins.
  Into the base of the meta-
carpal  bone  of the  middle
finger.

  Divides  into  four tendons,
which are inserted into  the
base of the second phalanges
of the finger, splitting at then-
termination to give passage to
the tendons of the deep flexors
(thence perforatus.)
Assists in extending the forearm.



Flexor of the wrist.




To assist In contracting the palm of the hand.


Tensor of the palmar fascia.



Rotates the radius upon the ulna and the hand Inward.


t




To assist in extending the hand.



Flexors of the second phalanges.
RADIO-CUBITAL,  OR  DEEP  ANTE-BRACHIAL,  8.
                             From the upper 2-3 of the radius, and part
                           of  the interosseous membrane.  Its  tendon
                           passes beneath the annular ligament.

                             From the middle and  posterior part of the
                           ulna, immediately below the insertion of the
                           anconeus, from  the  posterior  part  of the
                           middle of the radius, and from  the  interos-
                           seous membrane.

1 (W Fxtensor miml internodii !   From the interosseous membrane and radius,

     DolncU.                an<1 Passes through the Same  gr0°Ve aS
   ,                       I former.
101. Flexor Iongus pollicls.
102. Extensor ossta metacarpi
     pollicis.
  Into  the base of the last
phalanx of the thumb.
  Into  the base of the meta-
carpal  bone  of the  thumb.
Its tendon passes through the
groove  immediately in front of
the styloid process of the radius

  Into  the  base of the first
phalanx of the thumb.
Flexor of the last phalanx of the thumb.
Extends the meta-carpal bones of the thumb.
Extensor of the first phalanx of the thumb.
 
Name.
104.  Extensor  secundi inter-
     nodii pollicis.
105. Extensor indicia.
106. Flexor  profundus  digi-
    torum (perforans.)
107. Supinator brevis.
108. Pronator quadratus.
100. Abductor pollicis.


110.  Flexor ossis metacarpi
    (opponens pollicis.)

111. Flexor brevis pollicis.
112. Adductor pollicis.


113. Abductor minimi digitl
114.  Flexor
    digiti.
brevis  minimi
                 Origin.

  From the ulma and interosseous membrane.
Its tendon passes through a distinct canal in
the annular ligament.

  From the _ ulna as high as the ex. ossis
metac. pollicis, and from the interosseous mem-
brane.  Its tendon passes through  a distinct
groove in the radius.

  From the upper 2-8 of the ulna, and part of
the interosseous  membrane, and terminates
in four tendons, which pass  beneath the annu-
lar ligament, and between the two slips of the
tendons of the flexor sublimis  (hence per-
forans.)

  From the external condyle and  external
lateral ligament, and winds round the upper
part of the radius.

  From the lower and inner part of the ulna.
Insertion.
 Into the  base of the last
phalanx of the thumb.
  Into the aponeuroses formed
by the common extensor ten-
don of the index finger.
  Into the base of the
phalanges.
last
  Into  the  head, neck, and
tubercle of the radius.
  Into the lower one-fourth of
the oblique line of the radius.
Extensor of the second phalanx of the thumb.
Extensor of the second phalanx of index finger.
Common flexor of the third phalanges of the fingers.
Rotator of the fore-arm outward.
Rotator of the fore-arm inward.
Muscles  of  the   Hand.
METACARPO  CARPAL, OR   SUPERFICIAL  PALMAR,   7.
  From  the scaphoid bone and annular liga
ment.

  Prom the trapezium and annular ligament.
   Consists of two portions, between which lies
 the tendon of the flexor iongus pollicis.   The
 external portion arises from the trapezium
 and annular ligament; the  internal portion
 from the trapezoides and os magnum.

 Fleshy from almost the whole length of the me-
tacarpal bone, that sustains the middle finger.

  From the pisciform bone, and from that part
of the ligamentum carpe annulare next to it.

  From the unciform  bone and annular liga-
ment.
  Into the base of  the  first
phalanx.

  Into the whole length of the
metacarpal bone.

  They are both inserted into
the base of the  first phalanx
of the thumb, having  a ses-
moid  bone in each  of  their
tendons, to protect the joint.

 Into the inner part of the root
of the 1st phalanx of the thumb.

  Into the base of  the  first
phalanx of the little finger.

  Into the inner and anterior
part of first phalanx of the
little finger.                 j
Bends the thumb toward the radius.


Rotates the thumb toward the palm.


Flexor of the first phalanx of the thumb.





To pull the thumb toward the fingers.


Bends the little finger toward the ulna.


Flexor of the first phalanx of little finger.
co 
115.  Flexor ossis  metacarpl
    (adductor opppnens.)
  From the unciform bone  and annular liga-
ment.
  Into the whole length of the
metacarpal   bone  of  little
finger.
Rotates the little finger toward the palm.
116.  Lumbricales  (four
    number.)


117.  Interossei palmares.

     Interossei pollicis.

118. Interossei indicis.

119. Interossei annularis.

120. Interossei auricularis.

121. Interossei dorsales.

122.

123.

124.
125.  Obliquus  externus ab-
    dominis, descendens.
METACARPO  PHALANGEAN, OR  DEEP  PALMAR,  12.

                                                         Cooperative with the flexors of the fingers.
126.  Obliquus  internus
    dominis, ascendens.
  From the radial side of tendons of the deep
flexor (four in number.)
  From the base of the metacarpal bone of
one finger.
  Are bipenniform muscles, and arise by two
heads from the adjoining sides of the base of
the metacarpal bones.
  The radial artery passes into the palm of the
hand between the two  heads  of the first dor-
sal interosseous muscle anjl  the  perforating
branches of the deep  palmar arch between
the heads of the other dorsal interossei.
  Into the aponeurotic exten-
sion of the extensor tendons on
the radial side pf the fingers.
  Into the base of  the  first
phalanx and  aponeurotic ex-
pansion of the extensor  ten-
don  of  the same  finger, the
middle finger  being excluded.
  Into the base of  the  first
phalanges and aponeurosis of
the extensor tendons.   The
first is inserted into the index
finger; the second and  third
injo the  middle finger,  com-
pensating its exclusion  from
the palmar group ; the fourth
into the ring finger.
Adducts the thumb, or inclines it toward the ulna.



Adducts the fore finger and bends it toward the ulna.

Adducts or bends the ring finger toward the radius.

Adducts or bends the little finger toward the radius.

Adducts or bends the index finger toward the radius.

Adducts or bends the middle finger toward the radius.

Adducts or bends the middle finger toward the ulna.

Abducts or bends the ring finger toward the ulna.
         Muscles  of  the   Abdomen.
TORSO  PELVIC,  OR  ANTERIOR  ABDOMINAL,  5.
  By fleshy digitations from the external  sur-
face of the eight inferior ribs.   The five upper
digitations  being  received between  corres-
ponding processes of the pectoralis major and
serratus magnus, and the three  lower of the
latissimus  dorsi,  it spreads out  into a broad
aponeurosis.  The lower border of the aponeu-
rosis, which is stretched between the anterior
superior spinous  process  of  the ilium  and
spine  of the pubis is folded  inward, forming
Poupart's  ligament;  the  insertion  into the
pectineal line is Gimbernat's ligament.

  From the outer half  of Poupart's ligament;
from the middle of the crest of  the ilium for
two-thirds of its length, and by a thin aponeu-
rosis from  the spinous  process of the lumbar
  Into the outer  lip of the
crest of the ilium for one-half
its length, the anterior supe-
rior  spinous  process  of the
illium, spine of the  pubis, pec-
tineal line, front of the pubis
and linea alba.
  Into the pectineal line, crest
of the pubis,  linea alba  and
lower borders of the five infe-
rior ribs.
  The  external oblique muscle acting  singly,  would draw the
thorax toward the pelvis, and twist the body to the opposite side.
Both muscles acting together would flex the thorax directly on the
pelvis.   It is a muscle of expiration.  Its name is derived from
the obliquity of its direction,  and the descending course of its
fibres.
  Assists the former, but bends the trunk in the reverse direction.
This is the middle flat muscle of the  abdomen.  It  is a muscle of
expiration.
CO
-I 
           Name.

126.  Obliquus  internus abdo-
    minis,  ascendens  {Con-
    tinued.)
127. Transversalls,
128.  Rectus abdominis.
129.  Pyramldalis abdominis.
Origin.
Insertion.
vertebras.   Its fibres diverge from their origin,
so that those from Poupart's ligament curve
downward; those from the anterior part of the
crest of the ilium pass transversely, and the
rest ascend obliquely.
  The spermatic cord passes beneath the  arched border of the internal oblique
muscle, between It and Poupart's ligament.  During its passage some fibres
are given off from the lower border of  the muscle which accompany the cord
downward, to  the testicles, and form  loops around it; this is the Cremaster
muscle.  In the descent of oblique inguinal hernia, which travel the same
course with the spermatic  cord,  the Cremaster muscle  forms one of  its
coverings.
  From the outer third of Poupart's ligament
from the internal lip of the crest of the ilium,
its anterior two-thirds; from the spinous and
transverse processes of the lumbar vertebras,
and from the inner surfaces of the five infe-
rior ribs, indigitating with the diaphragm.  Its
lower fibres curve downward.
  By two heads from the ligament of the car-
tilage, which joins the two ossa pubis to each
other; runs upward the whole length of, and
parallel  to, the  linea alba, growing broader
and thinner as it ascends.
  It  is transversed  by several tendinous zig-zag lines called linae transversa;,
One of these is usually situated at  the umbilicus, two above that point, and
sometimes one below.
  AVith the lower fibres of the
internal oblique, into the pec-
tineal  line, and form the con-
joined  tendon.   Through the
rest of its extent it is Inserted
into the crest of the' pubis and
linea alba.   The  lower fourth
of its  aponeurosis passes  in
front of the rectus to the linea
alba; the upper three-fourths
with the posterior lamella of
the internal oblique, behind it.
  Into the cartilages of  the
fifth, sixth, and seventh ribs
and  often  intermixes   with
some  fibres of  the  pectoral
muscle,
Use.
  From the crest of the pubis in front of the
rectus.
  Into the linea alba  about
midway between the umbilicus
and the pubis.
  To support and compress the abdominal viscera, and it is so
particularly well adapted for that purpose that it might be called
proper constrictor of  the  abdomen.  This is the internal flat
muscle of the abdomen.  It is a muscle of expiration.
  Depresses the thorax and compresses the viscera muscle of ex-
piration.
  Compresses, lowers, and extends the linea alba muscle of expi-
ration.
00
-J
OS
130. Latisslmus dorsL
SUPERFICIAL  LUMBAR,  3.
  Prom the spinous processes of the six infe- j
rior dorsal vertebrae, all the sacral  and lum-
bar, from the posterior third of the crest of the
ilium, and from the three lower ribs by mus-
cular slips which indigitate With the external
oblique muscle of the abdomen.  The inferior
  With  the teres  major into
the posterior bicipital ridge of
the humerus.
  Post-motor, adductor, and depressor of the arm', which it rotates
inward. 
181.  Sacro-lumbalis.
182. Longlsslmus dorsL
Musculus accessorius (ad
 sacro lumbalem.)
Cervicalls ascendens.
fibres ascend obliquely, and the superior run
transversely over  the  inferior angle of the
scapula toward the axilla, where they are col-
lected, twisted, and folded.

  By a common origin from the posterior third
of the crest of the ilium, from the posterior
surface of the  sacrum, and from the lumbar
vertebrae.  Opposite the last rib a line of sepa-
ration begins to be marked  between the two
muscles.

  On turning  the  sacro-lumbalis a little out-
ward a number of tendinous slips will be seen
taking  their origin from  the ribs,  and termi-
nating in a muscular fasciculus, by which the
sacro-lumbalis is prolonged to the  upper part
of the thorax.

   This is the musculus  accessorius ad sacro-
 lumbalem; it arises from the angles of  the six
 lower ribs.

   Appears to  be a continuation of the sacro-
 lumbalis upward into the neck.
   From the angles of the four upper ribs.
  By separate tendons Into the
angles of the six lower ribs.
  Into all the  ribs  between
their tubercles and angles.
  By  separate tendons  into
the angles of the six upper
ribs.

  Into the  transverse  pro-
cesses of the four lower cervi-
cal vertebrae.
  Straightens the trunk and bends the thorax backward toward
the pelvis.
  Extends or straightens the trunk, or bends it backward and to
one side.
188.  Psoas magnus.
134. Psoas parvus.
135. Quadratus lumbormr.
DEEP  LUMBAR,   3.
  Into the posterior part of the
trochanter minor.
  Prom the Intervertebral substances, part of
the bodies and bases of the transverse pro-
cesses, and from a series of  tendinous arches,
thrown across the constricted portion of the
last dorsal and four upper lumbar vertebrae.
These arches are intended to protect the lum-
bar  arteries  and sympathetic  filaments of
nerves from pressure in their passages beneath
the muscle.   The tendon of the psoas magnus
unites with that of the  iliacus  and the con-
joined tendon.

   From the tendinous arches and interverte-    Into  the  pectineal line  of
bral substance of the last dorsal and first lum-  the pubis.  The tendon is con-
bar vertebrae, and terminates in a long, slen-  tinuous  by  its outer  border
der tendon.                                  with the iliac fascia.
Flexes the thigh on the pelvis, and rotates it inward.
  From the last rib, and  from the transverse
processes of  the  four upper lumbar verte-
brae.
Into the crest of the ilium.
Bends down the loins forward on the pelvis.
Depresses the last false rib, and bends the thorax to one side.
CO 
COCCYGEAL,  OR  ANAL,   3.
Name.
136. Sphincter ani.
137. Levator ani.
188. Coccygeus.
139. Erector penis.
140. Accelerator urinae.
Origin.
  Is a thin  elliptical plane of muscles closely
adherent to the integument, and surrounding
the opening of the anus.   It arises posteriorly
in the superficial  fascia around the coccyx,
and by a fibrous raphe from the apex of the
bone.  Internally it is a muscular ring em-
bracing the extremity of the intestine,  and
formed by an aggregation of the circular mus-
cular fibres of the rectum.

  From the Inner  surface of the pubis; from
the spine of the ischium, and  between those
points from the angle of  division between the
obturator and the pelvic fascia.  Its fibres
descend.
  From the spine of the ischium.  It is in
immediate contact with the lesser sacro-ischi-
atic ligament.
Insertion.
  Anteriorly  into  the tendi-
nous centre of the perineum,
and into the  raphe of the in-
tegument nearly as  far for-
ward  as the  commencement
of the scrotum.
  Into the extremity of  the
coccyx, into a fibrous raphe in
front  of  that bone, into  the
lower part of the rectum and
base of the bladder and pros-
tate  gland.  In the female
this muscle is inserted into the
coccyx and fibrous raphe ex-
tremity of the  rectum  and
vagina.

  Into the side of the coccyx
and lower part of the sacrum.
Use.
Constrictor of the anus.
GENITAL   OF  THE  MALE,  3.
141. Transversus perine.
  Prom the ramus  and  tuberosity of  the
Ischium,  and  curves  round the root of the
penis.   "
                                              The  upper  surface of  the
                                            corpus cavernosum where it is
                                            continuous with a strong fascia
                                            which  covers  the  dorsum  of
                                            the organ, the fascia penis.

                                              The  posterior fibres are in-
                                            serted  into  the ramus of the
                                            pubis and ischium ; the middle
                                            to encircle  the corpus  spon-
                                            giosum,  and  meet upon its
                                            upper  side, and be inserted
                                            partly into its fibrous structure,
                                            and partly  into the fascia of
                                            the penis.

  From the tough, fatty membrane that covers    Into the  central tendinous
the tuberosity of the os ischium.              part of the perineum.
  From a tendinous point in the centre of the
perineum, and from the raphe.  From these
origins the fibres diverge like the plumes of a
pen.
  Raises the anus.  It is the antagonist of the diaphragm and the
rest of the expulsory muscles, and serves to support the rectum
and vagina during their expulsive efforts.  It acts in unison with
the diaphragm, and  raises and falls like that  muscle in forcible
respiration.  Yielding to the  propulsive action of the abdominal
muscles, it enables the outlet of the pelvis to bear a  greater force '
than a resisting structure, and on the remission of such actions it
restores the perineum to its original form.
  The coccygic muscles restore the coccyx to its natural position
after it has been pressed backward during defecation or during
parturition.
  To compress the crura penis, by which the blood is pushed from
it into the forepart of the corpora cavernosa.  And the penis is
by that means more completely distended.
Accelerator of the urine and semen.
Constrictor of ihe urethra.
CO
— c
QC 
GEXITAL  OF  THE   FEMALE,  2.
142. Erector clitorldis.
148. Constrictor vaginas.
  Prom the crus of the os ischium internally,
and in its ascent covers the crus of the cli-
toris as far up as the os pubis.

  From the sphincter ani, and from the  pos-
terior side of the vagina, near the perineum;
from thence it runs up the side of the vagina,
near  its external orifice, opposite  to the
nymphael, and eovers the corpus cavernosum
vagina.
  into  tne  upper part ot the
•rus and body of the clitoris.
  Into the  crus and body, or
union of the crura clitoridis.
Erector of the clitoris.
Constrictor of the vagina.
144. Gluteus maximus.
145. Gluteus medius.
146. Gluteus minimus.
Muscles   of  the  Pelvis.
POSTERIOR  ILIAC,   OR  GLUTEAL,  3.
  From  the  posterior fifth of the external
crest of the ilium;  from the border of the
sacrum and coccyx;  and from the great sacro-
ischiatic ligament.  It passes obliquely out-
ward and downward.  This muscle forms the
convexity of the nates.
  From  the outer  lip of  the  crest of  the
ilium, for  four-fifths of  its length  from the
surface of the bone between the border, and
the superior curved line on the  dorsum ilii,
and from a deep and dense fascia.

  Is a radiated muscle, arising from the sur-
face of the dorsum ilii between the superior
and  inferior curved  lines, and  over  the
acetabulum.
  Into the rough line leading
from the trochanter major to
the linea asperia, and is con-
tinuous by  means of  its ten-
don with the fascia lata cover-
ing the outer side of the thigh.
A large bursa is situated be-
tween the broad tendon of the
muscle and the femur.

  Its  fibres converge to the
upper  part of the trochanter
major, into which its tendon
is inserted.
  Its fibres  converge  to  the
anterior  border  of the  tro-
chanter major, into which  it is
inserted, by means of a round-
ed tendon.
Extensor or post-motor of the thigh, which it rotates outward.
Abductor, and slightly a rotator of the thigh outward.
Assists the former.
i47. Illacus lnternus.
ANTERIOR  ILIAC,   1.
  Is  a flat, radiated muscle; it arises from
the inner  concave surface  of the ilium, and
after joining with  the tendon  of  the  psoas
Magnus.
  Into the posterior part of
the trochanter minor.
Flexes the thigh o* the pelvis.
CC
—J 
TELVI-TROCHANTERIAL,  5.
rx>
JO
©
Name.
Origin.
Insertion.
Use.
148. Obturator internus.
149. Obturator externus.
150. Pyriformls.
151. Gemellus superior.
152. Quadratus femoris.
  From the inner surface of the anterior wall
of the pelvis, being attached to the margin of
bone round the obturator foramen, and to the
obturator  membrane.   It passes  out  of the
pelvis  through the lesser sacro-ischiatic fora-
men.   The lesser  sacro-ischiatic notch over
which  this muscle plays as through a pulley,
is faced with cartilage, and provided with a
synovial bursa  to  facilitate its movements.
The tendon of the obturator is supported on
each side by the two gamelli muscles (hence
their names), which are inserted into the sides
of the tendon, and appear to  be  auxiliaries
or  superadded  portions  of  the obturator
Internus.

  From the obturate membrane, and from the
lower surface of bone  immediately surround-
ing it—viz., from the body and ramus  of the
os  pubis  and  ischium; its tendon passes
behind the neck of the femur.

  From the  anterior surface of the second,
third,  and fourth  bones of the sacrum,, by
little slips that are interposed between the
anterior sacral  foramina.  It passes out of
the pelvis through the great  sacro-ischiatic
foramen.

  From the spine of the ischium.
  Prom the external border of the tuberosity
of the ischium,  anterior to the biceps semi-
tendinosus and semi-membranosus.
  By a flattened tendon into
the trochanteric  fossa of the
femur.
Rotator of the thigh outward.
  With the  external rotator
muscles into the trochanteric
fossa of the femur.
  By a rounded  tendon into
the trochanteric fossa.
  Into the upper border of the
tendon of the obturator inter-
nus, and into the anterior tro-
chanteric fossa.

  Into  a rough line  on  the
posterior border of the tro-
chanter major, which is thence
named linea quadrati.
Idem.
Idem and abducting.
Idem.
Idem.
153. Rectus femoris.
           Muscles   of  the   Thigh.

FEMORO-ROTULAR,  OR ANTERIOR  FEMORAL,   2.
  By two round tendons, one from the anterior  I   By a broad and strong ten- I
inferior spinous process of the ilium, the other  I don, into the upper border of I
Extensor of the leg; and flexor of the thigh. 
I 154. Triceps extensor femoris
Cn    —viz.:
C
      Vastus extern us.
Vastus internus.
Crureus.
from the upper lip of the acetabulum.  It is
fusiform in its shape, and bipenniform in the
disposition of its fibres.
  From the outer border of the patella, nar-
row below and broad above.
  From the inner border of the patella, nar-
row above and broad below.
Prom the upper border of the patella.
the patella.   It is more  cor-
rect to consider the patella as
a  sesamoid  bone, developed
within the tendon of the rec-
tus ;  the ligamentum patellae
is the continuation of the ten-
don  to its insertion  into  the
spine of the tibia.
  Into the femur  and outer
side of the linea asperia, as
high as the  base  of the  tro-
chanter major.

  Into the femur and inner
side of the linea asperia, as
high as the anterior inter-tro-
chanteric line.

  Into the front aspect of the
femur, as high as the anterior
inter-trochanteric line.
Extensor of the leg.
FEMORO-ISCHIATIC,  OR  POSTERIOR   FEMORAL,   2.
155. Semi-tendinosus.
156. Semi-membranosus.
  In common with the long head of the biceps;
from the, tuberosity of the ischium,  and send-
ing down a long roundish tendon.

  Tendinous in common with the biceps and
Bemi-tendinosus from the tuberosity of the os
ischium,  sends down a broad flat  tendon,
which ends in a  fleshy belly, and in its de-
scent runs at first on  the forepart of the
biceps, and, lower, between it  and the semi-
tendinosus.
  Into the  inner  tuberosity
of the tibia.
  Into the  posterior part  of
the inner tuberosity of the
tibia; at its insertion the ten-
don splits into three portions,
one of which is inserted into
a groove on the inner side of
the head of the tibia, beneath
the internal lateral ligament.
The second is continuous with
the  aponeurotic  expansion,
that binds down the popliteus
muscle—the popliteal fascia;
and  the third turns upward
and  outward to the external
condyle of the femur, form-
ing the posterior ligament ol
the  knee-joint  (ligamentum
posticum VVinslowii).
  Post-motors and rotators of the thigh Inward, and flexors of the
thigh.
8 
           Name.

167.  Biceps flexor cruris.
158. Sartorlus (tailor's muscle)
159. Pectlneus.
160. Gracilis.
161.  Adductor Iongus.
162. Adductor brevis.
168. Adductor magnus.
                  Origin.

   By two distinct  heads—one by a common
 tendon with the semi-tendinosus;  the  other,
 muscular and much shorter, from the lower
 two-thirds of the external border of the linea
 asperia.  This muscle forms the outer liam-
I string.
         Insertion.

  By a strong tendon into the
head of the fibula, fascia and
outer tuberosity of the tibia.
                          Use.

Post-motor of the thigh, flexor and rotator of the leg outward.
00
00
FEMERO-PUBAL,  OR  INTERNAL  FEMORAL,  6.
  Is  a long ribbon-like muscle, arising from
the notch, immediately beneath the anterior
superior  spinous  process  of the  ilium;  it
crosses obliquely the upper third of the thigh,
descends behind the  inner  condyle of the
femur.
  From the pectineal line  (pecten a crest) of
the os pubis.
  By a broad but very thin tendon,  from the
edge of the ramus of the pubis and ischium.
It is situated along the  inner  border  of the
thigh.

  By a round tendon from the angle  of the os
pubis, assuming a flattened shape.  It is the
most superficial of the three adductors.

  Placed between the pectineus and  adductor
Iongus, is fleshy and thicker than add. Iongus.
Arises from the  body and famus of  the os
pubis.
  Is a broad and extensive muscle, forming a
septum of division between the muscles situ-
ated on the anterior, and those on the poste-
rior aspect of the  thigh. It arises  by fleshy
fibres  from the ramus and side of the tube-
rosity of the ischium, and radiating in its pas-
sage outward.
 By an aponeurotic expansion
into the inner tuberosity of the
tibia.  The inner border of the
sartorius is the guide to the
operation for tying the femo-
ral artery in the middle of its
course.

  Into the line leading from
the anterior inter-trochanteric
line to the linea asperia.

  By a rounded tendon  into
the  inner  tuberosity  of  the
tibia beneath the expansion of
the sartorius.

  Into the middle third of the
linea asperia.
  Into the  upper third of the
linea asperia.  It is pierced by
the middle  perforating artery,
and  supports  the  anterior
branch of the obturator nerve
and artery.

  Into the whole length of the
linea  asperia and  inner  con-
dyle  of the  femur.   It is
pierced by five openings; the
three  superior  for the three
perforating arteries; the fourth
for the termination of the pro-
funda ;  the fifth is the large
oval opening in the tendinous
portion of  the  muscle,  that
gives  passage to the femoral
vessels.
  Flexor of the leg and thigh on the pelvis, rotates the thigh, and
powerfully adducts the leg.
Adductor flexor and rotator inward of the thigh.
Flexes and adducts the leg.
Adductor of the thigh.
Idem. 
164. Tensor vagina femoris.
165  Tibialis anticus  (flexor
   ' tarsi tibialis.)
167. Peroneus Iongus (exten-
    sor tarsi fibularls longior).
168. Gastrocnemius.
169. Popliteus.
EXTERNAL  FEMORAL,  1.
I   Is a short, flat muscle, situated on the outer I   Between two layers  of the
 side of the hip   It arises from  the crest of  fascia lata, at about one-fourtn
 the ilium, near to its anterior superior spinous  down the thigh.
| process.                                  I
Abductor and tensor of the aponeurosis called fascia lata.
            Musoles  of  the   Leg.
SUPERFICIAL  TIBIO-PERONEAL  OR  TIBIAL,  4.
  From  the  upper two-thirds of the tibia,!   Into the inner side of the In-
from the Interosseous  membrane, and from  ternal  cuneiform  bone.and
the deep fascia : its tendon passes through a  base of the metatarsal bone of
distinct sheath in the annular ligament.        the great toe.
166.  Extensor  Iongus  com-!
    munis digltorum.
  Into  the  second and third
phalanges of the four lesser
toes.
  From the head of the tibia; from the upper
three-fourths of the  fibula; from the inter-
osseus membrane; and from the deep fascia.
Below it divides into four tendons, which pass i

beThemode tfTsertlo^oMhe extensor tendons both in the hand and in the
foot Is remarkable;  each tendon  spreads into a broad aponeurosis over the
firstDhalanx; this aponeurosis divides into three sups, the middle one Is in-
serted into the base of the second phalanx, and the two lateral slips are con-
tinued onward, to be  inserted into the base Of the third.
Flexes and binds the toot Inward,
Common extensor of the toes and flexor of the foot
  From the upper third  of the outer side of
the fibula, and  terminates in a long tendon,
which passes behind the  external malleolus,
and  obliquely  across the sole  of  the foot,
through the groove in the cuboid bone.
  By two heads from the two condyles  of the
femur, the inner head being the longest.
  Into the base Of the meta-
tarsal bone of the great toe,
  The upper part  of its origin
is pierced by  the peroneal
nerve; its tendon Is thickened
where it glides behind the ex-
ternal malleolus,  and a sesa-
moid bone is frequently de-
veloped  in that  part which
I plays upon the cuboid bone,

   By  means  of  the tendo
 Achillls into the lower part of
 the tuberosity of  the os calcis,
 a synovial bursa being placed
 between that tendon  and the
I upper part of the tuberosity.
Extends the foot and elevates Its outer edge.
Extensor of the foot and flexor of the leg.
MIDDLE   TIBIO-PERONEAL,  OR  TIBIAL,  3,
   By a rounded tendon from a deep groove on   Into a ridge at the  upper
 theouter  side of the external condyle of  and Internal edge of the tibia
 femur beneath the external lateral ligament,  a little below its head.
| spreads obliquely over the head of the tibia.  |
Flexes the leg and rotates It Inward,
00
X 
Name.
170. Soleus.
171. Plantaris.
Origin.
  From the head  and  upper third of the
fibula; from the oblique line and middle third
of the tibia.
                                             Its  fibres converge  to  the
                                           tendo Achillis, by which it is
                                           Inserted into the tuberosity of
                                           the os calcis.
  It is a broad muscle, upon which the plantaris rests.  Between the fibular
and tibial regions of this muscle is a tendinous arch, beneath which  the pop-
liteal vessels and nerve pass into the leg.
Insertion.
  Is a very small muscle, situate at its upper
third, between the gastrocnemius and soleus ;
arises from the  outer  condyle  of the femur,
above the gastrocnemius.
  By its  long and  delicately
slender tendon  into the inner
side  of the tuberosity  of the
os calcis, by the side of the
tendo Achillis.
Use.
Extensor of the foot.
oe
Extensor of the foot and flexor of the leg.
DEEP TIBIO-PERONEAL,  OR   TIBIAL,  6.
  Lies between the tibialis anticus and exten-
Bor Iongus digitorum.  Arises from the lower
two-thirds fibula and interosseus membrane.
  Lies beneath the peroneus Iongus; arises
from the upper 2-3 of the fibula.
                                                                        Its tendon passes through a
                                                                      distinct sheath in the annular
                                                                      ligament, and is inserted into
                                                                      the base of the last phalanx
                                                                      of the great toe.

                                                                        Terminates  in  a  tendon,
                                                                      passes behind  the  external
                                                                      malleolus, and passes through
                                                                      a groove in the os calcis, and
                                                                      is inserted into  the base of the
                                                                      metatarsal bone  of  the little
                                                                      toe.

                            From  the  lower  fourth  of  the fibula.    Into the base of the meta-
                           Although apparently but a mere division of  tarsal bone of the little toe.
                           the  extensor  Iongus  digitorum, this muscle
                           may be looked upon as  analogous to the
                           flexor carpi ulnaris of the forearm.  Some-
                           times it is altogether wanting.

                            Lies upon  the interosseus membrane be-
                           tween the two bones of the leg.  It arises by
                           two  heads from the adjacent sides of the tibia
                           and  fibula, their whole length,  and from the
                           interosseus membrane.  Its tendon passes in-
                           ward, beneath the tendon of the flexor Iongus
                           digitorum, and runs in the same sheath, lying
                           internally to it into the sole of the foot.

,  Plexor  loneus  pollicis    From  the  posterior half  of  the fibula.    Into the base of the last
 (pedis).                  I  Some way below its head, passes  under the  phalanx of the  great toe.
172. Extensor proprlus pollicis
    pedis.
173. Peroneus brevis.
174. Peroneus  tertius  (flexor
    tarsi fibularis).
175. Tibialis posticus (exten-
    sor tarsi tibialis).
  Into the  tuberosity of the
scaphoid  bone  and internal
cuneiform bone.
Extends the great toe and flexes the foot.
Extends the foot and raises its outer edge.
Flexor of the foot, which it inclines outward.
  Extensor of the tarsus upon the leg, and an antagonist to the
tibialis anticus.   It combines with the tibialis anticus in adduction
of the foot.
Flexor of the great toe. 
177. Flexor Iongus digitorum
    (pedis perforans).
178.  Extensor  brevis
    torum.
annular iigameui-; through a distinct tendinous
canal into the sole of the foot.

  From the surface  of the tibia immediately
below the popliteal line.  Its tendon passes
through a sheath common to it, and the tibi-
alis posticus behind the inner malleolus into
the sole of the foot,  where it divides into four
tendons.
  Into the base of  the  last
phalanx  of the four  lesser
toes,  perforating fae tendons
of the flexor brevis digitorum.
Common flexor of the toes and extensor
Muscles   of  the  Foot.
DORSAL,  1.
  From the outer side of the os calcis, crosses
the foot  obliquely,  and terminates in four
tendons.
  The innermost of which Is
inserted into the base  of the
first phalanx of the great toe,
and the other three  into the
sides  of the  long extensor
tendons of the second, third,
and fourth toes.
SUPERFICIAL  PLANTAR,   5.
179. Adductor pollicis.
180. Flexor brevis pollicis.
181. Plexor brevis digitorum
    perforatus.
182.  Flexor  brevis  minimi
    digiti pedis.
  From the cuboid bone; from the sheath of
the tendon of the peroneus Iongus, and from
the base of the third and fourth metatarsal
bones.

  By a pointed tendinous process from the os
calcis,  the  side of the cuboid, and from the
external and middle cuneiform bones.
  From the under surface of the os calcis,
and plantar fascia.
  Into  the base of the first
phalanx of the  great toe.
  By two heads into the base
of the first phalanx  of the
great  toe.   Two  sesamoid
bones  are  developed  in the
tendons of insertion of these
two heads, and the  tendon of
the flexor Iongus pollicis lies in
the groove between  them.

  By four tendons into  the
base of the second phalanx of
the  four  lesser toes.   Each
tendon divides previously to
its  Insertion, to give  passage
to the tendon of the long flexor
(hence perforatus).
  From  the base of the metatarsal bone of   Into  the  base  of  the first
IbfKSSe toe, and from the sheath of the ten-  phalanx of the little toe.
don of the peroneus iongus.                  I
Common extensor of the toet.
Adductor and flexor of the great toe.
Flexor of the great toe.
Common flexor of the toes.
Flexor of the little toe. 
           Name.

188.  Abductor minimi digiti
    pedis.
Origin.
  From the  outer side of the os oalols  and
from the base of the metatarsal bone of the
little toe.  It lies along the  outer border of
the sole of the foot.
Insertion.
  Into the base  of the first j
phalanx of the little toe.
Use.
Abductor of the little toe.
184. Musculus accessorius (se-
    cond  portion of  flexor
    long.  com.  digitorum—
    Massa   carnea  Jacobil
    Svlvii.)

1S5. Four Lumbricales.
 186.  Transversus pedis.


 187.  Interossei plan tares.

 188.       Idem.

 189.       Idem.

 190.       Idem.


 191. Interossei dorsales.

 192.       Idem.

198.       Idem.

194.       Idem.
                                      DEEP PLANTAR,  14.
,5 *W0-,?J,f  from. ?Ith?r ■"• of the under    mto the outer side  of  the
surface  of the os calcis, the inner slip beine
fleshy, the outer tendinous
ltJP? ,f°UI\8maU mu»cle» arising from the
tibial side of the tendons of the flexor iongus
digitorum.                           »-*"■
  By fleshy slips from the heads  of the meta-
tarsal bone of the four lesser toes.
  From the base of the metatarsal bones of
the toes.
  By two heads from the adjacent sides of the
metatarsal bones.
tendon of  the flexor Iongus
digitorum.
  Into the expansion of the
extensor tendons, and into the
base of  the first phalanx  of
the four lesser toes.

  Tendinous into the base of
the first phalanx of the great
toe.
  Into the inner side of  the
extensor tendon and  base of
the first phalanx of the same
toes.


  Into the base of  the first
phalanx, and into the digital
expansion of  the  tendons of
the long extensor.  The first
is inserted into the inner side
of  the  second  toe,  and is
therefore an adductor.  The
other three  are  inserted into
the outer side of the  second,
third, and  fourth toes, and
are therefore abductors.
  Rectifies the oblique action of the long flexor
toes.




  Bend the phalanges upon the metatarsus.




  Abdncts the great toe.


  Abducts the great toe.

  Adducts the third toe.

  Adducts the fourth toe,

  ■Abducts the fifth .toe.


  Adductor of the second toe.

  Adducts the second toe.

  Adducts the third  toe.

 Adducts the fourth toe. 
A TABLE OF INCOMPATIBLES.
                 A  TABLE  OP  INCOMPATIBLES.

                        BT SAMDKL R.  PERCY, M.D., NEW YORE.

  Most of the articles here presented must be understood to  be  in solntion.   Th* formulas
given of them are as they are obtained in  the dry state, and uncombined with water of crystal-
lization.  Many  of the vegetable preparations present  incompatibles  with their infusions
which are not incompatible with the alkaloids contained in their infusions, and it may be
doubted if such re-agents injure their medicinal activity.   The writer would respectfully sug-
gest that  there is at much, perhaps more, necessity for studying therapeutic  incompatibles
as chemical ones.

 1. Absinthium, with  acetate of lead,  tartar emetic,  nitrate of silver, sulphates  of iron
       and zinc.
 2. Aoacia—C" H10 0!,)—with alcohol,  sulphuric ether and its compound  spirits, strong
       acids, ammonia, subacetate of lead, tinct. mur. iron, nitrate of mercury.

 3. Acidum Aceticum—C* H5 0'—with alkalies, alkaline and earthy carbonates, metallic
       oxiftes, etc.

 4. Acidum Arseniosum—As 0s—with  lime water,  astringent vegetable  infusions and
       decoctions, hydrated peroxide of iron, magnesia.

 8. Acidum Benzoicum—C" H* 0* +  Aq—with the  mineral acids.

 6. Acidum Citricum—C* H* O4—with mineral acids,  nitrate and  acetate  of mercury,
       acetate of lead, alkalies, alkaline carbonates and sulphurets, metallic oxides.

 7. Acidum Gallicum—C7 H* 0s—with the sulphate of copper, lime water, carbonates
       of  iron  and potash, acetate of lead, nitrate of silver, solutions  of opium, Goulard's
       extract, iodide of iron, tartar  emetic, and albumen.

 8. Acidum Hydriodicum—HI—with atmospheric air, nitrate of silver, sulphate of cop-
       per and iron, nitric acid, chlorine, sulphuric acid.

 9.  Acidum Hydrocyanicum—HCy—with nitrate  of silver,  chlorine, mineral  acids,
       metallic oxides.
10.  Acidum Hydrochloricum—HCl—with alkalies,  alkaline earths and their carbonates,
       with most metallic oxides  and salts, especially those  of silver, sulphuret of  potas-
       sium, salifiable bases.
11.  Acidum Hydrosulphuricum—HS—with nitrate  of silver, acetate of lead, arsenious
       acid,  sulphate of copper, metallic  solutions, alkalies, etc.

12.  Acidum Lacticum—HO, C6  H* 0*—with mineral  acids, alkalies.
13.  Acidum Nitricum—NO4—with alkalies, alkaline  earths and their carbonates,  essen-
       tial oils, metallic oxides, salifiable bases.
14.  Acidum Oxalicum—Ca 01, HO + Aq—with alkalies, alkaline earths and  their carbon-
       ates,  metallic oxides, Hme-water, nitrate of silver,  chloride  of barium, sulphuric
       acid. 
8S8                     A TABLE  OF  INCOMPATIBLES.
15. Acidum Phosphoricum—P0»—with alkalies, alkaline earths  and their carbonates,
      chloride of barium, sulphate of lime and magnesia, nitrate of silver, acetate of lead.
16. Acidum Succinicum—C4 H2 03—with sesquichloride of iron, oils, acetate of lead,
      chloride of barium, nitrates of silver and mercury, mucilage.
17. Acidum Sulphuricum—SO3—with alkalies,  alkaline earths and their carbonates, sul-
      phurets, oxalic acid, phosphates, borates, hydrochlorates, nitrates, acetates, iodine,
      •metallic iodides, baryta strontia, lead.
18. Acidum Sulphurousum—SO2—with atmospheric air by which it is converted  into
      sulphuric acid, hydrosulphuric acid.  All the sulphites evolve sulphurous acid when
      treated with sulphuric or hydrochloric acid.   Chlorine converts most  sulphites  to
      sulphates,  chloride of barium" precipitates neutral sulphites, but not free sulphurous
      acid.

19. Acidum Tannicum—C1" H8 012—with albumen,  gelatine,  the  persalts of iron, alka-
      lies, alkaline earths and their  carbonates, acetate of lead, tartar emetic, solutions of
      the vegetable alkaloids.  (See Galla.)

20. Acidum Tartaricum—C4 H' 05 + H0—with alkalies,  alkaline  earths  and their  car-
      bonates, salts of potassa, chloride of calcium.

21. Aconitia—NC60 H47 O14—Precipitated from its solutions by potassa, soda and ammonia,
      but  is redissolved by an excess of ammonia;  by the  carbonates of these alkalies,
      which do not redissolve the precipitate ; by the vegetable astringents, magnesia and
      its carbonate, salts of iron, copper, zinc, silver lead.
           The same will apply to the tinctures and extracts of aconite.
         Tests of Purity.—It is fusible at a gentle heat; and is entirely dissipated, leaving
           no residue, at a high temperature.   It is sparingly soluble in water, requiring
           for its solution 150 parts of cold  and 50 parts  of  boiling water.   Is perfectly
           soluble in the dilute mineral acids, from which solution it should be precipitated
           without loss  of  weight by ammonia,  cautiously added.   Is soluble in ether and
           alcohol.

22. iEther Sulphuricus—C4 H5 0.—Ether, as it evaporates, should leave but little foreign
      odor.   When  shaken with an equal volume of water, it should lose twenty-two per
      cent, of its volume.   " In a test tube half filled and grasped in the hand for a short
      time, it should commence to boil very slowly on the addition of small fragments
      of broken glass."   It should not redden litmus paper.

23. JEtheris Spiritus Nitrici.—Sulphate of protoxide of iron produces a deep olive color;
      tincture of guaiacum, a blue changing to a green.  It should boil if held in water at
      a temperature of 160°F., upon the addition of small fragments of broken glass.

24. Albumen—C400 H310 N60 O120 S2 P—Nitric and hydrochloric acids, alcohol, corrosive
      sublimate, chloroform,  creasote,  heat, persulphate of iron, tannin,  alum,  nitrate
      silver.

25. Alcohol—C4 He Oa—with mucilages, nitrate of lime, chloride of barium.

26. Aloe, with galls, oak bark, and astringent vegetable  infusions, chlorine, alum proto-
      chloride of tin, nitrates of silver and mercury, tartar emetic, acetate lead.

27. Alumen—Al2 O3, 3SOs + KO, SO3—with alkalies and their carbonates, lime and lime-
      water, magnesia and its carbonate, tartarate of potassa, acetate of lead, astringent
      vegetable infusions, salts of mercury, ammonia.

28. Ammonia—NHS—with acids, mineral salts, alum, the  alkaloids, etc.

29. Ammonias Acetas—NH3, C4 H3 O3—(Ammonia Acetatis Liquor) with  strong acids
      alkalies, alkaline earths, nitrate of silver, corrosive sublimate, lime  water  alum'
      sulphates of iron, copper, zinc and magnesia.                                     '

80. Ammonias Bicarbonas—NH3,  2C02—with acids, fixed alkalies, lime-water, etc.

81. Ammoniae Carbonas—NH3, CO2—with  acids,  fixed  alkalies and their carbonates
      lime-water, magnesia,  chloride of calcium,  alum, bitartrate  and  bisulphate  of
      potassa, solutions  of iron (except the tartrate of iron and potassa), corrosive sub-
      limate, acetate of lead, sulphate of line. 
A TABLE OF  INCOMPATIBLES.
889
82.
         Test of Purity.—When  heated on a piece of glass, it should evaporate without
           residue.

    Ammonias  Hydrochloras—NH3, HCl—with nitric and sulphuric acids, acetate of
      lead, nitrate of silver, soda, potassa, lime and their carbonates.

S3.  Ammonias Hydrosulphuretum—Nil3 2HS—with acids, metallic salts.

84.  Amygdalin—        —with the alkalies, alkaline earths and their carbonates, when
      mixed with emulsin or emulsion of sweet almonds, it forms hydrocyanic acid and
      volatile oil of bitter almonds; this'  is caused  by a  fermentation  that takes  place
      between them, that may be prevented by adding alcohol or acetic acid.
         Tests of Purity.—It should form a perfectly transparent solution with water; inso-
           luble in ether;  should leave no residue on incineration.

35.  Amylum—C12 H10 O10—Iodine, acids, lime water, baryta water, subacetate of lead,
      tannin, bromine.

36.  Angustura, with sulphates  of iron  and  copper, tartar  emetic, acetate of lead, corro-
      sive sublimate, nitrate of silver, potassa, ammonia, tannin.

37.  Anthemis, with gelatine, gallic  acid, salts of iron, nitrate silver, corrosive sublimate.

88.  Antimonii  Oxidum—SbO3—Sulphureted hydrogen, tartaric acid, zinc, etc.

39.  Antimonii  el  Potassas  Tartras—SbO",  K02C4  H2  O5—with acids, alkalies, and
      their carbonates, most of the  earths and metals, chloride of calcium, acetate of lead,
      astringent vegetable infusions and decoctions,  soap, sulphureted hydrogen, impure
      water.
         Tests of Purity.—One  hundred grains dissolved in water should yield  forty-nine
           grains of ter-sulphuret of antimony to a solution of hydrosulphuric  acid.  A
           dilute solution should not be precipitated by chloride of barium, nitrate of silver,
           nor rendered blue by ferrocyanuret of potassium.

40.  Antimonii  Sulphuretum—SbS3—with  nitric  and nitro-hydrochloric  acids, tartaric
      acids.
41.  Argenti Cyanuretum—AgCy—with hydrochloric acid, hydrosulphuric acid, etc.

42.  Argenti Nitras—AgO, NO6—with  organic matter, impure  water,  the soluble chlo-
      rides; sulphuric, hydrosulphuric,  hydrochloric, tartaric acids  and their  salts; the
      alkalies and their carbonates ; lime water;  astringent vegetable infusions.
         Tests of Purity.—If copper is  present, its  solution becomes blue on being super-
           saturated with ammonia.  A solution of chloride of  sodium, added in excess
           to one of  nitrate  of  silver, throws down  a  white, curdy  precipitate, and
           nothing  besides; this precipitate should be  entirely soluble in ammonia.   To
           detect nitre, a very common adulteration, a solution of the suspected salt should
           be  precipitated by hydrochloric  acid,  and  sulphureted hydrogen;  the filtered
           solution, if the salt be pure, will entirely evaporate by heat; if it contains nitre
           it will be left.  " When a small piece  of caustic is  crushed  to powder and
           spread evenly over a piece of paper, and the paper and powder then rolled  up
           together, twisted, and burned as a match, it should leave a tasteless  residue."

43. Argenti Oxidum—AgO—with hydrosulphuric and nitric acids, heat, etc.

44.  Arnica, with sulphates of iron and  zinc, acetate of  lead, nitrate of silver.

45.  Assafoetida, with the mineral acids, lime, hydrosulphuric acid, nitrate silver.

46.  Atropa BeUadonna, with alkalies, alkaline  earths and their carbonates; vegetable
      astringents;  lime water.
                            +
47.  Atropia—NCS4  H23 0°=At—with alkalies,  alkaline  earths  and  their carbonates, lime
      water, tannin, the  salts of  iron, zinc, lead and copper.
         Tests of.Purity.—It is entirely soluble in absolute alcohol  and ether  ; 100  parts
           of chloroform dissolves 51  parts of atropia.  It  is perfectly soluble in the dilute
           mineral acids, and  is precipitated from its solution without loss of weight  by
           ammonia,  which should not be  added in excess,  as it redissolves the pre-
           cipitate. 
890
A TABLE OF INCOMPATIBLES.
48. Barii Chloridum—BaCl—with the sulphates, oxalates, tartrates, borates, carbonates
       and alkaline phosphates, nitrate of silver, acetate of mercury, acetate of lead.
49. Barytas Carbonas—BaO, CO2—with sulphuric acid and sulphates, sesqui-oxide of iron,
       alumina.

60. Belladonna—(See Atropa Belladonna.)
51, Benzole—C" H8—Is mentioned here more for its great solvent powers; its incom-
       patibles have not been sufficiently tested.  It dissolves sulphur, phosphorus, iodine,
       mastic, camphor, wax, fatty and essential'oils, caoutchouc, gutta percha.  It dissolves"
       quinia, but not cinchonia.   Its boiling point is 176°F.

52. Bismuthi Subnitras—BiO31NO6—with hydrosulphuric acid, carbonate and chromate
       of  potassa, vegetable astringents.

53. Brominium—Br—with chlorine, water, atmospheric air, nitrate of silver, starch.
                            +
54. Brucia—C48  H26 N2 08=Br— with potassa and carbonate of soda.
         lests of Purity.—Ammonia produces a white  precipitate  in solution of salts of
           brucia. which appears at first like a number  of minute drops of oil,  but changes
           subsequently—with absorption of water—to  small needles.   The precipitate
           redissolves, immediately after separation, very readily in an excess of the pre-
           cipitant, but after a very short time—or, in  dilute solutions  after a longer time
           —the brucia combined with crystallization water, crystallizes from the ammo-
           niacal fluid in small, concentrically grouped  needles which addition of ammonia
           fails to redissolve.
         Bicarbonate of  soda produces in neutral solutions of  salts of brucia a precipitate
           of brucia, which separates into concentrically aggregated needles of silky lustre
           and are insoluble in an excess of the precipitant, but dissolve  in free carbonic
           acid.   Concentrated nitric  acid dissolves brucia and  its salts to intensely red
           fluids, which  subsequently acquire a yellowish-red tint and  become completely
           yellow upon  application of heat.  Upon addition of protochloride  of tin or
           sulphide of ammonium to this yellow fluid, it changes to a most intense violet.
           Chlorine water imparts to solutions of its salts a fine bright  red tint, to which
           if  ammonia is added,  it changes to yellow brown.

55. Cadmii Sulphas—rCdO, SO3—with potassa ammonia  and their carbonates, hydro-
       sulphuric acid, lime water, the carbonates and sulphurets.

56. Calcis  Carbonas—CaO, CO2—with  acids,  acidulous  salts, alum, vegetable  astrin-
       gents, soaps.                                             /

57. C'alcii Chloridum—CaCl—with the  soluble sulphates, the carbonates  of potassa,
       soda, magnesia.

58. Calcis Liquor, with atmospheric air, mineral and vegetable acids, alkaline carbonates,
       and sulphates,  soap,  vegetable astringents, alum,  acidulous and metallic  salts
       spirituous  preparations.

59. Calcis Fhosphas—8CaO, 3P05—with oxalate  of  lime,  acetate of lead nitrate of
       silver, carbonate of soda, potassa, ammonia.

60. Calx Chlcrinata—CaO, CI—with  the  acids,  sulphate  of  iron,  nitrate  of silver
       iodides.                                                                        '

61. Camphora—C10 H"  0—with strong sulphuric and nitric  acids, assafoetida,  galbanum
       sagapenum, anime, tolu.
62. Cantharis, with strong acids, caustic alkalies.

63. Capsicum, with  sulphate of  iron, acetate of
       limate, sulphates and sulphurets of the meta

54. Castoreum, with strong acids, caustic alkalies, tannin.

65. Catechu, with gelatine, albumen, gluten, starch, the sj
       the salts of lead, copper, silver, mercury, tin.

66. Cinchona, with alkalies, sulphates of iron and zinc, sulphurets, lime, maenesii  «;*..„♦
       of silver, tartar emetic.                                        '   5»esia, nurate
63.  Capsicum,  with  sulphate of iron, acetate of  lead, nitrate  of silver,  corrosive  sub-
       limate, sulphates and sulphurets of the metals.

      astoreum, with strong acids, caustic alkalies, ta

65.  Catechu, with gelatine, albumen, gluten, starch, the salts of the sesqui-oxides of im,
       the salts of lead, copper, silver, mercury, tin.                                    ^ 
A TABLE OF INCOMPATIBLES.
891
67. Cinchonia—C40  H24 N2 02 = Ci—with  the  alkalies,  alkaline earths  and their car-
      bonates.
         Tests of Purity.—Cinchonia and its salts  are insoluble in ether and  benzole.
           Potassa, ammonia and  their neutral carbonates produce in solution of cinchonia
           a white, loose precipitate, which  does not redissolve  in an excess of the pre-
           cipitants.   If chlorine water  is added to a solution of the salts .of cinchonia,
           it does not change the color, but if ammonia  is added, a yellowish white pre-
           cipitate is  formed.   100 parts of chloroform  dissolve but 4.31 of cinchonia.
           Cinchotina,  with which it is  sometimes admixed, is soluble in ether.   (See
           Quinia.)
68. Chloroformum—C2 HCl3—with albumen.   It would  be  improper to mix chloroform
      with any of the vegetable  preparations whose alkaloid is  soluble in chloroform, in
      any quantity more than sufficient  for one dose, as the chloroform would dissolve the
      whole of the alkaloid.
         Tests of purity.—If equal parts of colorless, concentrated sulphuric acid and
           chloroform  are  shaken together in a glass-stoppered vial, there should be  no
           color imparted to either liquid, nor any sensible  heat  developed at the time of
           mixing.   If chloroform  is dropped into  water, it  should  not assume  a  milky
           appearance,  but should be  in  transparent  globules under  the  water.  It
           should evaporate from the  hand or bibulous paper without foreign odor.

 69. Cimicifuga, with the sesqui salts  of iron, with alkalies.

 70. Cocculus, with alkalies and alkaline earths.
 71 Coccus, with the salts  of zinc, bismuth and nickel,  which produce a lilac precipitate;
       with the salts of iron a dark purple;  with  the salts of tin a brilliant scarlet; with
       alumina the lakes.
 72. Colchicum, with  acetate  of lead, nitrates  of silver  and  mercury, tannin.  Acids
       are said to render its preparations more drastic, and  alkalies to render them milder
       in their operation, but as acids  dissolve and alkalies precipitate its alkaloid, it will be
       seen that  alkalies cannot be added but in extemporaneous  mixtures.

 73. Colocynthis, with sulphate of iron, acetate of lead, nitrate silver, tannin, alkalies.

 74. Conia__NC18 HIS=Co—with tannin, albumen, salts of aluminum,  copper, lead, zinc,
       manganese, iron, nitrate silver, alkalies.
 75. Creasotum__C13 H" 0s—with nitric and  sulphuric acids, nitrate and acetate  of silver,
       albumen.
 76. Cupri Subacetas—2CuO, C4 H3  O3—with sulphuric  acid, water which changes it to a
       neutral acetate and trisacetate, nitrate of silver, lime water.
 77  Cupri Sulphas—CuO, SO3—with  potassa,  soda  and  the  alkaline  carbonates;  by
       ammonia, which, if  added in excess, redissolves  the  precipitate;  borax, acetates of
       lead and iron,  nitrate  silver,  corrosive sublimate, tartrate of potassa, chloride of
       calcium, tannin, arsenites, hydrosulphuric  acid, metallic iron.

 78. Cuprum Ammoniatum—NH3, S03+NH3, CuO + HO—with potassa, soda, lime water,
       arsenious acid, acids; water and air on long exposure; tannin.

 79. Curcuma—alkalies change  its color  to reddish-brown, as  do  also the  concentrated
       mineral acids pure boracic acid and numerous metallic salts, so that it cannot alone be
       relied upon as a test for alkalies.  Its alcoholic solution produces colored precipitates
       with nitrate of silver, acetate of  lead and other salts.

 80. Datura Stramonium, with the salts of iron, lead, mercury, and silver, alkalies, alka
       line earths and their carbonates,  tannin.

 81. Daturia—NC34  H23 O8—with alkalies, tannin.
 82. Delphinia, with alkalies,  alkaline earths and their carbonates, tannin.

 83  Digitalis, with sulphate of iron, acetate of lead, nitrate of silver, vegetable infusions o
       tinctures containing kinic,  tannic or gallic acids. 
892                      A  TABLE  OF  INCOMPATIBLE3.

 84. Digitalin, with tannic and gallic acids, alkalies and their carbonates.

 65. Elaterium, with alkalies and their carbonates,, tannic and gallic acids.
 86. Elaterin, with strong mineral acids, alkalies and their carbonates, tannin,

 87. Emetia, with gallic and tannic acids,  acetate of lead, corrosive sublimate, alkalies.
 88. Ergota, with acetate of  lead, nitrate of silver, astringent vegetable infusions and
      tinctures.
 89. Ferri Ammonio Citras, with potassa, lime water, mineral acid, tannin.

 90. Ferri Chloridi Tinctura, with alkalies, alkaline earths and their carbonates, astringent
      vegetable infusions and tinctures, mucilage of gum arabic, Fowler's solution.

 91. Ferri Citras—Fe2 03, C12 H6 On—with mineral acids, alkalies, lime water, tannin.

 92. Ferri ferro-cyanuretum—Fe7 Cy9—with nitric and hydrochloric acids, oxide of mer-
      cury with chromate of lead, it forms a beautiful green.

 93. Ferri  Iodidi—Fel—alkalies and their carbonates, and all other substances by which
      the sulphate of iron is decomposed.

 94. Ferri  Liquor Perchloridi, with atmospheric  air, alkalies and their carbonates,
      metallic salts, vegetable astringents, nitrate silver, etc.

 95. Ferri Liquor Persulphatis (Mousel's solution),  albumen, fibrin, gluten, etc.

  96. Ferri Oxidum Hydratum—Fe2 03 + 2HO—used principally as an antidote to arsenic.
      is incompatible with the same substances as the other sesqui-oxides.

 97 Ferri Fhosphas—FeO,  P0s + Fe2 O6, PO6—same as sulphate of iron.

 98. Ferri  Pulvis—Fe—(iron reduced by  hydrogen)  atmospheric air, water,  acids and
      acidulous salts, solutions of vegetable astringents, vegetable extracts.

 99. Ferri Pyrophosphas.—This is a double salt, composed of about 49 per cent, of anhy-
       drous pyrophosphate of iron, 35  per cent,  of citrate of ammonia, and 16 per cent.
      of water.  Robiquct states that it is not incompatible with the vegetable tonics and
      astringents, but this is  not the case; but the changes  do not  take place quickly,
      therefore there is no objection to  their mixture  for extemporaneous administration.

100. Ferri Subcarbonas (Ferri Sesqui-oxidum)—Fe2 0s—with acids and acidulous salts.

101. Ferri Sulphas—FeO, SO3—with alkalies, alkaline  earths and their carbonates, lime-
       water, nitric acid, borax, iodide of potassium, acetate of lead, vegetable astringents,
       soap,  muriate of barytes, nitrate of  potassa, tartrate of  soda and potassa,  nitrate of
      silver, phosphate of soda.

102. Ferri  Sulphuretum—5FeS + Fe2S3—with   acids which  unite  with the  iron, with
       acidulous salts and vegetable astringents, etc.   (See Potassii Sulphuretum.)

103. Ferri Syrupus Superphosphatis, is a double salt in solution like the last, the phos-
      phoric acid being in excess.   It is decomposed by the same  substances that decom-
      pose most of the salts of iron.

104. Ferri Valerianas, with boiling water,  mineral acids, alkalies and their carbonates,
      vegetable astringents, salts  of copper and zinc, etc.

105. Ferrum Ammoniatum, with atmospheric  air, alkalies and  their carbonates, lime-
       water, acids and acidulous salts, astringent vegetable infusions and tinctures. '

106. GaUa—Sulphuric  and hydrochloric acids, acetate of lead, sulphates of iron and cop-
      per, nitrates of silver and mercury, lime water, carbonates of ammonia and potassa
      tartar emetic, corrosive sublimate, infusions  of  Colombo, opium, peruvian bark and
      most other vegetables containing alkaloid  principles, gelatin, albumen, gluten alka-
      lies and their carbonates.  (See Acid. Tannicum.)

107. Guaiaci Tinctura, with mineral acids,  spirits nitric ether, water.

108. Hematoxylon, with sulphuric, nitric, hydrochloric, and acetic acids, alum  sulnhatea
      of iron and copper, acetate  lead, tartar emetic, gelatine,  etc.             '

109. HeUeborus  Niger, with alkalies, alkaline earths and their carbonates, tannin. 
A  TABLE OF INCOMPATIBLES.
893
110.  Hydrargyrum-Hg—with the mineral acids, iodine, bromine.
111.  Hydrargyrum  Ammoniatum—HgCl, NH2—with  mineral acids, alkalies, protochlo-
      ride of tin, boiling wa ter.

112.  Hydrargyrum  cum Creta, with acids, iodine, bromine, acidulous salts, alum, etc.

113.  Hydrargyri Chloridum Corrosivum—HgCl2—with many of .the  metals, alkalies
      and their  carbonates, nitrate  of silver, soap, lime water, tartar emetic, acetate of
      lead, sulphurets of potassium and sodium, sulphur, hydrosulphates, iodide of potas-
      sium, protochloride of tin, volatile oils, several vegetable infusions and  decoctions,
      and animal  and  vegetable  substances  containing albumen,  gelatine,  or gluten,
      piperin.
        In  some books this  is called a chloride, in others a  bichloride.  It is better and
      safer, therefore, always to designate it by the epithet Corrosivum.
        Tests of Purity.—It should sublime, when heated, without residue.  It should be
          readily and entirely soluble in ether, and in water.   .

114.  Hydrargyri Chloridum Mite—HgCl—with  alkalies,  alkaline  earths  and  their
      carbonates, hydrosulphates,  hydrocyanic acid, bitter almonds, lime water, iodide
      of  potassium, iodine, soap,  nitric acid, salts of iron, lead and copper, nitrate of
      silver.
        Tests of Purity.—It is completely sublimed by heat.   Solutions of the fixed alka-
          lies strike wiiii it a black color free from a reddish tinge.   Calomel washed with
          boiling distilled water, and the water tested with ammonia, will give no precipi-
          tate,  if free from corrosive sublimate.  If any is present there will be a white
          precipitate.  Distilled water, with which calomel has  been washed,  should
          yield  no precipitate to nitrate  of silver, sulphureted hydrogen or iodide of
          potassium.

115.  Hydrargyri Cyanuretum—HgCy*—with the mineral acids, nitrate of silver, hydro-
      sulphates, iodide of potassium, etc.

116.  Hydrargyri Iodidum—Hgl—with mineral acids, chloride of sodium, etc.   It should
      completely sublime by heat.   If it contains biniodide it may be separated  by washing
      with alcohol.

117. Hydrargyri Iodidum Rubrum  (Biniodiduin)—Hgl2—with  mineral acids,  nitrate
      of silver, alkalies,  acetate of lead, tartar emetic, sulphurets, etc.
         Tests of Purity.—It should completely sublime by heat.  It is perfectly soluble
          in alcohol, and in solutions of iodide of potassium and chloride of sodium.

118.  Hydrargyri Oxidum Nigrum—HgO—with mineral acids, acetic acid, iodine, etc.

119.  Hydrargyri Oxidum Rubrum—HgO2—with the mineral acids, ferrocyanurets.

120.  Hydrargyri Sulphas—HgO2 2S03—with the  alkalies and their carbonates, chloride
      of  sodium, lime water, etc.

121.  Hydrargyri Sulphas Flavus—3Hg02, 2S03—with the alkalies, iodine, etc.

122.  Hyoscyamus, with alkalies and their carbonates, nitrate of silver, sulphate of iron,
      tannin.

123.  Hyoscyamia, with alkalies and their carbonates, tannin.

124. IchthyocoUa Gelatine—C98  H82 N16 O38—Alcohol, tannin, and creasote,  corrosive
      sublimate.
125. Iodinum—I—with starch and vegetable preparations containing it, magnesia.

126. Ipecacuanha, with acetate of lead, vegetable  astringents, nitric acid, corrosive sub-
      limate, alkalies.
127. Jalapa, with mineral acids, tannin, lime water.

128. Jalapin, with mineral acids.
129. Kino,  with lime water, sesquichloride of iron, gelatine.

130. Lactucarium, with acetate lead, tannin, nitrate silver,  corrosive  sublimate, alkalies,
       lime  water, oxalates. 
804:                      A  TABLE OF INCOMPATIBLES.
 131.  Lobelia, with alkalies, alkaline earths, and their carbonates, tennin, nitrate of silver,
       corrosive sublimate.
 132.  Lobelina, with tannin, alkalies, and  their carbonates; it is decomposed by boiling
       water.

 133,  Lupulin, with the mineral acids, water.
 134.  Magnesia—MgO—with acids and acidulous salts, metallic salts.
 135.  Magnesia  Carbonas—3(MgOC02-f-HO)-|-NgO, HO—with acids and acidulous salts,
       hydrochlorate of ammonia, nitrate  of silver, corrosive  sublimate, cream of tartar,
       acetate of lead,  phosphate of soda.
 136.  Magnesia Sulphas — MgO,  SO3—with  potassa, baryta, soda, and  their  carbonates,
       lime, strontia, baryta, and their soluble  salts, ammonia  partially  forming with the
       remaining salt  a double sulphate;  carbonate  of ammonia and  bicarbonates  of
       potassa and  soda, do not decompose it when cold, but do upon boiling ; phosphate
       of soda.

 137. Mangesii  Binoxidum—MnO2—with  acids.

 138. Maranta.   (See Amylum.)

 139. Mel, with nitric acid.

 140. Mistura Ammoniaci, with  acids, ether,  spirits of nitric ether, corrosive  sublimate,
       nitrate silver, acetates potassa and lead.

 141. Mistura Amygdalae, with alcohol, tinctures, oxymel and sirup of squills, spirits of
       nitric ether,  hard water, cream of tartar, corrosive sublimate.

 142. Mistura Creta, with cream of tartar acids and acidulous salts, etc.
                              +
 143. Morphia—C34 H19 N0"=Mo—precipitated from its solutions by potassa, soda, and
       ammonia,  and redissolved by an excess of these alkalies ; the  carbonates of these
       alkalies  precipitate but do not redissolve the morphia by vegetable astringents con-
       taining tannin,  which  precipitate  is soluble in acetic acid; magnesia, the salts  of
       iron, copper, zinc, silver, and lead, alum.  (See also narcotina.)
         Tests of Purity.—It  is almost insoluble  in ether and  chloroform, one hundred
           parts of chloroform dissolving but .57  of morphia, whereas one  hundred parts
           of chloroform  dissolve  31.17 of  narcotina.   It  should be perfectly soluble in
           dilute nitric, hydrochloric, sulphuric, and  acetic acids, and  precipitated  by
           potassa  and ammonia, which precipitate should dissolve in an excess of these
           alkalies.  Should leave no residue  on incineration.  A given weight of morphia,
           dissolved in  dilute  sulphuric acid, should be precipitated from its  solution  by
           potassa cautiously  added, without loss of weight.  It is but sparingly soluble in
           benzole.

 144. Moschus, with corrosive sublimate, nitrate of silver, sulphates of iron and  copper.
       mineral acid, infusion of cinchona, tannin.
145. Mucilago.  (See Acacia, Tragacantha.)

146. Narcein—NC28 H20 O12—with alkalies  and  their carbonates, tannin.
         Like morphia,  it is insoluble in ether; it does  not, like  morphia, become blue  by
           the action of the salts of iron, nor red  by that  of nitric acid.   Mineral  acida
           slightly diluted render it blue.
                              +
147. Narcotina—C48 H2* N014=Na—with alkalies, alkaline carbonates, and bicarbonates and
       the precipitate is insoluble in an excess of the precipitants; tannin.   It is soluble in
       cold acetic acid, but is separated if the solution is heated.
         It may be  distinguished from morphia by its solubility in chloroform and ether •
           by its insolubility in alkaline solutions when added in excess; by  not forming a
           blue color with the salts of iron, and by not affecting vegetable colors
         If the solution of a salt of narcotina is mixed with chlorine water it  acquires a
           yellowish green  color, to  which,  if  ammonia is added, it becomes yellowish
           red. 
A TABLE OF ^COMPATIBLES.                      895
148. Nickel—(protoxide) NiO—with sulphide of ammonium, hydrosulphuric acid, potassa,
      soda, cyanide of potassium.

149. Nicotia   N2 C20 H14—with alkalies and their  carbonates, tannin.  It is soluble  in
      alcohol, ether, water, oil of turpentine.

150. Olea  Destillata, with alkalies, mineral acid, sulphur, heat  and light, corrosive  sub-
      limate, nitrate of silver.

151. Olea Expressa, with alkalies and alkaline earths, chlorine, mineral acids, acidulous
      salts, corrosive sublimate, lime water.

152. Opium,  with alkalies, alkaline earths  and  carbonates;  nitrate of silver, salts  of
      copper, iron, zinc, and lead, tannic and gallic acids.  (See Chloroform.)

153. Phosphorus—P—atmospheric aid, heat, nitric  and  nitro-hydrochloric  acids, alkaline
      solutions.

154. Piper, alkalies and their carbonates, corrosive sublimate.

155. Piperin—N2 C10 H37  O10—with corrosive sublimate, the alkalies and their carbonates.
      It is soluble in alcohol and ether, and is precipitated from these solutions by water,
      or the infusion of  any substance  in water.   It is not  precipitated  by  tannin  in
      solutions  of alcohol, or ether,  or chloroform.  It is  very  soluble in  chloroform.
      With hydrochloric  acid  diluted with  two  parts  of water, its solutions strike a
      brilliant yellow-green color, but do  not precipitate the  piperin.  With  nitric and
      sulphuric acids treated in the same manner, the color  produced is a  bright yellow.
      It is incompatible with soap,  and therefore with the liniments containing it.

156. Plumbi Acetas—PbO, C4 H3 O3—with  sulphuric hydrochloric, citric and tartaric,
      lime-water, cream of tartar, alum, borax, metallic  sulphates  and sulphurets, soap,
      milk, infusion of opium, hard water,  vegetable astringents, with iodide of potassium,
      it forms a yellow precipitate, with  sulphureted hydrogen, a  black  precipitate;  with
      carbonated alkalies, a white one;   with chromate of potassa, a beautiful  lemon-
      yellow ; albumen.

157. Plumbi  Carbonas—2(PbO,   CO2) + PbO,   HO—with  sulphureted hydrogen,  the
      acids.

158. Plumbi Iodidum—Pbl—with solution of potassa, sulphuric acid.

159. Plumbi Liquor Subacetatis—2PbO, C4 H3 O3—with  hard  water, alkalies, alkaline
      earths, and their carbonates, sulphuric and hydrochloric acids, sulphates, sulphurets,
      hydrochlorates, the  soluble  iodides  and chlorides, lime  water, infusion  of  opium,
      vegetable  astringents,  soaps and  liniments  containing  it,  tartrates, chromate  of
      potassa, solutions of acacia, albumen, gelatine.

160. Podophillin, as at present prepared,  is  a compound of two  resinous  principles, one
      soluble in ether and alcohol, the other  in  alcohol only.  It  is precipitated from its
      solution  by hydrochloric acid;  sulphuric acid darkens  it; nitric acid produces a
      color much  resembling  tincture  of iodine.   Like jalapin, it is rendered milder
      in its operation by trituration, and by combination with an alkaline carbonate.

161. Potassa—KO—with  acids and most  acidulous salts, carbonic acid, ammonia and its
      salts.
162. Potassae Acetas—KO, C4 H3 O3—with  mineral acids, sulphates  of  magnesia and
      soda, tartaric acid, nitrate of silver, corrosive sublimate, ammonia and its  salts, lime
      water.
163. Potassae Arsenitis  Liquor, with  acids, lime  water, nitrate  of silver, chloride  of
      calcium, sulphate  magnesia, alum, the  salts of copper, tincture of chloride  of iron,
      sulphureted hydrogen, vegetable astringents,  piperin,  infusions of vegetables con-
      taining alkaloids.
164  Potassae  Bicarbonas—KO,  2C02—with acids, and   acidulous  salts,  lime water,
      tincture of chloride  of iron, nitrate of silver.

165. Potassae Bichromas—KO, 2Cr03—with nitric, sulphuric,  hydrosulphuric, tartario
      and oxalic acids, nitrate of silver, acetate of lead, chloride of barium, sulphites. 
896                     A TABLE OF  INCOMPATIBLES.
166. Potassae Bisulphas—KO 2S03—with many of the metals and most oxides,  with
      alkalies, alkaline earths, and their carbonates, lime water, etc.
167. Potassae Bitartras—KO, 2C4 H2 O6—with salifiable bases which  form soluble tar-
      trates, as  soda, antimony, iron, etc., it gives rise  to  double salts.  It is  rendered
      very soluble by addition of boracic acid or borax.   It  is decomposed  by strong
      acids, lime water, sulphate  of magnesia, ammonia, carbonates  of  soda, pptassa and
      magnesia, acetate of lead, nitrate of silver.
168. Potassae Carbonas—KO, CO2—with acids and acidulous  salts, sulphates of  mag-
      nesia, copper, iron and zinc, lime and  lime water, acetate and hydrochlorate, and
      carbonate  of ammonia, chloride  of calcium, iodine,  tartar emetic,  nitrate  of
      silver, calomel, corrosive sublimate,  tincture of chloride  of  iron, acetate of  lead,
      alkaloids.
169. Potass  Citras—3K0, C12 H6  0"—with sulphuric and  other acids,  the salts of  lead,
      lime and silver.

170. Potassas Chloras—KO, C10B—with  sulphuric  and muriatic  acids,  sulphur,  phos-
      phorus, nitrate of silver.
171. Potassae Liquor, with carbonic acid, acids and acidulous salts, and all metallic and
      earthy preparations held  in solution  by an  acid,  calomel,  corrosive  sublimate,
      ammoniacal  salts,  iodides  of• iron,  zinc,  mercury, silver;  with  all  vegetable
      infusions  containing an alkaloid  principle.   The neutral and  acid solutions of
      potassa are precipitated of a yellow color hy bichloride of platinum and of a  white
      color by tartaric acid.
172. Potassae Nitras—KO,  NO6—with sulphuric acid sulphate of magnesia, and metallic
      sulphates, alum, tartaric acid.

173. Potassas Sulphas—KO, SO3—with  nitric  hydrochloric and tartaric acids, nitrate of
      silver, acetate of  lead, corrosive sublimate,  chloride  of  calcium and barium,
      sulphate of magnesia, chlorinated lime, chloride of platinum, nitrate of strontia.

174. Potassae Tartras—KOC4 H2 06—with strong acids and many acidulous salts, chloride
      of barium and calcium, acetate of lead, lime water, nitrate of silver."

175. Potassii Bromidum—KBr—with acids, chlorine, nitrate of silver, starch.

176. Potassii Cyanuretum—KCy—with most of the salts  with metallic oxides.

177. Potassii   Ferrocyanuretum—2KCy,   FeCy=2K,  Cfy—with   soluble  salts  of
      metallic oxides, chlorides, the  salts of sesqui-oxide  of iron, with  which it strikes
      a deep blue color, a brown  color  with the salts  of copper,  and a white one with
      those of zinc.

178. Potassii  Iodidum—KI—with  nitrate  of  silver, acetate of lead, tartaric   acid,
      metallic salts, corrosive sublimate, acids and acidulous salts except  cream of tartar,
      chlorine.
179. Potassii Sulphuretum—K, S3—with acids, which unite with the potassium and set free
      the sulphur, precipitate part of it, and expel the  other part in the form  of sulphu-
       reted hydrogen gas; with metallic solutions, which unite with the sulphur and form
      sulphurets; with water, whose oxygen unites with the potassium  of the bisulphuret
       forming potassa, and whose  hydrogen  unites with the  sulphur, forming  sulphuret-
      edhydrogen; when  exposed to the air, oxygen combines with the sulphur, forming
       sulphuric acid, and  with the potassium of  the  bisulphuret, forming potassa,  and
      these  two  new combinations  unite  and form sulphate of potassa.
180. Populin, with alkalies and their carbonates.

181. Quassia, with  nitrate of silver, tannin; but as it contains no tannin,  it is not incom-
       patible with the salts  of iron, copper, zinc, lead, corrosive sublimate, iodine, chh
       rine, gelatine.
182. Quercus Tinctoria.  (See Acidum  Tannicum.)
                              +
183. Quinia—C40 H24 N2 O4 == Q—with  tartaric acid, tartrate of potassa,  lime water  ta;
       nin ; with  alkalies,  their carbonates, alkaline earths, the precipitate rodissolves to
       very slight extent in  potassa,  but  more freely in  ammonia, the alkaline carbonate 
A TABLE OF  INCOMPATIBLES.                      897
      do not redissolve it.   Soluble  salts of baryta and lead precipitate it from its solu-
      tions and the precipitate from baryta is insoluble in the acids ;  concentrated nitric
      acid dissolves quinia to a colorless  fluid, becoming yellowish upon the application
      ° i  au   ^h° a<^'tion 0*" chlorine water to a solution of a salt of quinia imparts no
      color, but if ammonia is added, the fluid acquires an emerald green color.  If to the
      chlorine solution, ferrocyanide of potassium in solution  is added, a dark red color is
      produced, which ultimately passes into green.  This docs not take  place with cincho-
      nia.   If a solution of quinia is  precipitated with ammonia, ether added, and the mix-
      ture shaken, the quinia redissolves  in the  ether, and the clear fluid  presents  two
      distinct  layers.   Such may  also be done with  benzole.  This is not the case with
      cinchonia.  Chloroform dissolves,  to each 100 parts, 57.47 of quinia,  whereas, of
      cinchonia, 100 parts dissolve but 4.31.   (See Cinchonia.)

184. Quinoidine, or amorphous quinia, bears the same relation to quinia that uncrystalliz-
      able sugar does  to crystallizable.   It would probably  be more used if it were  not so
      much  adulterated.  It should be  entirely soluble in  alcohol and in dilute  sulphuri.j
      acid, and its precipitate from these solutions, by ammonia, should  weigh as much as
      the original substance.

185. Rheum, with the sesquioxide of iron and  its salts, nitric  acid, lime water, infusion of
      cinchonia, solution of quinia,  acetate of lead, nitrates  of silver and  mercury, Gou-
      lard's extract, corrosive sublimate, tartar emetic.

186. SabadiHa.   (See Veratria).

187. Salicine—C26 H18 O14—is soluble in alcohol and water,  and insoluble in ether.   >>o
      reagent precipitates salicine as such.  If salicine is treated with  concentrated sul-
      phuric acid, it agglutinates into a resinous lump, and acquires  an intensely  blood-
      red color without dissolving in the acid; the color of the acid is  at  first unaltered.
      If an aqueous solution of salicine is mixed with hydrochloric acid or dilute  sulphuric
      acid, and the mixture boiled for a  short  time, the  fluid suddenly  becomes turbid,
      and deposits a finely granular  crystalline precipitate (saliretine).  It  is not precipi-
      tated from its solutions by the alkalies.   As silicine is frequently added to  quinia  as
      an adulteration, it may be readily distinguished by these tests.

188. Salvia, with the  sesquisalts of iron,  and vegetable infusions containing alkaloids.

189. Sanguinaria, with alkalies.

190. Sapo—and liniments containing it—with acids, earths, earthy and metallic salts.

191. Scillas, with alkaline carbonates, nitrate of silver, acetate of lead, lime water.

192. Senna, with strong acids, tannin, solution of subacetate of lead.

193. Soda—NaO—with  acids and most acidulous salts, carbonic acid, etc., etc.

194. Sodas Acetas—NaO;  C4 H3 O3—with mineral acids, carbonate of lime, phosphate of
      sesqui-oxide of iron.

195. Sodas Bicarbonas—NaO, 2C02—with the same as the carbonate, excepting sulphate
      of magnesia in the cold.

196. Sodas Boras—NaO, 2B03—with acids, salts of ammonia, and  many metallic oxides,
      carbonate of soda and potassa.

197. Sodae Carbonas—NaO, CO2—with acids,  acidulous salts, lime  water,  earthy  and
      metallic  salts,  hydrochlorate  of ammonia, borax, vegetable  acids, tartar  emetic,
      sulphates, sulphureted hydrogen, calomel, corrosive  sublimate, salts of iron, alka-
      loids, sulphate of magnesia.
198. Sodas Liquor, with carbonic acid, acids and acidulous salts, and all  metallic and
      earthy  preparations  held  in  solution by an acid;  calomel,  corrosive sublimate,
      ammoniacal  salts, iodides of iron, zinc, mercury, silver; with all vegetable infusions
      containing an alkaloid principle.
199. Sodee Liquor Chlorinatas^with  acids, lime water, carbonic  acid, alum, nitrate  of
      silver, iodides, calomel, sulphate of iron.

200. Sodee Phosphas—2NaO, PO6—with  all  the soluble salts  of lime, and magnesia;
      mineral acids, nitrate of silver, alum, neutral metallic salts.

  VOL.  II.—57 
898                      A  TABLE  OF INCOMPATIBLES.
201. Sodas  et Potassas Tartras—KO, C4 H2  O'-fNaO, C4 H2 06—with acids  and acidu-
      lous  salts  except cream of tartar, soluble salts of lime  and baryta, acetate and
      subacetate of lead, nitrate of silver.
202. Sodas  Sulphas—NaO, SO3—with carbonates and acetates of potassa, chloride of cal-
      cium, nitrate  of silver,  acetate  and  subacetate  of lead, lime water, ammonia, but
      not its siibcarbonate, salts of barytes, chlorinated lime and soda.

203. Sodii  Chloridum—NaCl—with nitrate of silver, nitric and sulphuric acids, carbonate
      of potassa, protoxide of mercury, sulphates of soda and potassa,  salts of iron.

204. Stramonium.   (See Datura.)

205. Stanni Protochloridum—SnCl—chloride  of  mercury,  hydrosulphuric  acid, nitrate
      of  silver,  potassa,  ammonia,  and their  carbonates,  terchloride  of gold,  coccus
      cacti.
                                +
206. Strychnia—C44 H24 N2  04=Sr—Potassa and  carbonate of soda produce  in solution
      of the salts of strychnia, precipitates of strychnia, which  are insoluble in an excess
      of the precipitants.  Ammonia  produces the  same  precipitate which redissolves in
      an excess of ammonia, and after  a time  crystallizes in  needles.  Strong chlorine
      water produces a white precipitate which dissolves in ammonia to a colorless fluid.
        Concentrated  nitric  acid dissolves strychnia to  a colorless fluid, which becomes
      yellow by heat.
        On putting a drop of concentrated sulphuric acid on a watch-glass, and adding to
      it a little strychnia or  salt of strychnia, solution ensues without any particular reac-
      tion ; but  if  a drop of solution of chromate of potassa is  now  added,  it instantly
      acquires a deep blue  color, which speedily changes  to red.  If the  strychnia is
      rubbed together with  binoxide  of lead and concentrated  sulphuric  acid containing
      one per cent, of nitric acid, the mass acquires first a blue, then a violet color, which
       changes to red, and finally to yellowish green.
         It is incompatible with tannic, but  not with gallic acid, nor with sesqui-oxide of
      iron.  One hundred parts of  chloroform dissolve 20.16 of strychnia.  It  is  but
      sparingly soluble in benzole.

207. Sulphur—S—with nitric and nitrohydrochloric acids, boiling  solution of  soda.

208. Sulphuris Iodidum—IS2—with heat, boiling water, the acids, chlorine.

209. Tobacum, with  oxides  of mercury and antimony, nitrate  of silver, sulphurets, chlo-
       rine, mineral acids.

210. Toxicodendron, with  the  sesquisalts  of iron, alkalies, and alkaline  carbonates,
       acetate  of lead, sulphate, and valerianate of  zinc.

211. Tragacantha, with sulphate of copper, iron, acetate of lead,  alcohol, iodine.

212. Uva Ursa, with subacetate of lead, carbonate of potassa,  gelatine.

213. Valeriana, with salts of iron and zinc, nitrate of silver.

214. Veratrum  Album, with alkalies their carbonate, tannin.

215. Veratrum Viride, with alkalies  their carbonates, tannin.
                              +
216. Veratria—C34 H22 N08=Ve—with alkalies, their carbonates, tannin, corrosive sub-
       limate, chloride of gold, tincture of iodine.  Veratria is insoluble in water, sparingly
       so in ether, freely in alcohol; 100 parts of chloroform dissolve 58.47 of veratria.   I.
       is soluble in the dilute  acids.   The alkalies and  their  carbonates and  bicarbonates
       precipitate veratria  from its solutions  and  the  precipitate  is not dissolyed by an
       excess  of the precipitants except  ammonia in the cold, heat again causing a preci-
       pitate.   Sulphuric acid produces with veratria  a ruby or crimson-red  coTor  nitric
       acid a yellow color, tincture of iodine a brownish  red, soluble on boilin» into clear
       red liquid, to which if ammonia was added while warm, it gave a yellow°precipitate
       gradually changing to  white.   Solution of chloride  of  gold caused a yellow precipi-
       tate, insoluble in an excess of the precipitant until boiled, when  it  formed a creen-
       ish liquid, in which caustic potassa gave a purplish  black  precipitate
         Mr Richardson  has given a very elaborate treatise on veratria in the " Ameflean
       Journal of Pharmacy," 3d series, voL v., No. 3, p.  209, in which he has proved the 
A  TABLE OF INCOMPATIBLES.
899 •
      similarity of the veratria obtained from veratrum viride  and V. alba, so far as thev
      are amenable to chemical tests.  The writer has repeated these tests  upon veratria
      from V.  viride, made by himself, and veratria from V. album made by Merck, with
      the same results arrived at by Mr. Richardson,  but although  apparently identical  in
      their chemical  characteristics, they are not, according  to the writer's observations,
      identical in their medicinal or therapeutic characteristics.

217.  Zinci Acetas—ZnO,  C4  II3  O3—with  the mineral acids and acidulous salts, car-
      bonates of ammonia, potassa, and soda, lime water,  vegetable astringents, ferrocy-
      anuret of potassium, hydrosulphuric acid.

218.  Zinci Chloridum—ZnCl—with nitrate  of silver, carbonates  of soda,  potassa, and
      ammonia, ferrocyanuret of potassium; ammonia and potassa throw down a white
      precipitate which is dissolved in an excess of the precipitants.

219.  Zinci Oxidum—ZnO—with ammonia, potassa, soda,  acids, acidulous salts.

220.  Zinci  Sulphas—ZnO,  SO3—with  alkalies  and their carbonates,  ferrocyanuret  of
      potassium, hydrosulphate of ammonia, nitrate  of silver, acetate of lead, lime water,
      chloride of  barium, hydrosulphates, mucilages, milk, vegetable astringents.

221.  Zinci  Valerianas,  with  acids  and  acidulous salts,  alkalies  and  their carbonates,
      metallic salts, vegetable astringents. 
LATIN   VOCABULARY.
OR LATIN  TERMS USED  BT MEDICAL MEN.
 Abdomen,  lg—The belly (abdominales).
 Abduco, 3d—To draw from (abductor).
 Abluo, lui—To wash away (abluents).
 Abnormis,  e—Abnormal, out of the usual rule or order.
 Abomasum. i—The fourth stomach of the Kuminantia.
 Abortio, nis—Premature expulsion of the fetus.
 Abrado, si—To rub off, abrasion.
 Absedo—To separate (abscess).
 Absente febre (abs. febr.)—While the fever Is absent.
 Absorbeo—to suck up (absorbents).
 Absorptio,  onia—The function of the absorbents.
 AbS-!ineo, ui—To refrain from food, abstinence.
 Ac (ac si, as if) (simul ac, as soon as)—And.
 Acceli'ratio, onis—Increased rapidity of the pulse, respi-
  ration, etc.
 Accelerator, oris—A muscle which contracts to  accele-
  rate the passage of the urine.
 Accessio, onis—The approach of the pyrexlal period in
  fevers.
 Acclimatio, onis—Naturalization to a foreign climate.
 Accurate—Accurately.
 Accurate misceantur—Mix them thoroughly..
 Accurate pensi—Weigh them accurately.
 Aciditas, or acidum (acer, sour)—Sourness, acescenee.
 Acini (pi. acinus, a  grape stone)—The minute parts of
  the lobules of the liver, connected together by vessels.
 Acme—The height of a disease.
 Acrimonia, ae—Sharpness of flavor.
 Acutus, a, um—Disease or pain of a sharp  character.
 Aeupungo, pupungi—To insert needles into the skin or
  flesh.           r
 Ad—To, at, u»til.
 Ad libimm  (ad lib.)—At pleasure.
Adde—Add.
 Atldantur—Let them be added.
 Addendus—Being added.
 Addendo— By being added.
 Adduco,  xi—To draw to (adductor).
 Adeps, ipis—Fat, animal oil.
 Adliaereo, haesi—To adhere, adhesion.
 Adiposis—Hypertrophy of the adipose substance.
 Adjuvo, juvi—To assist or promote the operation of
  another (adjuvants).
 Adjuvanta—Medicines which assist to relieve diseases.
 Admoveatur (admov.)—Let it be applied.
 Admoveantur—Let them be applied.
 Adnascor—To grow to (adnata).
 Adolescentia, ae—Youth, from the  age of puberty to 25.
 Adstante febre (ads. febr.)—While  the fever is present.
 Adultus, a, um—Adult age from 25 to 50.
 Adultero, avi—To adulterate, to corrupt.
 .figer—A male patient.
 .figra—A female patient.
 ;£ias, atis—Age, term of life. •
 Alferens, tis—Afferent vessels that convey lymph to the
  lymphatic glands.
 Afttnitas, tis—Relationship, attraction, affinity.
 Agglutino,  avi—To form an adhesive union,  agglutinate.
 Aggressus—A ti attack.
Aggressus febris—An attack of fever.
Agito—To shake.
 Ala,  ae—A  wing  (alae nasi, etc.)
 Albumen, inis—Albumen.
 Albus—White (albino).
 Alga, ae—Seaweed.
Aiienatio, onis—Estrangement, mental derangement
Aliformis, is—Wing-like.
Alimentum, i—Substances which nourish the body.
Aliquot—Some.
Aliquoties—Sometimes.
 Alter, a, um—The other (alteraUves).
Alterne—Bv turns, alternately.
Alternis horis—Every other hour.
AHernis diebus—Every other day.
Altrix, icis— A  nurse.
 Alumnus, i— He  that is brought up a pupil,
 Aluta—Soft leather.
    900
 Alvearlum,  1 (a beehive)—The meatus  audltorius pi-
   ternus.
 Alveolus, 1 (channels)—The alveolar processes or sock-
   ets of the teeth.
 Alvus, 1—The bowels, the belly (hence looseness, flux).
 Alvo adstricta—The bowels being costive.
 Alvo relax—The bowels being loose or relaxed.
 Amentia, ae—Senseless, imbecility of intellect.
 Amplus, a, um—Large.
 Ampullula, ae (a liUle  bottle)—The extremity of each
   villus of the mucous coat of the intestines.
 Amputatio,  onis—The removal of a limb or other part
   of the body by means of the knife.
 Amuletum, i—A supposed charm against infection or
   disease.
 Amylum, i—Starch.
 Anatomia, ae—A surgical dissection of the body.
 Ancon, onis—The elbow.
 Angina, as—An inflammation of the throat.
 Angina pectoris—Spasm of the  chest.
 Angor, oris—A strangling, a choking.
 Anhelitus, us—Difficulty of breathing, dyspncea.
 Anima, ae—The vital principle,  the souL
 Animal, is—A living creature.
 Animalculus—Animalcule.
 Annulus—A ring, a circle, a rounded margin.
 Ante—Before.
 Anteversio  uteri—A morbid inclination of the fundua
   uteri forward.
 Antidotum,  i—A counter poison, antidote'.
 Anus, i—The fundament.
 Antrum Maxillare—A cavity above the molar teeth of the
   upper jaw.
 Aperiens, entls—Opening, mildly purgative.
 Apex, icis—The extremity of a part.
 Apotheca, ae—A place in  which anything is laid up.
 Apparatus,  us—That with which preparation Is made.
 Apendix,  icis—An appenda-e.
 Appetitus, us—A longing or desire after anything.
 Applicans, antis—Applying.
 Applicantur—Let there be applied.
 Aqua—Water.
 Aqua communis—Common well water.
 Aqua bullientis (aq. bul.)—Boiling water.
 Aqua ferventis—Hot water.
 Aqua fluvialis—River water.
 Aqua fonlis—Spring water.
 Aqua marina—Sea water.
 Aquula, ae—A fatty tumor under the skin of the eyelid.
 Arbor, oris—A tree (arborescent).
 Arctatio, onis (narrow)—Constipation of the intestines,
  also  preternatural straitness of the vagina.
 Arcus senilis (bow of old age)—An  opacity round the
  margin of the cornea occurring in advanced age.
 Ardor, oris—A heat, sense of heat, burning.
 Ardor urinae—A sense  of  scalding on  passing the
  urine.
 Area,  ae—An open space.
 Area differens, area serpens, area pellucida, ar«a va*
  culosa.
 Areola, sb—The pink  or brown circle which surround*
  the nipple.
 Aridus, a, um—Dry, arid, without moisture.
 Ars, artis—A knowledge acquired by learning.
 Artena, as—An artery.
 Arthriticus,  a, um—Afflicted with the gout
 Articularis,  e—Relating to the joints.
 As, assis— A pound  weight.
Assimilatio,  onis—Conversion of food Into nutriment
■Jfi?1?.80' inxi--To ben<l or draw together (astringent).
Athleticus, a, um—Athletic, strong           ^*  *
Atomus, i—Any small invisible body, an atom.
Atque—And, also.                         ^
Atqui—But, however.
 Ater, tra, trum—Black, fatal, mortal
Ater panis—Black bread.
Atra febris—A malignant fever. 
LATIN  VOCABULARY.
901
Atrum venenum—Rank poison.
Attente—Carefully.
Attenuo, avi—To make thin, attenuate.
Attollens, entis—A muscle which  draws any part up-
  ward.
Attondeo—To shave.
Attonsum caput—The head being shaved.
Attraho, xi—To draw toward oneself (attraction).
Attrahens auris—The muscle which draws the ear for-
  ward and upward.
Attritus—Rubbing, chafing.
Audio, ivi—To hear.
Auris, i (pi. es, ibus)—The ear.
Auriscalpium, i-An ear pick.
Aurium tinnitus-A ringing noise In the ears.
AuscuUatio, onis-Listening by  the appUcation of the
  ear in the examination of disease.
 Aut—Or.         ,,  ,
 Autem—But, notwithstanding.
 Aviditas, atis—Eagerly, greedUy.

 Bacca-A berry.
 Balneum arense—A sand batn.
 Balneum maris—A sea bath.

 Bainlum oS8S&utt3&S& bath to be made hot.
 Balsamum—A balsam.
 Barba,  ae—The beard.
 Basis, is—That  on which anything rests.
 Ben«—Well.
 Bene mane—Very early.
 Bene multi—A great many, plenty.
 Blbe-Drink.
 Bibat (bibo)—Let him drink.          „„,„-.
 Bess or bcssis-Two thirds of a pound weight
 Biceps, ipitis-That has two heads.

 Bi(dOUmni"b?duo veiytriduo)-Every two or three days.
 Biduo continente—During two days.
 Bifidus, a, um-Bifid, divided into two parta.
 Bifer, a, um—That bears twice a year.
 Biformis—Double formed.
 Bifurcus-Bifurcated having two points.
 Bilinguis— Double-tongued, treacherous.
 Biliosus—Full of bile.        „».„..
 Bimembris—Having double members.
 Binominis—Having two names.
 Binoctium—The space of two nights. -
 Bipartio—In two parts.
 Bipatens—Open on both sides.
 Bipennis,  e—Having two wings.
 Bipes,  edis—Two footed, biped.
 Bis—Twice.
 Bis in die—Twice daily.
 Bis terve—Twice or thrice.
 Bis quinque—Ten.
  Bis tamo—As much more.
  Bolus—A  bolus, a large pilL
  Bonus, a,  um—Good.
  Brevi—Soon after, shortly.
   (Ad brevi)—A little whUe.
  Bulliat—Let it boil.             .   „„„„,i,in»
  Blandimentum-Means of charming or soothing.
  Blandus,  a, um—Caressing, coaxing.
  Blatero, avi—To talk foolishly.
  Borabyx,  ycis-A silkworm.
  Braoa—A covering for the legs and thighs.
  Brachialis-Of, or belonging to the arm.
  Brachium-The arm from the wrist to the elbow.
  Bubo—A  swelling of the glands of the grom.
  Bucca—A cheek.
  Buccea—A mouthful.
  Bucco—Chub-cheeked (hence a fool).

  BuSaTt-mebs, vesicles raised by a watery fluid.
  Butyrum—Butter.

  Cachinno, are—To laugh immoderately.
  Caco,  avi—To go to stool.
  Cadaver,  eris—A corpse, a dead body.
  Caduca—The deciduous membrane.
  Caeco, avi—To blind (caecum).
  Caelebs—Single, unmarried.




  Calefacio—To make warm.
  C.ilide—Hotly, warmly.
  Calidus—Hot, scalding.




  n.,11,., i__Hai-'l skin, want 01 leenug.


  Calveo.ere-Tobebald.
Calvlties, ei—Baldness.           «„_«,
Calyx,  yds—the bud or calyx of a flower.
Campa,ae, e, es-Canke.r worm, caterpillar.
Canalis, is—Canal, a conduit.         „„«,.,»«!
CanceUo, avi-Tomake lattice-wise, cross-barred.
Cancer, cri—A crab.
Candefacio—To make red hot.
Caedela, se—A taper, a candle.
Candesco, ere—To become of a glowing heat
Canesco, ere—To become grey or white.
Canis,  is—A dog.
Canities, ei—Grey hair.
Cannabis, is—Hemp.
Canula—A small tube.
Canus—Hoary, old.            _._,,v.
Capillamentum, i-False hair, a Peruke.
Capillus, i-The hair of the head (capillary).
Capito, onis-That hath a large head.
Capripes—Goat footed,
Capsula—A cover, a small chest.
CaDto  avi—To snatch at, to catch.         ___
Capularis, e (caPulus>-Of, or belonging to a coffin.
Caput, ilis—A head.

8af c^^--Take a tablespoonful.

Sa^nauromnrmtnracvespere-To be taken  eve,,
  morning and evening.
Carbo, onis-A coal.     ,„„„„,___
Carbunculus-A carbuncle, anthrax.
Career—A prison, a gaol.
Carcinoma—A cancer.


 Canes—Decay, rottenness.
 Carlosus—Corrupt, rotten.
 (jarnifex  icis—A tormenler, a gaoler.
 cfrnivorus, a, urn-Feeding on flesh.
 Carnosus—Fleshy, muscular.
 Carno, carnis—Flesh.
 Carpus—The wrist.

 ^runl^rSpiece of flesh.

 gSSk'^KS.tily, honesty.
 Castro avi—To castrate, geld.
 Casus us-A falling, an  accident

 Silcum^K^n^^ing medicine.


 SiS^3^Mmtfuii
 ctuffiuVis"toe-Cautiously, carefully.

 Cavea, ae—A cavity.
 Caverna, re-A hoUow place.


 Centum—A hundred.

 Cerllum"-Acerate made with wax.

 geTeoru'r TKetp^lon of the brain.
 Ceroma-An ointment composed of wax.
 Certe—Certainly, surely.
 Cervical—Of the neck.
 Cervix—The neck.
 Cerevisia, se—Ale, beer.
 Cestus-A band, a tie, a girdle.
 Ceterus (et cetera)-The other
 Ceu—As, like as, as if.
 Chalce us—Brazen, of brass.
 Chaos-Infinite empty space.
 Charta—Paper.
 Charta cerulea-Blue P»P«-. _

 Shar^Lr/o-rdi^drDi^futro ten papers, or pow

 ChirSra-The gout in ihe.^nd








  CiK-lny'thinB which is eaten, food.
  Cicada—A tree cricket.
  Cicatricosus, a, um-Full of scars.
  Cicatrix, icU-The scar of a wound.
  Cilium, i—The eyelash.
  Cimex, icis—A bug.               .
  Clnclnnus—Curled hair, a lock, a curl.
  Cinctus—A girdle, a belt.
  Cinefactus—Reduced to ashes.
  Cingo—To bind, to dress.
  Cinis—Ashes, lye. 
902
LATIN  VOCABULARY.
Circa (circiter)—Around, about, near.
Circulalio, onis—The flow of blood through the heart, etc.
Circulatrix—A female mountebank, quackish.
Circumcido, idi—To circumcise.
Circumcisio, onis—Circumcision.
Circumligo, avi—To bind around, to encompass.
Circumpllco, exi—To fold around.
Circumtondeo—To shave all round.
Cirrams (cirrus)—Having curled or crisped hair.
Cis—On this side, within.
Citalim (cito)—Hastily, quickly.
Citissime—As quickly as possible.
Clan, or clauculum—Secretly, privately.
Clandico—To be lame, halt, limp.
Clando—To limp.
Clausus, a, um—Covered.
Clauso vase—In a covered vessel.
Clavicula,  ae—The clavicle or collarbone.
Clementer—MiMly, gently.
Clinicus—A physician who visits patients who are con-
  fined to their beds.
Cloaca—A common sewer.
Clyster, eris—A clyster.
Coagulum, i—Curdled.
Coalesco, lui—To grow  together.
Coccyx—A cuckoo, the lower end of the spine.
Coctus—Boiled.
Cochlearum—A spoon.
Cceeum—The cul de sac, coecum.
Coeliacus, a, um—Belonging to the stomach.
Coena,  ae—Dinner, the principal meal.
Ceenaturio, ire—To have an appetite for eating.
Coenito—To take a meal frequently.
Coeno—To eat at table, to take a meal,
Coenula—A lunch, a  lesser meal.
Cofeuatio, onis—Alliance by birth, relation by blood.
Cola—Strain, filter.
Colatus—Strained.      •
Cola trans chartam—Strain through paper.
Colato liquori—To the strained liquor.
Colentur—Let  them  be strained.
Collacrimo, avi—To  weep together, to bewail.
Collaris—Belonging  to the neck.
Colliquefacio, feci—To make fluid, to melt
Colloco, avi—To place,  or put.
Collum—The neck.
Colluo, ui—To wash, to  wet
Collyrium—A wash for  the eyes.
Colo, avi—To sift, to strain.
Colon—The colon, the large intestine.
Color,  oris—Color, complexion.
Colostrum—The first milk in the breasts after the birth
  of young.
Colum—A strainer, colander.
Coma—The hair of the head.
Comans, tis—Having hair.
Combibor—To be drank together.
Comburor—To be burned.
Comedo—To eat, eat away, eat up.
Commaculo, avi—Tt pollute.
Commendo, avi—To intrust to one's charge.
Commissura, ae—A commissure, a joint
Commorior—To die at the same time.
Compar, aris—Equal.
Compositus—Compound, put together.
Comprimens—Binding, pressing together.
Coueaco—To bedaub, to pollute with ordure.
Conceptio, onis—Conceiving, becoming pregnant
Concerpo—To tear to pieces, to rend.
Concha—A shell, a sea  shell.
Conditorium, i—A coffin.
Condylus, i—A knuckle.
Congelo, avi—To freeze, to congeal.
Conguis—A gallon.
Conjunctiva—The mucus membrane of the eye.
Conjugium, i—A union, marriage.
Connubialis, e—Relating  to marriage.
Consanguincus, a, um—Related to blood.
Conscreor, ari—To spit, to hawk.
Consorbinus, a, um—Born of two sisters, cousins.
Conspergo, si—To sprinkle, bestrew.
Constipatio, onis—Costiveness of the bowels.
Consultum—DeliberaUon.
Consumptio, onis—Wasting away, phthisis.
Contact us—A touching  contagion.
Contagio (contingo)—Contagion.
Contamino—To pollute, contaminate.
Contemero—To violate, dishonor.
Contero, trivi—To grind, crush, pound.
Continuantur remedia—Let the medicines be continued.
Contra—Over, against, opposite.
Contra—Otherwise,  on  the other haud.
Contundo, tndi—To beat, to bruise.
Contusus—Bruised.
Contusio—A bruise, a contusion.
Convalescentia—A regaining of health.
Convomo—To cover with vomiting.
Convoluto—To roll round.
Couvuls us—Convulsed.
Copulatio, onis—Joining together.
Coquo—To cook.
Coque—Boil, cook.
Cor,  dis—The heart
Coram—Before, in the presence ot
Cordolium—Sorrow at heart
Corium—Leather, the hide.
Corneus—Horny (cornea).    •
Coruipes—Horny feet, hoofed.
Cornu—A horn.
Cornu cervi ustum—Burnt hartshorn.
Corona, as—A garland (coronal).
Corporeus, a, um—Corporeal, having a body
Corpulentus—Corpulent, fleshy.
Corpus—Body, anything not spiritual.
Corpusculum—A little body.
Corrodo—To corrode.
Cortex, icis—The end, bark, peel.
Corvus—A raven, a surgical instrument.
Cosmeta,  ae—A female slave, an adorner.
Costa,  83—A rib.
Coxa, ae, coxendrix—The hip bone.
Coxendrix luxa—Dislocation of the hip.
Cras—To-morrow.
Cras mane—To-morrow morning.
Cras mane sumendus—To be taken to-morrow morning
Cras nocte—Tomorrow night
Crastinus—Of tomorrow.
  (In usum crastinum—For to-morrow's use.)
  (In crastinum differre—To put off tUl to-morrow.)
Crassamentum, i—The dregs, thickening.
Crepitus,  us—A creaking.
Creta—Chalk.
Cribro, avi—To sift.
Cribrum—A sieve (cribriformis).
Crinalis—Of, or belong to the hair.
Crinis—Hair which is combed, a tress.
Crisis—Judgment, a state.
Croceus—Like saffron.
Crudesco—To grow raw, of wounds when they open.
Cruditas—Indigestion.
Cruor—Blood which runs out of a wound.
Cruralis—Of, or belonging to the shin or leg.
Crus—The leg from the knee to the ankle.
Crusta, aa—A hard rind, a scab.
Crypta, ae—A passage, a vault.
Crystallum, i—A crystal.
Cubicularis, i—Of a bedchamber.
 Cubitalis—Belonging to the elbow.
 Cubito, are (cubo)—To lie down.
 Cujus—Of which.
 Cuius, i—The fundament
 Cum—With, when, although.
 Cum minime—With the least
 Cum plurimum—Most frequently.
 Cuneus—A wedge.
 Cupreus—Of copper.
 C urate—Carefu lly.
 Curator—One who takes the management of & thine.
 Curo—To take  care of, heal, cure.
 Cuticula, ae (cutis, is)—The skin.
 Cyathus—A cup, a drinking vessel.
 Cyathus vinarius—A wineglass.

 Da, detur, dentur—Give, let it be given.
 De—In respect of, about.
 Deambulo—To walk abroad.
 Deartuo—To rend limb from limb.
 Deauro—To gild.
 Debilitas, atis—Lameness, weakness.
 Debihto—To lame, to maim.
 Decern—Ten.
 Deaurentur pilulae—Let the pills be gilt
 De die in diem—From day to dav
 Debitus—Due,  proper.

   (Aencdee)bltam  BPissltU(lmeni-To the proper consist.

 Decies—Ten times.
 Deciduus—Deciduous, that falls off.
 n!!:!™,0-10 tok.e out a tentn Part, decimate,
 Decoctus, us—A decoction.         win»w.
 Decoctor—One who decocts anything
 Decoquo, xi—To boil down.
 Decumbo—To lie down to sleep.
   (Hora decubitus—At bed lime.)
 Defaeco—To clean from dregs
 Deformis, e—Misshappen, deformed.


 Deglmietur—Let it be swallowed
   $w°A oniVA castin6 down, dejection
   frortdu., dejectiones aM-Wr twortvine evacu*.


   ^moved^twice1")9 ie^-™ the bowels have been 
LATIN  VOCABULARY.
903
Dcllnquo,  liqul—To omit.
Deliqtiesco, cui—To melt down (deliquescent).
Deliquo, are—To strain, to render fluid.
Delirium,  i—Madness, low of reason.
Delumbo,  avi—To lame in the hip, or loins, to enervate
Deluo—To wash, to cleanse.
Dementia—Madness, folly.
Demo, nisi—To diminish,  withdraw.
Dcmum—At last, at length.
Denaso—To deprive of a nose.
Denique—Finally, lastly.
Dens, lis—A tooth.
Dentio, ire—To cut teeth.
DeiUiscalpium—A toothpick.
Dentilio—The teething of children, dentition.
Dentifricium, ii—A dentifrice.
Denuo—Again, anew.
Depilo, avi—To pull off hair.
Depilatus—Made bald.
Dcpono, sui—To lay aside.
Depuratus—Purified.
Desideratum—That which is desired.
Desperatus, a, um—Given over, past hope.
Despuo—To spit out.
Desquamo—To scale  off, to desquamate.
Desterto—To cease snoring.
Destillo—To distill.
Desudo—To sweat, so exude.
Detego—To lay open, to uncover.
 Dexter—The right.
   (Manus dextra—The right hand.)
   (Auri dextro—The right ear.)
 Diaeta—Diet, food.
 Diaetetisus—Pertaining to food, or regimen.
 Dico, avi—To say, to tell.
 Dictus, a, um—Spoken of, said.
 Dies—A day.
 Die—In a day.
   (Bis dies—Twice a  day.)
   (Tertius diebus—Every third day.)
   (De die—In the day time.)
 Digestus, a, um—That has a good digestion.
 Digitus—A finger.
 Digitalis—Of or belonging to a finger.
 Digitulus—A little finger.
 Dilutus—Thin, diluted.
 Dilutium—An infusion or dilution.
 Dimidius—The half.
 Diploma—A public document.
 Directio, onis—Direction, order.
 Directione propria—With the proper direction.
 Discipulus—A scholar, a pupil.
 Dispenso—To weigh out to dispense.
 Dissectus (disseco)—Cut asunder, dissected.
 Dissolutio—Separation, dissolution.
 Dissolvo—To dissolve, to loosen.
 Distincte—Distinctly.
 Diu, diurnus—By day.
   (Tere diu—Rub for a long time).
 Diutiuus—Lasting, durable.
 Diuturna trituratione—By long continued trituration.
 Divido, isi—To part, divide, separate.
  Do, dedi, datum, dare—To give.
  Doctor,  oris—A teacher,.instructor.
 Doctrina, ae—Teaching, instruction.
 Doctus,  a, um—Learned, skillful.
 Docnmentum—Anything by which one can learn, etc.
 Dogma—An opinion or tenet of a philosopher.
 Dolor, oris (dolens)—Pain.
 Domus—Home, a dwelling place.
   (Domus et placens uxorcula.)
   ionec (donicum)—Until.
   >ormio, ivi—To sleep.
   l'ormitor, oris—A sleeper.
   Iorsum, i—The back.
   Dachma—A drachm.
   D'opax, acis—An ointment that takes off the hair.
   Dictus,  us—A duct   ,
  Duicis, e—Sweet
 Dum—Whilst, during.
 Duo, ae, o—Two.
 Dupdecem—Twelve.
 Duodenum—A portion of the intestine,
 Duplex—Double, twofold (daplicalure).
 Duplicatio, onis—A doubling.
  Ourahte dolor—While the pain continues.
   Juris, a, um—Hard.
   lura mater—The outer membrane of the brain.

   E  or ex—Out of, or from.
   Eullio—To bubble up (ebullition).
   Emx, acis—Gluttonous, voracious.
   Edmto,  avi—To deprive of teeth.
   Ed., edi—To eat, to consume.

   Ed lcorMorB(duicis)—A wash bottle, for separating by

   Efliminatus—Womanish, delicate.
Effervesco, vi—To ferment, to effervesce.
Effetus—That has brought forth young.
Effligo, xi—To strike dead, to kill.
Effloresco—To blossom, to effloresce.
Effundo,  udi—To pour out.
Effluvium—Exhalation, vapor.
Egilidus—Coolish, lukewarm.
Ejaculator—To cast out (ejaculatores muscles).
Ejusmodi—Of that kind, like.
Elanguesco—To faint, to grow languid.
Elavo—To wash out, to bathe away.
Electe—With choice.
Elementum—Element, first principle.
Elepharitus—An elephant (elephantiasis).
Elinguis—Speechless, dumb.
Elinguo,  are—To deprive of the tongue.
Eliquo, are—To make liquid.
Emitto to send out, to send forth.
Emetica, se—An emetic.
Emollio,  avi—To soften.
Emorior—To die, to pass away.
Empirice, es—An art of healing founded on mere prac-
  tice.
Empiricus, i—A physician instructed only by practice,
  a quack, an empiric.
Emplaslrum—A plaster for a wound.
Emulsio—An emulsion.
Eneco, cui—To kill, to torture.
Enema—A clyster.
Enervis, e—Weak enervated, feeble.
Enim—For, therefore.
Enimvero—Surely, of a truth.
Enixus,  us—The act of bringing forth young.
Enterocele, es—A kind of rupture or hernia.
.Enterocelicus, a, um—Afflicted with rupture.
Enucleo, avi—To take out the kernel, enucleate.
 Enudo, avi—To make bare.
 Eo, avi—To go.
 Eo, (adv.)—Thither, for that reason.
 Eodem—To the same purpose.
 Epiphora, se—A stoppage of humors in the body.
 Epitaphium, i—An epitaph.
 Epulae,  arum—Upright.
 Ergo—Therefore,  because.
 Erodo—To eat away.
 Eratim—An error.
 Erubesco, bui—To redden, to blush.
 Eructo,  are—To belch or vomit forth (eructationX
 Erudite, adv.—Learnedly (tactus eruditus).
 Eruptio, onis—A breaking out, an eruption.
 Esculentus, a, um—Eatable.
 Esse (est, sunt)—To be.
 Esito, avi—To eat.
 Estur—A gormandizer.
 Estrix—A female  eater, a gormandizer.
 Esurio,  iro—To hunger, to be hungry.
 Esuritor, oris—A hungry person.
 Et—And.
 Ethicus, a, um—Belonging to moral or manners.
 Etiam—Also, although.
 Etiam atque etiam—Again and again.
 Etsi—Although, yet, but.
 Eu 1 (euge, evax)—Well done, well, brava
 Eunuchus, i—Eunuch.
 Evaporatio, onis—Evaporation.
 Evanesco—To vanish, to disappear.
 Evigilo—To wake, be wakeful.
 Eviro, avi—To castrate.
 Evomo, ui—To vomit forth.
 Exania—A falling down of the anus.
 Exanimus, e—Without breath.
 Exanthemata—An eruptive disease.
 Excaudenscentia. ae—Heat of passion, violent anger.
 Excelsus, a, um—High, lofty, elevated.
 Excido, idi—To hue or cut out of, excise.
 Excite— To stimulate (excitants).
  Excrementum, i—That which passes from the body.
  Kxempli gratia (e. g.)—As.for example.
 Excorio—To take off the skin (excoriation).
 Exedo—To eat out of, destroy.
 Exhalatio, onis—An exhalation, an evaporation.
 Exhalo, avi—To breath out, exhale,  evaporate.
  Exhibeo, ui—To exhibit, to give, to impart
  Exhumo—To disinter.
  Exique—Briefly,  shortly.
  Exoculo, avi—To deprive of eyes.
  Exosis, ossis—Without bone.
  Exosso, avi—To deprive of bone.
  Exostosis, osis—A morbid enlargement of bone.
  Exacerbo—To exasperate, (exacerbation).
  Excresco—To grow from (excrescence).
  Exfoetatio—Extra uterine fetation.
  Exfoliatio—Separation of dead bone from the living.
  Expecto—To wait for (expectant).
  Expectoratio—Expectoration.
  Expedite—Easily, promptly, quickly.
  Experientia, ae—Proof, trial, experience..
  Experimentum—Experiment, trial. 
904
LATIN  VOCABULARY.
  Experto, ivi—To attain anything, to aim at
  Expiratlo—Expiration, to breathe out.
  Exploratio, onis—An examination, investigation.
  Exsectio, onis—A cutting off or out.
  Exsicco—To dry up, make dry.
  Exspisso—To make thick, to exspissate.
  Kxtendo—To stretch out, to extend.
  Extensor—A muscle which extends.
  Externus—External, outward.
  Extirpo—To pluck up by the roots, extirpate.
  Extractum—An extract.
  Extravasaiio—The passage of fluids out of their proper
   vessels.
  Exudatio—Transpiration.
  Exuviae—The slough the cast off covering of certain ani-
   mals.

  Fac—Make.
  Facio,  feci—To make, to do.
  Fades—The face.
  Fades hippocratica—A  peculiar appearance of the face
   before death.
  Fades rubra—The old name for gutta rosacea, or acne.
  Factitious,  a, urn—Artificial.
  Faculas—From facere, to make (faculty).
  Faacula, a—The dregs, the lees.
  Faax, cis (faeces pi.)—Sediment, dregs, excrement
 Falciforma—Like a sythe.
 Falx—A scythe, a sickle.
 Falx cerebri,  falx cerebelli—Processes  of the  dura
   mater.
 Fama,  aa—Fame, public opinion.
 Fames, is—Hunger.
 Far—Corn.
 Farina—Meal, flour.
 Farcimen—Farcy.
 Fascia, se—A long, narrow band.
 Fascia  lata—The aponeurosis of the thigh.
 F'ascia  stiperficialis—A  membrane extending over the
   abdomen.
 Fascialis—The tensor vaginaa femoris.
 Fasciculus, i—A small bundle.
 Fastidium. i—Nausea, or distaste for food.
 Fatuus—Insipid, tasteless.
 Faux, cis (fauces pi.)—The throat, the gullet.
 Favus,  i—Honeycomb, a non-acuminated pustule.
 Febris, is—A fever, pyrexia.
 Febriculoscus, a, um—Sick of a fever.
 Febricula—A slight degree  of fever.
 Febrifugum—A febrifuge.
 Febrifugum magnum—A name given to cold water as a
   drink in ardent fever.
 Febris accessus—The accession of a fever.
 Febris decessus—The decline of a fever.
 Febre durante—While the fever continues.
 Fecunde—Fruitfully.
 Fecundo—To make fruitful, fertilize.
 Feeunlatio—Impregnation.
 Fel, fellis—Gall, bile.
 Fel, bo vis—Ox gall.
 FelU, is—A cat (feline).
 Felliflui passio—Ancient name for cholera (gall flux).
 Feinella—A little woman, a girl.
 Femina, as—A female.
 Feminalis—Belonging to a woman.
 Femineus—Womanlike.
 Femur, femoris—The thigh.
 Fenestra—A window (fenestra ovalis, etc.)
 Feralis, e—Of, or belonging to the dead, fatal.
 Fere—Almost, nearly.
 Fermento, avi—To cause, to ferment.
 Fermentum, i—That which causes anything to ferment,
  leaven.
 Fermentatus panis—Leavened bread.
 Ferrum, i—Iron.
 Ferrugineus, a, um—Of, or pertaining to iron, the color
  of iron.
 Fertilizatio—The function of the pollen of plants, etc.
 Ferula, ae—An umbelliferous herb with a soft pith in
  which fire was easily harbored.
 Fervefacio, eel—To cause to boil.
 Fervefactus—Made hot.
 Fervens, entis—Hot, glowing.
 Ferveo—To be hot, or heated, to burn.
 Fervesco—To begin to boil, to grow hot
 Fessulus, a, um—Somewhat fatigued.
 Fessus—Weary, tired.
 Fetura,  se—A trea ling, a bearing.
 Fetus (foetus)—Offspring, young.
 Fibra—A fibre, a filament (fibrin, fibril).
 Fibraa— The entrails (old).
 Fibuli,  ae—A clasp or  buckle, the lesser  bone  of the
  1 g from its being opposite to where the knee buckle
  was attached.
Fica'io,  or ficus—A fig-like tuberclo about the anus.
Fi.-us—A fig.
Filla,  aa—A daughter.
 Filius, I—A son.
 Filum, i—A thread.
 Filamentus—A small thread, a filament
 Filaria—A thread-like parasitic worm.
 Filix, icis—A fern.
 Filiformum—Thread-like.
 Filtrum—A  strainer.                       »..«..
 Fimbra—A fringe, the fringe-like extremity of the Fal-
   lopian tdbe.
 Flmbriatus—Having the margin bordered with filiform
   processes.
 Fimus—Excrement of animals.
 Finis—An end, limit.
 Fio fieri—To make, to become.
 Fissura—A Assure, a groove.
 Fistula—An ulcer, a fistula, a pipe.
 Fistula, in ano—Fistula in the rectum.
 Fistula lacrymalis—Fistula of the lacrymal sac.
 Flabelliformis—Fan shaped, like the rays of a fan.
 Flaccidus—Languid, without force.
 Flagelliformis—Whip-like, long, taper.
 Flamma, aa—A flame.
 Flammatus—Inflamed.
 Flatus—A blast, wind in the intestines.
 Flavus—Yellow.
 Flebilis—Tearful, mournful.
 Flecto, xi—To bend.
 Flexio, onis—Bending (flexor).
 Floccitatio—Picking of the bedclothes, forerunner of
   death.
 Flocculus—Vel lobus nervi pneumogastrici.
 Floreo ((lores)—To flower, to blossom.
 Fluctus—A flowing (flux).
 Fluctuatio—Fluctuation, perceptible,  motion on  pres-
   sure.
 Fluidus—Fluid, not solid.
 Foeteo—To stink, to smell badly.
 Folium—A leaf, a herb.
 Folicula—A minute secreting cavity.
 Foraentum—A fomentation, an application.
 Fomes, fomites pi.—Substances imbued with contagion.
 Fons, tis—A fountain.
 Fontanella—Spaces left In the head of an infant
 Fonticulus—A little fountain, an issue.
 Foramen (foro)—An opening, aperture.
 ■Forceps,  icis—A pair of tongs, pincers.
 Formica—An ant, a creeping itching.
 Formico—To raise in pimples, to creep.
 Formidibalis—Terrible, formidable.
 Formula—A prescription, a given form.
 Fornix—An arch, a triangular lamina in the brain.  .
 Fortis, e—Strong.
 Fossa—A depression, a sinus
 Eractus (frango)—Brittle, broken, (fracture).
 Fragmentum—A piece broken off.
 Frater, tris—A brother.
 Frenum—A bridle (frenum lingue).
 Frenum labiorum—The fourchette.
 Fremitus—Vibration (in auscultation, etc.)
 Frigidus—Cold.
 Frigeo, xi—To freeze.
 Frons, frontis—The forehead.
 Fructus—Fruit.
 Frumentum—Corn or grain for making bread.
 Fuligo—Soot or smoke (antimony guv.)
 Fuligo ligni—Soot of wood (fuliginous).
 Fulmer—Lightning that strikes.
 Fumigatio (fumo)—To smoke, to perfume.
 Functio (fungor, to do)—To discharge an office, function
 Fundus—The bottom of any viscera.
 Fundamen—A foundation.
 Funebris—Of, or belonging to a funeral.
 Funginus (fungus)—A mushroom, a fungus.
 Fungiformis—Like a fungus.
 Funiculus—The spermatic cord.
 Funis (umbelicus)—The umbilical cord.
 * unus, eris—A dead body, a corpse.
 Furfur—Bran, a desquamation of the cuticle.
 Furor—Madness, vehement desire.
 Furor uterinus—Old name for nymphomania.
 Fusus—Melted, poured out, (fusibility).
 Fusiformis—Spindleshaped,
 Futurus—That shall or will be.
 In futurum—Hereafter.

 Galla—Galls.
 Gelu (gelatus—Frost (gelatine).

 a2!S™1.us7Dollble• t.wins'the name of t^o muscles.
 Gemma—Precious stones, the leaf bud       "»«"»
 Gena—The cheek.
 Genero, avi—To produce (generation).
Oenesis—Generation, creation, birth.
Genu—The knee.
Genus—A race.
Germen—A bud (germinate).

Glacfe"°-Har^rfcythe "^ °' *>"S™<7.
Glans, dU—An acorn, a gland.
Glandula—A small gland. 
LATIN  VOCABULARY.
905
 Glaucoma, atis—An optical illusion
 Globo, avi—To make round
 Globus, i-A globe, a ball, a pellet
 Globulus, i—A globule.
 Globus hystericus—A sensation of hysteria.
 Gluten,  inis, glutinum, i—Glue, gluten.
 Gradatim—Step by step, by degrees.
 Gratus,  a, um—Pleasing, agreeable.
 Granum—A grain, a small portion.
 Granula—A little grain.
 Gravido, avi—To load, to impregnate.
 Gra vitas—Heaviness.
 Gula—The gullet,  the esophagus.
 Gulosus—Gluttonous.
 Gurgulio—The windpipe (hence gargle).
 Gustatus—A tasting (gustatory).
 Gutta—A drop.
 Guttifera—Drop bearing.
 Guttatim—By drops.
 Guttatus, a, um—Spotted, speckled.
 Guttur—The throat.
 Gymnas, adis—Exercise.
 Gyrus, i—A circle, the spiral cavity of the Internal ear,
   the convolutions of the brain.

 Habendus—To be had or held.
 Habeo, in—To have, to hold.
 Hac—Here, thither.
 Haesitalio—Stammering, hesitation.
 Halitus—An aqueous vapor, exhalation.
 Hallucinatio—Erroneous imagination.
 Halo—A circle surrounding a light, areola.
 Hamulus—A little  hook.
 Hamulus cochleae—A portion of the Inner ear.
 Haustus (haurio, to draw)—A draught
 Hemitritaeus—A semitertian ague.
 Hepar—The liver.
 Hepatarius—Relating to the liver
 Hepaticus—Diseased in the liver.
 Herba, ae—Herbage, an herb.
 Hereditas—Inheritance.
 Heri—Yesterday.
 Hesperus—The evening.
 Hiatus—An opening, an aperture.
 Hibrida, ae—Of ambiguous origin.
 Hie, haec, hoc—This, such.
 Hiems, emis—Winter.
 Hieto—To gape, to yawn.
 Hilum—The base of a seed at its attachment
 Hilus lienis—A fissure in the spleen.
 Hinc—Hence; from this place.
 Hinc et hinc—On this part or that.
 Hlra, aa—A gut.
 Itircus—A he-goat,  a goatish  smell, the rank smell  of
   the armpits.
 Hirudo—A leech.
 Hirsutus—Shaggy, superfluous growth of hair.
 Hodie—To-day.
 Homicidium—Manslaughter, homicide.
 Homo, inis—A human being, a man.
 Hora—An hour.
 Hora somni—At the hour of sleep.
 Hora decubitus—At bed-time, or time of lying down.
 1 foris intermediis—At intermediate hours.
  (In horas—Every hour.)
 Hordeum—Barley.
 Hornus—Of this year.
 Horridus, a, um—Dreadful, terrible.
 Humanitas,  atis—Humanity, human nature.
 Humanus, a um—Human.
 Humerus, i—The upper bone of the arm.
 Humidus, a, um—Moist, wet, damp.
 Humo—To bury, to inter.
 Humoris,  oris—A moisture, a humor.
 Humus, i—The earth, the ground.
 Hyalus—Glass.
 Hydraulicus, a, um—Relating to the scientific motion of
  the water.
 Hydrocele, es—A watery rupture, a hydrocele.
 Hydropsis, is—The dropsy.
 Hydrargyrum,  i—Mercury, quicksilver.
Hymen, inis—A membrane.
Hystericus, a,  um—Hysterical.

Ibl—There, in that place.
Ibidem—In the same place.
Ictericus,  a, um—Jaundiced,                  ....
Icterus—Jaundice,   a small yellow  bird, the sight of
 which was said to cure the jaundice.
Ictus solis (ictus, a blow)—Sun stroke, coup de soleU.
Idea, aa—An image, from (hence idea, notion).
Idiota—A senseless person.
Idolum, 1—An image that is present to our eyes or mind,
 a spectre, a ghost.
 lgneus—Fiery, burning.
Ignis fatuus—A luminous appearance.
 Ignis sacer—(Old) St. Anthony's fire, erysipelas.
 lie, is—A small gut, the ilium.
    Iliacum, os—Os coxarum, old name for os innomination.
    Ille, a, ud—He, she, that.
    Illusio, onis—Deception as to the sight, imagination, etc
    Illutatio, onis—Mud bathing.
    Imago—Image, shadow, image of the mind,
    Imbibo—To drink, imbibe.
    Imbecilis, e—Weak, infirm  of mind.
    Imberbis, e—Without a beard,  beardless.
    Imbibo—To drink, to suck in.
    Imbrex—A roof tile,  (imbricated).
    Immanis, e—Wild, savage, cruel, inhuman.
    Immaturus—Untimely, unripe.
    Immergo—To dip, to plunge, immerse.
   'Immortalis,  e—Immortal, divine.
    Impar—Unequal, uneven.
    Impatientia,  ae—Impatience, unability to suffer or en-
     dure.
    Impenetrabilis, e—Impenetrable.
    Imperfectus—incomplete, unfinished.
    Impetigo (impeto to infest)—A pustular disease.
    Implantatio,  onis—Ingrafting.
    Impluvium,  i—A shower bath.
    Impono—To place, set, or apply upon.
    Impotens—Powerless, weak, impotent.
    Impransus—That has not taken any food, fasting.
    Imponderabilis—Without weight
    Impregnatio—Impregnation, conception,
    Imprimo—Principally, in the first place.
    Impubes, eris—Beardless.
    Impudicus—Shameless, unchaste.
    Impure,  (adv.)—Filthily, impurely.
    In—In.
    In die—In a day.
    Indies—Every day, daily.
    Inanimis—Without breath, lifeless.
    Inanis—Void, empty, (inanition).
    Inauris, is—An ear ring.
    Incandesco—To grow white, (incandescence).
    Incanto—To enahant, to bewitch.
    Incarcero—To imprison, to incarcerate.
    Incarnatio (in carnis, flesh)—Granulation.
    Inceptio—To begin.
    Inceste—Unchastely, impurely.
    Incisio, onis—An incision.
    Incisorus, es fl.—The front or cutting teeth.
    Incontiens—Not holding together, incontinent
    Incoquo—To boil together.
   Ineubatio—Incubation.
   Incuratus—Unhealed.
   Incubus—Nightmare, oppressive sensation.
   Incus,  udis—An anvil, a small bone of the internal ear.
   Inde—Hence, from that place.
   Index (indico, to front out)—The forefinger.
   Indicatio—A pointing out, indication.
   Indigena—A  native of the country, indigenous.
   Indigestio (indigero, to distribute)—Dyspepsia, indiges-
     tion.
   Indolens—Indolent, slow in action.
   Inductus—Persuaded, induction.
   Induratio (induro)—Induration,  hardening.
   Inebrio, avi—To make drunk.
   Inedia, ae—Abstinence from food,
   Inertia—Inactivity.
   Ineruditus—Unlearned, awkward, Unskilled.
   Infans—An infant, that cannot speak.
   Infantiscldo (infans caedo, to kill)—Infanticide.
   Inficio, eci—To stain, to poison (infection).
   Infirmitas—Weakness, infirmity (infirmary).
   Infiltratio—Diffusion of fluid into the cellular tissue.
   Inflammatio (to burn)—Inflammation.
   Inflatio—A blowing up, inflation.
   Infloresco—To flourish, inflorescence.
   Infra—Beneath, below, under.
   Infundibulum—A little funnel-shaped process.
   Infusus—Pouring into, infusion.
   Ingestus—A pouring in, ingesta.
   Inguen, inis—The groin.
   Inhalo—To breath on (inhalation).
   Inhumanus—Inhuman, not human.
   Inhumo—To inter.
   Inibi—Therein.
   Injectus—A throwing in, an injection.
   Injuria, ae—Hurt,  injury, harm, damage.
   Innominatus—Nameless.
   Innuptis, a, um—Unmarried.
     (Nuptiae innuptiae—An unfortunate marriage.)
   Inoculatio—An insertion of virus.
   Inopia—Poverty, need, destitution.
   Inquletus, a,  um—Restlessness, unquiet.
   Inosculatio (osculum, a little mouth)—Union of vessels,
     anastomosis.
   Insaluber, bris—Unwholesome, not conducive to health.
   Insanabilis, e—That cannot  be cured or healed.
   Insania, aa—Madness, phrenzy.
   Insecta—An insect.
   Inserto, avi—To put in, to Insert.
   Insiccatus—Undried.
I   Insidiosus, a, um—Dangerous. 
906
LATIN  VOCABULARY.
 Insolo, avi—To dry in the sun.
 Insolubilis, e—Thai cannot be dissolved.
 Insomnia,  ae—Want of sleep, sleeplessness.
 Iusouanium,  i—A dream.
 Inspiio—To breathe upon, inhale (inspiration).
 Inspergo—To sprinkle upon.
 Inspico, exi—To inspect, examine.
 Inspisso—To render thick, inspissate.
 Instrumeutum, i—Instrument, tool.
 Insufflatio—To blow into, insufflation.
 Insulatio—Insulation.
 Integumentum,  i—A covering, integument, cuticle.
 InteUigens—Intelligent, sensible.
 Intemperans, tis—That cannot moderate himself.
 Intente—With earnestness.
 Inter—Between or among.
 Interdie—By day, lathe daytime.
 Interim—In the meantime.
 Intestinus, a, um—Internal, intestine.
 Intime—Most intimately.
 Intra—Within, on the inside.
 Intolero—That cannot be borne.
 Intumesco—To swell, intumesence.
 Intus susceptio (inlus, within, suscipio, to receive)—The
   descent of a higher portion of intestine into a lower
   one.
 Invaginatio (in vagina, a sheath)—Synonymous with in-
   tus-susception.
 Inverminatio—An affection in which worms or larvae in-
   habit the stomach or intestines.
 Inverto—To turn, turn up or about
 Involucrum—The designation of membranes that cover
   any part.
 Ipse—Self.
 Ira—Anger, wrath, rage.
 Irritabilis, e—Easily excited, Irritable.
 Irrito—To Incite, to irritate, excite.
 Irrigo—To irrigate, to apply cold water or lotion to an
   affected  part.
 Ita—Thus, even so.
 Item—Also, likewise.
 Iterum—Again, the second time.

 Jactatlo, vel jactitatio (jacto)—Restlessness, change of
   position.
 Jam—Now,  at this time, at present.
 Janitor, oris—A porter, a doorkeeper.
 Jecur, oris—The liver.
 Jecusculum, i—A small liver.
 Jejunum, 1—The upper two-fifths  of the small intes-
   tines, so called from this part being usually found
   empty.
, Jejunus, a,  um—Fasting, hungry, empty.
 Jentaculum—A breakfast.
 Jento, avi—To break one's fast.
 Juba, ae—The mane, the flowing hair of an animal.
 Jugulum, i—The throat.
 Junctim—Unitedly, jointly.
 Jus, juris—Broth, soup.
 Jusculum—Diminutive of jus.
 Jurens—Consisting of broth, full of broth.
 Jus ovilli—Mutton broth.
 Jusculum, coactum—Jelly.
 Juxta—Near to, by.

 Labium, i—A lip.
 Labellum—Lip-like, used In  botany.
 Labor, oris—Work, toil, child-birth.
 Lac,  tis—Milk.
 Lac vaccinum—Cow's milk,
 Lac recens—New milk.
 Lacti depulsus—Weaned.
 Lacero—To tear,  (laceration).
 Lacertus, i—The arm, (hence lacertus, a blow).
 Lacryma, ae—A tear.
 Laerymo—To shed tears.
 Lactitio, are—To give milk, to suckle.
 Lactuca,  se—A lettuce.
 Lacuna, ae—A lake, follicles in the mucous membrane
   of the urethra.
 Lallo, are—To sing to sleep, to sing lulla, or lullaby.
 Lamina, ae—A thin plate or leaf.
 Lana—Flannel, wool.
 Lana philosophica—White oxide of zinc.
 Languor, oris—Faintness, feebleness, weariness.
 Lancctta (lanca a shear)—A lancet
 Lapis, idis—A stone.
 Larva,  ae—A visor, a mask.
 Lascivus—Wanton, lustful.
 Lassitudo, inis—Faintness, weakness, fatigue.
 Latus, eris—A side, a flank (lateral).
 Lavo, avi—To wash, to bathe.
 Laxo, avi- To loosen (laxatives).
 Lectus, i—A bed.
 Lectulns, 1—A sofa, a lounge.
 Lecto leneri-To be sick in bed.
 Legumcn. mis—P,ulse.
 Lc-tiio ivi  To j'teviate, to soften, to mitigate, (lenitives).
Lens, tis—A. bean, a lentil (lenticular).
Lentigo-Freckles, yellow spots on the skin.
Lentus-Glutinous, clammy, (lentor of the blood).
Lesio—Hurt, injury, morbid change.
Lethe, es—Forgetfulness.
Leto—To kill.
Letum, vel lethum—Death.
Letum ibi, consciscere—To kill oneself.
Levator—A lifter up.           .
Levlgo—To polish, to smooth (levigation).
Liber, a, um—Free.       H
Liber, bri—A book.
Libet,  lenit—It pleases, Is agreeable.
Libet adlibitum—As you please).
Libitina—Any  kind of furniture for funerals.
Libra, ae—A pound.
Libramen—A balance, counterpoise.
Lien, enis—The milt or spleen.
Ligamentum—A band, a ligament
Ligo, avi—To bind, to tie,  (ligature).'
Lignum—Wood.
Limax (limus,  slime)—A snail (cochlea terrestrls).
Linamentum (linum, linen)—Lint, a tentfor a wound.
Lineamentum, i—Features, lineaments, a line.
Linimentum (lino, to besmear)—A liniment, embroca-
  tion.
Linum, 1—Flax,  lint
Lippio—To have blear eyes.
Lippitudo, inis—An affection of the eyes.
Ligueo, qui—To be liquid or fluid.
Liquefacio—To melt, to liquefy.
Liquor, oris—A  liquid, fluid.
Lividus—rOf a  bluish color.
Livor, oris—Black and blue, a mark produced by a
  blow.
Lix, licis—Lye, (lixivium).
Lob us (lobulus)—A lobe, a lobule.
Locales—Local diseases.
Locomotio—Moving from one place to another.
Lomentum, 1—That which is used for washing, an emo-
  lent used for softening the skin.
Longus—Long.
Lotio—A lotion, a wash.
Lubrico, avi—To make smooth, to lubricate.
Lues, Is—A contagious disease, a pestilence.
Lues Venerea—The plague of Venus, syphilis.
Lumbus, 1—A loin.
Lumbricalis—Muscles of the hand and foot
Lumbricus—The earth worm.
Luna—The moon (lunatic).
Lunula (a little morn)—The white semilunar  mark at
  the base of the nails.
Lupia—A wen, a tumor.
Lupus (a wolf)—A tubercular affection, noli me tangere.
Luscus—Blind in one eye. .
Lusciosus—Purblind, dimsighted (luscltas).
Luxus, us—A dislocation, luxation.
 Lympha—Water (lymphatics).

 Macero, avi—To make soft, to steep,  to macerate.
 Macies, ei—Leanness, thinness.
 Macula, ae—A spot.
 Magis—More.
 Magnus,  a, um—Large, great.
 Magnesia—An earth, oxide of magnesium.
 Mala, ae—A cheek bone, jaw.
 Male^-Badly,  ill.
 Malignus—Of a bad kind, malignant.
 Malleolus, i—A small hammer, the ankle bone.
 Malleus—One of the small bones of the ear.
 Malus, a, ura—Bad, evil.
 Maliformis—Badly formed, malformed.
 Malus, i, vel malum, l—An apple.
 Mamma,  ae—The breast.
 Mammalia—Vertebrata with mammary glands.
 Mamilla—Synonymous with papilla.
 Mancus—Maimed, defective in limbs.
Mane—In the  morning.
Mane prime—The first thing in the morning.
 Maneo—To remain.
Manes, ium—The spirits of the dead.
 Mania, ae—Madness, insanity, rage.
Mampulus,  i—A handful.
Manebrium, i—A handle, the upper bone of  the ster-

Manus, us—A hand.
Mare, is—The sea.
Margo, inis—An edge, border.
Maritus, a, um—Of, or belonging to marriage.
Masculus, a,  um—Male, masculine.
Massa—A lump, a mass.
Mastico—To chew, to masticate.
Matella  te—A chamber pot, a night stool
Masturbatio—Masturbation.
Mater—A mother.

"Ss^^dTcTnt1 ^^ °f mediC41 8C,**<* "»**
Matnmonium, i—Marriage, matrimony. 
LATIN  VOCABULARY.
907
M iluro—To ripen (maturation).
M ixilla—The cheek bone.
Maximus, a, um—The greatest, largest
Meatus,  us—A passage.
Medicabilis, e—That can be healed or cured.
MeJicamen, inis—Any remedy applied to diseases or
  wounds.
Medlcainentum, i—That heals diseases.
Medicinus, a, um—Of, or belonging to physic.
Medico—To heal, to cure.
Medicus—A physician.
Medulla, aa—The marrow of bones, the pith of plants.
Mel, mellis—Honey.
Melancholia, aa—Black bile, melancholy.
Membrana, ae—The skin or membrane that covers the
  separate members of the body.
Meuibratim—By members, limb by limb.
Membrum—A limb, a member of ihe body.
Mens—The mind.
Meusis,  is—A month.
Menstruus, a,  um—That happens every  month  (men-
  struation).
Mensura, ae—A-measure.
Mentum—The chin.
Mephitis, is—A noxious and pestilential vapor.
Meridies—Mid day, noon.
Metallicus—Of, or belonging to metals.
Metamorphosis, is—Transformation, change.
Miliaria—Miliary fever, vesicuhe.
Milium—A millet seed, a small white tumor.
Mille—A thousand.
Minimum—The least.
Misceo—To mix, to mingle.
Missus (mitto)—Sent.
Mistura, sb—A mixture.
Mitella,  ae—A bandage around the head.
Mitigatio, onis—A mitigation, alleviation.
Mitto, misi—To send.
Mitra—A mitre, a covering of the head (mitral).
Moderate—With moderation, temperately.
Modus,  t—Way or manner, measure.
Modo praescripto—In the manner directed.
Molaris (mola,  a millstone)—A double or grinding tooth.
Molestus—Troublesome.
Mollis, is—Soft.
Molluscum—A wen, a movable tumor (ord. tubercula).
Mons—A mountain.
Mons veneris—The eminence over the os pubis  in wo-
  men.
Monstrum, i—A monster, contrary to the usual  course
  of nature.
Mora, ae—A delay, tarrying.
Morbus, i—A disease.
Monleo—To bite with the teeth.
Mordex—A tooth.
Moribuudus—Dying, ready to die.
Morior—To die.
Mors, tis—Death.
Mortalis, e—Mortal, subject to death.
Morticinus—That has died through disease.
Morpheus—The God of sleep (morphia).
Mortificatio (mors fio)—Mortification.
Motio, onis—A moving, a motion.
Moveo,  movi—To move, to set iu motion,  to stir.
Mucosus, a, um—Slimy, mucous.
Mucus,  i—Mucus, the discharge from the nose.
Muliebris, e (mulier)—Womanly.
Mulier,  eris—A woman.
Multiformis, e—Having  many forms or shapes.
Multiplex, icis—That has many folds.
Multus, a,  um—Many, numerous.
Musca,  ae—A fly.
Muscaa  volitantes—An  appearance of motes or small
  bodies floating before the eyes.
Musculus, i—A muscle of the body
Muto, avi—To move, to change.
Mutus,  a, um—Dumb, silent, mute.

Naevus, i—A mark or mole on the body.
Nam—For.
Nanus—A dwarf.
Nares,  ium, vel nasus,  i—The nose.
Naris, is—A nostril.
Narthedum, i—A chest for ungnenls and medicines, a
  gallipot.
Nala, ae—A daughter.
Natalis, e—Of, or belonging to one's birth.
Nalis, is—A buttock.
Natura, ae—Nature, birth, the universe.
Natus—A son.
Nausea, ae—Desire to vomit, nausea.
Kauseo, avi—To feel sick, to be ready to vomit, to loathe,
  to be disgusted with.                _,,            .
Navicular!, os—A boat-shaped bone of the carpus and

Nebula"'**— A mist, vapor, cloud, haziness.
NVc—Neither, nor.
Nervus, I—A nerve.
Nex, necis—Death by violence.
Nicto, avi—To wink with the eyes (nictitation).
Niger, gra—Black.
Nisi—If not, unless.
Nix, nivis—Snow.
Noceo, ni—To injure, to harm, to hurt.
Nocturnus, a, um—By night, nocturnal.
Noctambulatio, onis—Night-walking.
Nodo, avi—To knot.
Nodus, 1—A swelling of the bone, a node.
Nodula—A  smail bone.
Nodus cerebri—The pons varolii or tuber annulure ol
  the brain.
Nolo—To be unwilling.
Noli me tangere—Touch me not. Lupus (tubercula).
Nomen, inis—A name, appellation.
Norma, aa—Rule, prescript (normal, abnormal).
Nostrum—Our own, a quack medicine.
Nothus, a,  um—Spurious, counterfeit, not genuine.
Novo, avi—To make anything new, to renew.
Nox, noctis—Night.
Nocte (or de nocte)—By night.
  (De multa nocte—Late at night.)
Noxius, a,  um—Noxious, hurtful, harmful.
Nubes, is—A  cloud.
Nebula, as—A small cloud.
Nubilis, e—Marriageable.
Nubo, psi (to veil, to cover)—To marry, as the bride puts
  on a veil.
Nupta, ae—A  bride, a wife.
Nucleus, i—The kernel, the solid centre.
Nudus, a, um—Bare, naked.
Nullus, a um—None, nothing.
Numero, avi—To number, to reckon, to count
Nunc—Now.
Nunquam—Never.
Nuptae, arum—Marriage, wedding.
Nurus, us—A daughter-in-law.
Nuto, avi—To nod.
Nutrimentum, 1—Nourishment, support
Nutrio, avi—To give nourishment.
Nympha, ae—A veiled bride, the chrysalis of an Insect
Nymphae—Labia minora.
Nymphomania—Lascivious madness in females.

Obesus, a,  um—Fat, corpulent (obesity).
Obliquus—Oblique, crooked, slanting.
Oblitero, avi—To efface, to deface, to close.
Oblivio—Forgetfulness, failure of memory.
ObsoletUs—Old, no longer new.
Obstetrix, Icis—A midwife.
Obsto, iti—To stand before or against.
Obstructio—A stopping up, obstruction.
Obturo, avi—To stop up, (obturator).
Occiput,  itis  (ob.' caput)—The  back part of the head,
  occiput.
Occlusus, a,  um—Shut, closed.
Occulto—To hide, to conceal.
Oceanus, i—The ocean.
Ocellus, i—A little eye.
Octes—Eight  times.
Octo—Eight.
Oculatus, a, um—Furnished with, or having eyes.
Oculus, i—An eye (oculist).
Odor, oris—Scent, smell.
Cdorifer, a, um—That brings an odor or scent
Oestrus,  1—The gad fly.
Officina, aa—A workshop (officinal).
Olea, ae—An. olive.
Oleum,!—The expressed oil of olives, an oil.       •
Olfactorius, a, um (olfacio)—That serves or belongs to
  smelling.
Olla, S3—A pot, a jar.
Ollaris,  e—Preserved in jars.
Omasum, i—The third stomach of Ruminantia.
Omentum,  i—The membrane which incloses the bowels.
Omitto, isi—To lay aside, to leave off, omit
Omnis, e—AIL
Onvx, ycbis—A finger nail.
Onychia—An abscess near the finger nail.
Opacus—Shaded, opaque.
Operosus,  a,  um—Full of pains or endeavor.
Ophthalmicus, a, um—Of, or relating to the eyes.
Opposio, sui—To set or place against, oppose.
Optio,  onis—Free will, choice.
Orbiculus,  1—A small circle.
Orbis, is—Anything of a circular shape.
Orbita, ae—The cavity in which the eye Is fixed.
Organum,  i—A part which has a determinate office in
  the animal  economy.
Origo, inis—An origin, beginning.
Oriflcium.  1—An orifice, a mouth or entrance.
Os, oris—The mouth.
Os, ossis—A  bone.
Osseus, a,  um—Of, or pertaining to bone.
Ossiflcatio, onis—Becoming bone, formation of bone.
Ostium—The door of a chamber (osteum abdominale).
Ovis, is—A sheep. 
908
LATIN  VOCABULARY.
  Ovarium (ovum)—An organ containing the ova.
  Ovulum, i—A little egg (ovula).
  Ovum,  1—An egg.

  Pabulum, 1—Food,  nourishment, support.
  P«dor—Nastiness, by want of proper attention.
  Palam—Openly, publicly.
  Palatum, l—The palate.
  Pallidus, a, um—Pale, wan, pallid.
  Palma,  «—The palm of the hand.
  Palpebra, ae—An eyelid.
  Palpatio, onis (palpo)—Manual examination, palpation.
  Palpitatio, onis (palpito)—An action of the heart.
  Panacea, aa—A herb said to cure all diseases.
  Panis—Bread.
  Pannus—(A rag, a cloth) a disease of the eye.
  Papilla, aa—The nipple of the  breast, a small eminence.
  Papula, ae—A pimple, a papule.
  Par, paris—Equal, even.
  Parasitus, 1—A parasite, a sponger.
  Parate—Preparedly, carefully.
  Parco, pepersi—To spare.
  Parce— Sparingly, moderately.
  Parens, tis—A parent.
 Paries, parietis—Partition wall, parietal.
 Paro, avi—To prepare, to make.
 Par3—Part, piece.
 Parturio, ivi—To bring forth, to be in travail.
 Parturifaciens, tis—A medicine which causes uterine
   pains.
 Parvus—Small,  little.
 Pastillus, i—A perfumed or sweet ball.
 Patella,  aa—The knee pan.
 Patens, tis—Open, passable.
 Pater, tris—A father.
 Patiens, tis—Patient, enduring.
 Patulus, a,  um—Open, standing open.
 Pecco, avi—To  do  a thing wrongly, to be  in fault
   (peccant).
 Pecten, tinis—A comb (pectineus, peclenate).
 Pectus, oris—The  breast (pectoralia).
 Pediculus—A louse.
 Pediculosus, a,  um—Full of. lice, lousy.
 Peduculatio, onis—An affection of the skin, phthelrlasls.
 Pediluvium,  i (pes lavo)—A foot bath.
 Pedunculus—Splay footed, peduncle.
 Pellicula, ae  (pellis)—A thin  skin, pdlicle.
 Pellis, is—A hide,  or skin.
 Pellucidus,  a, um—Transparent, pellucid.
 Pendeo, pependi—To hang down, to suspend.
 Pendo, pependi—To hang down (pendent).
 Pendulus, a, um—Hanging, hanging down.
 Peniculum,  i—(A painter's pencil) a tent, a pledget.
 Penis, is—The male  organ  of generation,  membrum
  viriie.
 Peuite—Inwardly, internally.
 Penna, ae—A feather, a wing.
 Peunaius, a, um—Winged,  feathered.
 Pennipes, edis—Feather-footed.
 Penso, avi—To weigh, to weigh out.
 Penus, us—Provision, store  of food.
 Per—Through, by.
 Percolo,  avi—To filter or strain through, to percolate.
 Percutio,  ussl—To strike through, percussion.
 Perditus,  a, um—i.ost, hopeless.
 Perennis, e—That lasts for a year or more, perennial
 Perfectus, a, um—Perfect, complete.
 Perforo,  avi—To bore through, to  pierce through, to '
  perforate.
 Perfrico, cui—To rub over.
 Periodus, i—A period.
 Peritia, sb-Skilljpractlcal knowledge.
 Peritus, a um—Well versed  or skilled, able, expert.
 Permeo,  avi—To pass through (permeate).
 Perna, ae—The hip together with the leg.
 Pernio, onis—A  chilblain.
 Permitto,  issi—To permit, to allow.
 Perscribo, psi—To  write down, to write out at length.
 Perscriptio, onis—Any written  composition.
Persona, ae—A mask, a person, an individual.
Perspiro—To breath through (perspiration).
Pertineo, nui—To extend, to  reach.
Perturbo,  avi—To disturb (perturbation).
Pertussus—A cough, hooping cough.
Pervado, si—To pass through.
Pervigil,  is—Very watchfal,  always wakeful.
Pervius, a, um—That may be passed through,
Pes,  pedis—A foot
Pestiferus, a, um—Causing or bringing pestilence.
 Pestilens,  tis—Pestilential,  unwholesome.
 Pestis, Is—A  plague, pestilence, infestlon.
Petra, ae—A rock, a stone.
Phalanga, ae—A  phalanx, bones of the fingers and toes
Phantasia, aa—A thought, an idea, phantasm, hallucina-
  tion.
Phantasma, atis—An apparition, spectre.
Pharmaceutia, aa—(An eao-u?.ntress) the compounding
  of drugs.                                        °
  Pharmacopola, aa—A seller or dealer in medicine*.
  Phiala, ae—A drinking vessel, a small glass.
  Philosophus, a,  um—Philosophical, erudite.
  Philtrum, i—A charm, a love potion.
  Phlegmon, onis—A tense, painful swelling.
  Phosphorus", i—A bringer of light.
  Phrenesis,#is—Phrenzy, madness.
  Phthisis—A consumption.
  Physica, ae—The science or study of nature.
  Physice—Physically.
  Physicus, a, um—An inquirer into nature.
  Physiognomon, onis—One who judges of the character
   of men by their features.
  Physiologia,  ae—The science of natural philosophy.
  Pica, ae—Depraved appetite,  craving for improper sub-
   stances.
  Pico, avi—To bedaub with pitch.
  Pigmentum,  i (pingo)—A paint, a color, a pigment
  Pila,  ae—A mortar.
  Pilum, 1—A pestle or pounder for a mortar.
  Pilula, ae—A pill.
  Pilus, i—A hair, a short hair.
  Pingo, nxi—To paint.
  Pinguls,  e—Fat.
  Pinna, aa—A feather.
  Pinus, us—The fir tree.
  Piper, eris—Pepper.
  Pirum, i—A pear tree.
  Picis, is—A fish.
  Pisinnus, i—A little boy.
  Pisinna,  se—A little girl.
  Plsum, 1—A pea.
  Pisiformis—Pea like.
  Pltuita, ae—Phlegm, viscid mucus.
  Pix, picis—Pitch.
  Placenta, ae (a cake)—The afterbirth.
  Placenta praevia—Presentation of the placenta
 Placidus, a, um—Soft,  gentle, mild.
 Planta, aa—A vegetable, a plant.
  Planta pedis—The sole of the foot
  Plantaris, e—Of, or belonging to the sole of the foot
 Planus, a, um—Smooth, plain, even.
 Plenus, a, um—Full, loaded.
 Plecto, xi—To plait, to braid, to weave.
 Plexus—A net-work of  blood vessels.
 Plico, avi—To fold, to knit together.
 Plica, aa—A fold,  a duplicature, a plait
 Plica polouica—A disease of the hair.
   (Saepe sub pica latet seu foetus seu plica.)
 Ploro, avi—To cry, to weep, to bewail.
 Pluma, ae—Down, soft  feathers.
 Plumbago,  inis—Lead ore.
 Plumbum, i—Lead
 Pluo,  pluvi—To rain.
 Plurles—Often, frequently, several times.
 Pluviometer—A rain gauge, pluvio.
 Pneumaticus, a, um—Of, or belonging to the air.
 Poculum, i—A little cup, a poisonous draught
 Podagra, ae—Gout in the feet.
 Podex, ids—The fundament.
 Polenta, ae—A prepared barley.
 Pollen, inis—Very fine meal or flour, powdery matter.
 Pollex, leis—The thumb.
 Polluo, ni—To pollute, contaminate.
 Polypus—A polypus, a swelling or excrescence.
 Pomum, i—Fruit, an apple.
 Pondus, eris—A weight.
 Pono,  posui—To set, lay, place.
 Pons—A bridge.
 Poples, ltis—The leg behind the knee.
 Populus,  i—The people.
 Populus,  i—A poplar tree.
 Porcus, i—A hog,  swine.

 ^heskiiT3 (porrum- g«lic)-A pustular disease of

 Porta, »—A gate, an entrance (portal).
 Portio, onis—A part, a portion.
 Porto, avi—To carry,  to bear.

 p^fUm'r,potui~?'0 be able-t0 J^e we Power.
 Post—After, or since.                 k""<=«.
 Post mortem—After death
 Postea—Afterward.

 P°ot,tir^ni^TFdlUkLtgme8'  future Stations.

 ?otnp'o^vT^oedri?irgP°WeC
 Potus  us—A draught, a potion.
 Praa—Before.

 K&on^l^riX Ca9t d0™' P^'P'tate.
 Priecordia, orum-The diaphragm.
 I r;e lico, xi-To say beforehand, predicate
Pnegnans, tis-With child, pregnant
Praemalurus, a, um—Vervearfv ■■n.ir-  i
Prepare,  avi-To make ready beiW&VJ?M^tlm,L
Praaputium,  i (put.,, to cut ott-)-The nre^.^T^f-
Praascribo, psi—To oroscrih..  11?aL prePuce. foreskin.
  hand.            prescribe, order, appoint  before- 
LATIN  VOCABULARY.
909
Prse.^criptio, onis—Order, rule, prescriDtinn

pSvu^^i10!?"1 het°? bwSxSSra, to dine.
Pravus, a, um—Depraved, deformed.
Prehenso, avi—To take hold of, to seize.
Pressura, ae—Pressure, expressed
Prima—The first.
Prima? vise—'The first passages, the stomach and intes-
  tines, as distinguished from the lacteals or secundse viae
Primipara, aa—One who is delivered of her first child
Priapus—Permanent rigidity of the penis, priapism.
Pro re nata—According lo the nature of the case.
Probo, avi—To try, examine, inspect.
Proboscis, ldis—The snout of an animal  proboscis.
Procedo, essi—To spring forth, proceed (processus).
Procreator, oris—One who brings forth, procreator.
Procresco,  ere—To grow forth, to spring up.
Procurator, oris—One who  superintends anything.
Produco, xl—To bring forth, to produce.
Professor, oris—A public teacher.
Proflatus,  us—A snoring.
Progenero, are—To generate, beget, bring forth.
Progenitor, oris—The founder or progenitor of a family.
Prognosticum, 1—A sign or token of anything future
  (prognosis).
Progressus, ns—A going before, advancement
Prohibeo,  ui—To restrain, hinder, prohibit.
Prolapsus, a,  um—A falling,  a slipping  down of a
  part.
Procidentia (cado, to fall)—Synonymous with prolapsus.
Proluvies, ei—Filth cast forth.
Promineus, tis—That which projects, a prominence.
Promiscuus, a,  um—Mixed, in common.
Frompte—Without delay, quickly.
Pronitas, atis—Pronation, a bending down.
 "ronus, a,  um—Bent, inclined.
 .'ropagatlo, onis—A propagating, enlarging.
Propluqultas, atis—Relationship, nearness.
Proscribo, psi—To make a thing publicly known  by
  writing.
Proseda ae—A common prostitute.
Proslibilis,  e (pro,  sto)—That publicly exposes itself for
  hire.
rYotrudo—To thrust or put forward.
Prosector, oris—One who prepares subjects for anato-
  mical lectures.
Proximo, are—To approximate.
Prurigo, inis—An itching, severe itching (pruritus).
l'scllismus—Misenunciation, stammering.
Psilothrum, 1—An ointment by means of which the hair
  falls off.
Ptisanarium, i—A decoction of barley or rice, ptisan.
Pubeo, ui—To be pubescent.
Pubertas,  ati—The age of puberty.
Pubes, Is—Puberty, the pubis.
Pubis, os—The pubic bone.
Pudendum—The external  parts  of generation in  the
  female.
P udeo, ui—To be ashamed.
Puella, ae—A young woman, a girl.
Puellus, t—A little boy.
Puer, eri—A child, a boy.
Puerpera, ae—A woman recently delivered.
Puerperium, i—Child-birth, child-bed.
Pugnus, i—A fist.
Pulcher, chra—Beautiful.
Pulmo, onis—The lungs.
Puhnoneus, a, um—Of, or belonging to the lungs.
Pulpa, se—The flesh with fat or bone.
Puis,  tis—A gruel or pottage made of pulse.
Pulsatio, onis—A beating, throbbing, pulsation.
Pulsus cordis—The impulse  of the heart.
Pultatio,  onis  (puis.)—Substances having  the  consis-
  tence of porridge.
Pulvis, eris—Dust,  powder.
Punctum, i—A small mole, a puncture.
Pungo, pupungi—To prick, to penetrate, to enter.
Pupula, ae—The pupil of ihe eye.
Purgatus,  us—Cleansed, a purging.
Purgo, avi—To purge (purgatives).
Puriformis, is—Resembling pus.
Purpura, aa—An eruption of the skin.
Purus, a, um—Pure, clean.
Purifico, avi—To cleanse, to purify.
Pus, purls—Matter.
Pustula—A pimple containing matter, a pustule.
Puteo, ui—To stink, to rot
Putreeco—To rot, to putrefy.
Putrefactio, onis—Decomposition, putrefaction.
Putridus, a, um—Fetid, stinking.
Pyga, ae—The buttocks.
Pyramis, idis—A pyramid.
Pytessa, are—To spit out
Pyriformis—Pear shaped.

Qui—How, in what manner.
Duadrans, tis—The fourth part, quarter (quadrant).
Quadratus, a, ura—Square, four-cornered,  the name of
  several musles.
 Quadrigeminus, (four double)—A term applied to four
  tubercules in the brain, nates, testes.
 Quadrupes, edis—Four-footed, quadruped.
 Quam—How, as, as much as.
 Quam,  vis—As much as you like.
 Quantitas,  atis—Extent quantity, number.
 Quantus, a, um—How great, how much, as much as.
 Quantum sufficiat Q. S.—As much as is sufficient
 Quies, etis—Rest, quiet, calm.
 Quiesco, evi—To be a rest quiet.
 Quarante—Forty (quarantine 40 days).
 Quotidianus, a, um—Daily, every day, quotidian.

 Rabies, ei—Maddess, phrenzy.
 Rabide—Ravlngly, madly.  ""
 Racemus, 1—A bunch of grapes (raceme). •
 Radlcula—A small root, radicle.
 Radius, 1.—A rod, the small bone of the arm.
 Radcx,  icis—A root.
 Radialio, onis—Radiation.
 Ramentum, i—Filings, shavings, scrapings,
 Ramtx, icis—The vessels of the lungs.
 Ramus, i—A branch.
 Rana, ae—A frog.
 Ranula, ae—(A Utile  frog, frog-tongue, a tumor under
  the longue.
 Rancldus—Rancid, stinking.
 Rapidus, a, um—Rapid, quick, swift.
 Rare—Thinly.
 Raptus, (raplo to seize)—Raptus nervosum, or cramp,
  raptus supinus, or opisthotonos.
 Rarefacio—The act of making a substance less dense.
 Ratio, onis—A reason, a principle, a maxim.
 Raucus, a, um—Hoarse, husky of voice, raucitas.
 Ravio, ire—To speak oneself hoarse.
 Reago—To act again  or upon (re-action, re-agent).
 Recalvus, a, um—Bald-headed.
 Recedo, essi—To go back, recede.
 Recens, tis—Fresh, recent, new.
 Receptacuium,  i—A receptacle.
 Receptaculum chyh—The receptacle of the chyle.
 Recipio, epl—To take, to secure, take back.
 Recipe—Take.
 Reclino, avi—To lean or support onself upon, recline.
 Recte—Righily, directly.
 Rectificatio, onis—Redistillation, rectification.
 Rectum, i—The straight gut,  the last portion of in-
  testine.
 Rectus, a,  um—Straight, the name of several muscles.
 Recumbo,  ui—To lie back, recline.
 Recuperatio, onis—A recovering, obtaining again.
 Recuro, avi—To heal or cure.
 Recurro cucurri—To run back, recurrent.
 Reduco, xi—To take  or draw back (reduction).
 Reduvia—A whitlow, agnail.
 Reflecto, xi—To bend back (reflection).                s
 Refrigero—To make cool, refrigerate (refrigerants).
 Regimen, inis—A rule of diet,  etc., prescribed for a
  patient
 Regio, onis—Region, artificial divisions of the body.
 Regurgitatio, onis—Regurgitation.
 Relapsus—Relapse, recurrence.
 Relaxo, avi—To loosen, to relax.
 Remedium, i—Remedy, means of healing or cure.
 Remissio, onis—A cessation of febrile symptoms.
Remitto—To remit (remittent, a class of fevers).
Remora, aa—A stoppage or obstacle.
Remotus, a, um—Remote, distant.
Ren,  renis—A kidney, usually plural renes, kidneys.
Reniformis, is—Kidney shaped.
Repello, pull—To drive back (repellent).
Reproduco—Generation, continuation of the species.
Reptilia, ae—A reptile.
Requiesco,  evi—To rest, repose, recreate.
Res—A matter or thing.
Resauesco, nui—To grow sound, or heal again.
Reseco, cui—To cut out, to cut off (resection).
Resina,  ae—A resin.
Resolvo, soivi—To loosen again, to dissipate (resolv-
  ents)..
 Resono, avi—To reecho, resound (resonance).
 Respiratio, onis—The act of  fetching breath in and ex-
  piration.
 Resuscitato, onis—The act of recovering life, or reviv-
  ing.
 Restiformis—Cord-like, two cord-like  process  of  the
  brain.
 Rete, is—A net a vascular net-work, or plexus of ves-
  sels.
 Retentlo, onis—A keeping back, retention.
 Reticulum,  i— A little network, the second stomach of
  the ruminantia.
 Retlformis—Net-like.
 Retina—A  net-like expansion  of the* optic nerve,  the
  retina.
 Retraho, xi—To draw back (retractor, relrahens).
 Recro—Behind, backwards.
 Retrocedo, ere—To go back, to retrocede. 
910
LATLN  VOCABULARY.
Retroveraio, onis—A turning backwards.
Retroversio  uteri—A morbid Inclination of  the  uterus
  backward.
Reverbero, avi—To beat back again.
Revulsus—A pulling away, revulsion.
Rhonchus, i—A snorting, a snoring, rale.
Rictus, i—The mouth wide open.
Rideo, si—To laugh.
Rigidus, a, um—Stiff, Inflexible, rigid.
Rigor, oris—Stiffness, rigor.
Rigor mortis—The stiffness of death.
Rima, ae—A fissure, a cleft (rima, glottidis).
Risus—Laughter.
Rlsus sardonicus—A species of convulsive laughter.
Roboro, avi—To strengthen (roborants).
Robustus,-a, um—Hardy, strong.
Rodo, si—To gnaw (rodentia).
Rosa, aa—A rose.
Rosalia, ae—Old term for scarlatina.
Roseola (roseus, rosy)—Rose colored  efflorescence.
Rostrum i—The MU or beak of birds.
Rota, aa—A wheel, a circuit
Roto, avi—To turn around (rotator, rotation, rotifera).
Rubefacio, eci—To make red, rubefacient
Rubeola, ae (ruber, red)—Measles.
Bubigo—Rust
Ructus, us—A belch, an act of belching.
Ruga, ae—A fold, a wrinkle.
Bugosus, a, um—Full of wrinkles (rugose, rugosity).
Ruminatio,  onis—A chewing  again, ruminating (ruml-
    nantia,
Ruptus, a, um—Broken, a rupture

Saccbarum. i—Sugar.
Saccus, 1—A sack or bag, a natural or morbid cavity.
Sacculus,  1.—A little bag, minute vesicular bags.
Sacrum, i—The base of the vertebral column.
Saepe—Often, frequently.
Bagltta, ae—An arrow (sagittalis, sagittate).
Sal, salis—Salt.
Salinus, a,  um—Of, or belonging to salt, saline.
Saliva, aa—Spittle.
rialivatio, onis—Salivation,  augmentation of the secre-
  tion of the saliva.
Baltus, us—A spring, a bound, a leap.
Salubritas,  atis—Heathfulness, salubrity.
Salveo, ere—To be well, or in good health.
Salvatella, aa—A vein of the foot, the opening of which
  was said to preserve health, and cure melancholy.
Sanatio, onis—A  curing, healing.
Sanate—Inviolably.
Sanguen, Inis—Blood.
Sanguis, inis—Blood.
Sanguillcatio, onis—The process by which chyle is con-
  verted into blood.
Sanies  ei—A thin,  serous, foetid matter.
Sanitas, atis—Soundness of body,
Sano, avi—To heal, to cure.
Sanus,  a, um—Sound In body, in good health.
Sapo, onis—Soap.
Sartor, oris—A tailor, a muscle of the leg
 Sat, satis—Sufficient enough.
Satietas, atis—Fullness, satiety, disgust
Saturo, avi—To satisfy (saturation).
Saucio, avi—To wound, to hurt mortally.
 Scabies, ei—Scab, itch.
 Scabo, bi—To scratch, to rub (scab).
 Scala, ae—A ladder, a flight of stairs (scalaa of the coch-
  lea).
 Scalpellum, i—A scalpel.
 Scalpo, psi—To rub, to scrape.
 Scambus,  a, um—Crooked-legged, bow-legged.
 Scapula,  aa—The shoulder-blade.
 Bcarabeus, 1—A  beetle.
 Scarlficio, avi—To lance, to scarify.
 Sciens, tis—Knowing,  skillful.
 Scientia,  aa—Knowledge, science.
 Scintilla,  as—A small spark.
 Scoria, ae—The dross or refuse of metals, excrement.
 Scrobis, is, vel scrobs, is—A depression.
 Scrobiculus cordis—The pit of the stomach.
 Scrofa, as—A sore  (scrofula).
 Scrotum, i—A leather bag, the envelope of the testes.
 Bcrupulus, i—A scruple, 20 grains.
 Scutiformis—Shield-shaped.
 Sebum, vel sevum, 1—Suet, tallow.
 Secerno, crevt—To separate, remove (secernents).
 Secretio,  onis—A separating, parting, secretion.
 Secta, aa— a party, set, faction.
 Sectio, onl3—A cutting off, section.
 Seculum, 1—A race, a generation.
 Secundarius,  a,  um—The second In  order (secundlnes).
 Sedamen, Inis (sedo allay)—The means of allaying or
   composing, seMative.
 Sedimen,  inis (sedo, to settle)—That  which setttes at the
    bottom of a liquid.
 Seduco, xi—To lead aside, mislead,  seduce.
 Secundum—According to.
Segmentum, l-A cut, incision, segment.
Seleclio, onis—A selecting, choosing.
Sella, aa—A seat.
Sella Turcica-Part of the sphenoid bone
Semen, Inis (seminum, i)—Seed, fecundating fluid.
Semi—Half.
Senesco,  nui—To  grow old.
Senex, senis—Old, aged (senilis).
Sentio, sensl-To  perceive by the senses  (sensation,
  sensibiUty, sensorium).
Separatus,  a, um—Separated, divided.
Sepes, is—A hedge (septum).
Sepulcrum, 1—A grave, a sepulchre.
Sequor, quutus—To follow or  move after.
Sequela,  as—A morbid affection which follows another.
Sequestrum, 1—The portion of bone which Is detached
  In necrosis.
Sericeus, a, um—Silky, covered with fine, long hairs,
  giving a silky appearance.
Serpens, tis—A serpent.
Serpigo,  iginis (serpo) —Ringworm, tetter.
Serratus, a, um—Serrated Uke a saw (serratus magnus
  posticus).
Serum, 1—The watery part, serum.
  Serum lactis, serum sanguinis, serum chyli.
Sesqui—Half as much more.
Sesqui-hora—One hour and a half.
Seta, ae—A bristle (seton).
Siccus, a, um—Dry, without moisture.
Sideratio, onis—An old name  given  to erysipelas of the
  face or scalp, from an idea of its being produced by the
  influence of the planets.
Silentium,  i—Silence, quietness.
Silex, Ids—A flint
Silus, a,  um—Snub-nosed, nose turned up.
SUva, aa—A forest
Similes,  e—Like, similar.
Simplex, icis—Simple, not mixed.
Sin—But if, if however.
Sine—Without.
Sinciput, itis—The fore part of the head.
Singulus,  a, um—Single, one alone.
Singultus,  us—A sobbing, hiccough.
Sinister, tra—Left, to the left hand,  or side.
 Sinus, us—A  hollow, a gulf, a cavity  within the sub
  stance of bone. etc.
 Sipho, onis—A siphon.
 Sitis, is—Thirst
 Sol, solis—The sun.
 Solamen, inis—Comfort, solace, consolation.
 Solea, ae—The sole of the foot.
 Solidus, a, um—Solid, dense.
 Solus, i—Alone,  only.
 Solutio,  onis—A  loosening, dissolving, solution.
 Solvo, vi—To loosen, dissolvo, solvent.
 Somnus, i—Sleep.
 Somniferus, a. um—That causes sleep.
 Somnambulo—To walk in the sleep.
 Sono, ui—To sound, to make a noise.
 Sophisticatlo, onis—Adulteration.
 Sopor, oris—Profound sleep (soporific).
 Sorbeo, ui—To suck in, absorb.
 Sordes,  is—Dirt, filth, viscid  matter.
 Spado, onis—A eunuch, a gilding.
 Spargo, si—To strew, to sprinkle, to moisten.
 Spatha, aa—A spatula.
 Specto,  avi—To  look at anything.
 Spectrum, i—A form or image, whether real or imagin-
   nary.
 Specularis, e—Like a mirror (speculum).
 Sphaera, sb—Any round body.
 Spica, ae—A point, an ear of corn, the name of a band-
   age.
 Spina, ae—A thorn, the back bone.
 Splra, ae—A spire, fold (spiral vessels.
 Spiritus, us—Spirit.
 Spisso,  avi—To make thick,  to thicken.
 Splen, enls—The spleen.
 Spongla,  ae—A sponge.
 Spumo, sb—Foam, froth.
 Spumo, avi—To foam.
 Spuo, ui—To spit up or out
 Sputo, are—To spit.
 Sputum, I—Spittle, expectoration.
 Squamo,  as—The scale of a  fish, scale-Uke substance.
  Stagno, avi—To stagnate.
  Stamen, inis—The male organ of flowering plants.
  Statura, ae—Stature, size of body
  Stella, seA star  (stellated).
  Stercoreus, a, um—Of the nature of exerement, dung.
  Stenhs, e—Unfruitful, barren.               .«""«•
  Sternum, i—The breast bone.
  Sterto,  ui—To snore.
  Sternutatio, onis—Sneezing (sternutatories).
  Stigma, tis—A mark, a small red speck
  ^!fmar"In P,lanls- 'he upper extremity of the Distil
  Stillicidium,  i-A liquid which falls by drops  strani'urv
    a discharge of the  urine guttatim.       P ' slraoSury 
LATIN  VOCABULARY.
911
Stlmulo, avt-To goad, to Increase the vital activity of
  an organ (stimulant).                    »v.uv»ijr ui
Sto, steti—To stand.
Stotcus, a, um—Belonging to the Stoics or their philoso-
  phy.
Stomachius,  a, um—Having a weak stomach
Stomachus, i—The stomach (stomachic).
Strabo, onis—Squint-eyed, one that has a cast in the eye
  (strabismus).                                    *
Stramen, inis—Straw, litter.
Stramentum, I—That which is spread, or strewed under.
Strangulo, avi—To strangle, to stifle.
Strangulatio, onis—The close constriction of a part
Stranguria, ae—Strangury.
Stratum, i—A thing thrown upon another.
Strictura,  aa—A contracted  state of some part of a tube
  or duct.
Stridor, oris—A grating, creaking.
Stridor dentlum—A grinding or gnashing  of the teeth,
  brygmus.
Stridulus, a, um—A hissing, goating, creaking.
Strigilis, is—A scraper, or flesh brush used by the Ro-
  mans in bathing.
Struma, ae—Scrofula, king's evil.
Btudeo, ui—To apply the mind to a thing, to study.
Stupefacio, onis—To produce stupor or insensibiUty.
Stupor dentium—An affection called teeth on edge.
Stuprum, Disgrace, rape.
Buadeo, si—To persuade, to give advice.
Suavls, e—Pleasant, agreeable to the senses.
Sub—Under,
 Subduo, didi—To put or lay under, subdue.
 Bubsultus—Twitching, sudden and irregular twitching
   of the tendons.
 Succedaneus, a, um—A medicine substituted in place
   of another.
 Succussus,  us—A shaking, a mode of exploring the chest
   by shaking the patient's body and observing the sounds
   produced.
 Succus, i—Juice.
 Sudo, avi—To sweat, perspire (sudorlfics).
 Sufllo, ivl—To fumigate.
 Sufiitus—Fumes of burning substances used for inhala-
   tion.
 Suffoco, avi—To suffocate, arrest of the respiratory func-
   tion.
 Suffundo,  fudi—To pour  under,  suffusion,  (suffuslo
   nigra).
 Sugellatio,  onis—Discoloration of the skin by a  blow,
   ecchymosis.
 Sulcus, i—A groove, furrow, depression.
 Sulfur, sulphur,  uris—Sulphur.
 Sumo, ere—To take (by the mouth).
 Suner—Above, over, beyond.
 Supercilium—The eyebrow.
 Superficies, ei—A surface.
  Bupino, avi—To bend backward, to lie on the back (su-
   pination,  supinator).
  Suppositus, a, um—Put in the place of, substitute, (sup-
   pository).
  Bupprlmd,  essi—To check, to stop,  cessation of  secre-
   tion.
  Suppuro, avi—To suppurate, gather matter or pus.
  Sura, aa—The calf of the leg.
  Burditas, atis—Deafness, hardness of hearing.
  Suspento, di—To hang up (suspension, suspensory).
  Susplro, avi—To exhale, to draw a deep breath.
  Susurrus,  i—An  acute,  continuous hissing  sound,  a
   whisper.
  Butura (suo, to sew)—A seam, a  suture.
  Synthesis,  Is—The formation of  any body from its ele-
   ments.
  Slrupus—A sirup.

  Tabella, aa—A tablet.
  Tabeo, ui—To waste away.
  Tabes, is—A gradual wasting away by disease.
   Tabes mesenterica, tabes dorsales, tabes saturnia.
  Tabula vitrea—A term appUed to the  dense internal
   plate of the skull.
  Taanla, ae—A tape-worm.
  Taenia, aa—A ligature, a long narrow riband, (tenia hip-
   pocampi, etc.)            .
  Talipes,  dis—Clubfoot, walking on the ankles.
  Talus, 1—The ankle bone.        ...
  Talpa, ae—A mole, a tumor under the skin.
  Tango tetcgi, tactum—To touch (tactus erudilus).
  Tarsus—Th.- instep ; also the  thin cartilage situated at
   the edge of the eyelids.                         .
  Tegumnmtum, l (tego, to cover)—A covering of the body,

  Tela'^—a'web, a term appUed to web-like tissues.

  £miSera.ur7T .-Temperature,  state  of  the  atmos-
    phere or a body, as to heat.
  Tempus, oris—Time.
  Tempora,  aa-The temples (temporal s).
  Temltieuius. a, urn-Drunk, intoxicaied.
Tendo, tetendl—To stretch, extend (tensor).
Tenaculum, i—A hook to take hold of bleeding vessels.
Tenesmus,  i—Painful and constant  urgency to alvine
  discbarges.
Tenuo, avi—To make thin or weak, lessen.
Tepidus, a,  um—Lukewarm, tepid.
Teres,  etis—Long and round (teres major and minor).
Tcrmiuatio, onis—A fixing of limits,  an ending.
Tero, trivi—To rub, to make smooth.
Terra,  ae—Earth.
Testa,  ae—A shell.
Testis, is—A testicle, testis vlrilttatls.
Tetre—Foully, shockingly.
Thalamus,  i—A bedroom ; that part of the brain from
  which the optic nerve arises.
Theca, ae—A sheath, a case, an envelope.
Thorax, acis—The  breast, the chest.
Tibia,  ae—The shin bone.
Tibialis,  e—The name of two muscles, anticus and pos-
  ticus.
Tinea, ae—A gnawing worm,a disease of the scalp.
Tinnitus, us—A ringing.
Tinnitus aurium—Kinging in the ears.
Titubatio, onis—General restlessness with a perpetual
  desire of changing the position, fidgets.
Toleratio, onis—A bearing, suffering, enduring.
Tonsilla, aa—A tonsil.
Tormen, inis—A griping pain In the  intestines, tormina.
Torpor,  oris—Numbness,  torpor.
Torreo, torrui—To burn,  to consume, inflame.
Tortus, a,  um—Crooked, twisted.
TorticolUs—Wry neck.
Toxicum, i—Poison in which arrows were dipped,poison.
Trabecula,  aa trabs,  a  beam—The small  medullary
  fibres of  the brain, which constitute the commissures.
Tractus, us—A line, a region, a space tracius opticus,etc.
Tranquillitas, atis—Calmness, tranquillity, rest.
Trans—Beyond, on the further side of.
Translormatio, onis—Change from one shape to another.
Transversus, a, um—Lying across, transverse (trans-
  versaUs.
Tremor, oris—A trembUng, tremulous motion (tremor
  tendinum).
 Triceps, ipilis—Three headed, (several muscles).
 Tricuspis,  idis—Three  points, three  triangular folds be-
  tween the right auricle and ventricle of the heart.
 Tritura, ae—A rubbing or pounding, trituration.
 Trochus, i—A lozenge, a round tablet.
 Truncus, i—The trunk of the body.
 Tuba, ae—A tube, trumpet (tuba eustachiana).
 Tuber,  eris—A protuberance, excrescence.
 Tuberculum, i—A tubercle, a pecuUar morbid product
 Tubulus,  1—A little tube or pipe, (tubuli lactiferi).
 Tumefacio, eci—To cause to swell,  tumefaction.
 Tumeo, ui—To swell,  tumor.
 Turbo,  inis—That turns round in a circle, turbinated.
 Turgidus, a, um—Swollen, inflated, turgid.
 Tus, vel thus, uris—Frankincense.
 Tussis,  is—A cough.
 Tuto—With safety.
 Tympanum, i—The drum of, the ear.

 Uber, eris—A teat, a nipple.
 Ubi—Where.
 Ulcus, eris—An ulcer, sore.
 Ulna, ae—The elbow, the large bone of the fore-arm.
 Umbilicus, i—The navel.
 Uncia,  aa—An ounce.
 Unetus, a, um—Anointed, greasy.
 Uncus, i—A hook.
 Unciformis—Formed iike a hook, a bone of the carpus.
 Unguentum, is—An ointment.
 Unguis, i—A nail of the finger or toe.
 Unio. onis—Joining together, the growing together of op-
   posite surfaces.
 Urina,  a;—Urine.
 Urtica, aa—A  nettle, an Itch.
 Urticaria—Nettie rash.
 Ustus,  a,  um—Burnt, scorched.
  Uterus, l—The womb.
  Uva, a;—A berry, a grape.
  Uvula, aa—The pendulous body that hangs  down from
   the middle of the soft palate.

  Vaccinatio, onis—The act of inserting vaccine matter.
  Vacuus, a, um—Empty, vacuum.
  Vagina, as—A sheath, the membranous canal that ex>
   teuds from the os externum to the cervix uteri.
  Valens, Us—In good health, strong.
  Valetudinarius, a, um—Sickly, ill,  infirm of health.
  Valgus, a, um—Bent outward, bowed.
  Valva, aa—The folding door, a valve.
  Valvula,  ae—A little valve.
  Vapor, oris—Steam, vapor, exhalation.
  Varix, icis—A swollen or dilated vein in the leg.
  Varus—A spot, a pimple eruption.
  Vas, vasis—A vessel  (vas deferens, vasa brevia etcj
  Vectis, is—An iron bar. 
912
LATIN  VOCABULARY.
Vehlculum, I—Any vehicle.
Velum, i—A veil, a curiain.
Vena, «b—A vein.
Venesectio, onis—Blood-letting.
Ventriculus, i, (ventus)—The stomach (ventricles of the
  heart).
Vermis, is—A worm.
Vermiculus, i—A little worm.
Vermifbrmis—Worm-like.
Vermifugo—To expel worms, vermifuge.
Verminatio, onis—Breeding of worms, lnfestment by
  parasitic animalcules.
Verrucosus, a, um—Full of warts.
Vertpeltis, e—That changes Its hide or skin.
Vertebra,  aB—A bone of the spine.
Vertebrata, ae—Animals that have a vertebral column.
Vertigo, inis—giddiness, dizziness.
Veru, u—A spit.             .
Veru  montanum—A little  eminence of the urethra,
  caput gallinaginis.
Vesania, 83—Madness without coma or pyrexia.
Vesica, se—A bladder, the urinary bladder (vesicate).
Vesicula, ae—A Uttle bladder.
Vespera, ae—Evening.
Vcstibulum, 1—A threshold.
Veternus,  a, um—Old, lethargic, sluggish.
Via, ae—A way, a passage.
Viae lacrymales—The tear passages.
Vibro, avi—To move quickly, to vibrate.
Vibrissa, ae—The hair of the nostrils.
Vlcarlus, a, um—A substitute, vicarious.
Vlctus, us—(vivo)—Nourishment, provision.
Video, vidi—To see (vidian),
Vigilans, tis—Watchful, careful.
Vigor, oris (v-igeo, to live)—Life, vigor, activity.
Villosus, a, um—Covered with long, soft, shaggy hair.
Villus, i—The shaggy hair of beasts, villi or villosities
  of the mucous membranes, resembling downy tissue.
Vinum, i—Wine.
Vlr, i—A man, male person.
Virgo, inis—A virgin.
Vlridis, e—Green.
Virllis—Of, or belonging to man.
Virus, i—Venom, poison, virus.
Vis Is—Force, power.                       ,
  Vis atergo  Vis inedicatrix naturae, \ is vttae, efe.
Vlscus, eris, viscera—Any organ which has an appro-
  priate use.
Visio, onis—A seeing, sight, vision.
Vila, ae—Life.
Vitalis, e—Of, or pertaining to life, vital.
Vitetius ovi—The yolk of an egg.
Vitio,  avi—To corrupt, spoil, vitiate.
Vitrum, i—Glass.
Vivo, vixi—To live, be alive.            .
Vivipario—Animals which bring forth their young allvo
  and perfect, as distinguished from oviparous animals.
Vivisectio, onis—Dissection of  living animals for  the
  purpose of study.
Vocalis, e—That is heard vocal.
Vola,  ae—The hollow of the hand or foot.
Volo,  avi—To fly.
Volo, volui—To will, be willing.
Vulsella,  ae—Small pincers, tweezers.
Volvo, vi—To roll, to turn.
Volvulus—Intussusceptio.
Vomer, eris—The middle bone of the nose.
Vomica,  ae—An abcess of the lungs.
Vomicus, a, um—Purulent, nasty, noxious.
Vomlto, are—To vomit, to spit up. -
Voracitas, atis—Voracity, ravenousness.
Vorax, acis—That swallows greedily, consuming.
Vox, vocis—The voice.
Vulnero,  avi—To  wound (vulnerary).
Vulpis morbus—Alopecia, baldness, decay and fall of the
  hair.
Vulsus, a, um—Smooth, bald, without hair.
Vultus, us—The looks, the countenance.
Vulva, aa—The elliptic  opening inclosed by  the labia
  majoraa of the pudendum.
Vulva cerebri—A small aperture of the brain.

Zona pellucida—A thick membrane constituting the ex-
  ternal investment of the ovum.
Zonula ciliarls—A thin vascular layer  connecting  the
  anterior margin of the retina with the circumference of
  the lens.
Zotheca,  ae—A  small private chamber for study.
              PHARMACEUTICAL  ABBREVIATIONS,


AND  EXPLANATION  OF   TERMS   USED  IN   PRESCRIPTIONS.
A, aa, ana, of each—Either by weight or measure.
Abdom., Abdomen—The belly.
Abs. feb., Absente febre—Fever being absent
Ad du. vie, Ad duas vices—For two times.
Ad sec. vie, Ad secundum vices—To the second time.
Ad gr. acid., Ad  gratam acidltatem—To an agreeable
  acidity.
Ad def. animl, Ad defectionem animl—To fainting.
Ad del. an., Ad deliquium animi—To fainting.
Ad lib..  Ad Ubltum—At pleasure.
Add., Adde vel addentur—Add, or let them be added.
Adden., Addendus—To be added.
Adjac,  Adjacens—Near, adjacent
Admov., Admove, admoveatur, admoveantur—Apply,
  let it be applied, let them be applied.
Ads. feb., Adstante febre—While the fever is present
Alter, hor., Alternis horis—Every other hour.
Alvo adstr.,  Alvo adstricta—When the bowels are con-
  fined.
Aq. astr., Aqua astricta—Frozen water.
Aq. bull., Aqua buUiens—Boiling water.
Aq. com., Aqua communis—Common water.
Aq. dest, Aq. destiUata—Distilled water.
Aq. fluv.. Aqua fluviatilis—River water.
Aq. mar., Aqua marina—Sea water.
Aq. niv., Aqua nivaUs—Snow water.
Aq. pluv., Aqua pluvialis—Rain water.
Aq. ferv., Aquafervens—Hot water.
Aq. font, Aqua fontana—Spring water.

Bis ind., Bis indies—Twice a day.
Bib., bibe—Drink.
Bbds., Barbadensis—Barbadoes (as aloe bbds.)
Bam. mar., Balneum marae (or maris;—A sail water
   bath.
Bam. ar.. Balneum arenaa—A sand bath.
Bain, tep., Balneum tepiduxn—A tepid bath.
Bain, vap., Balneum vaporis—A vapor bath.
Bol., Bolus—A bolus.
Bui., Bulliat—Let it boil.
But, Butyrum—Butter.

Cap., Capiat—Let him take.
CieruL, Oaeruleus—Blue.
Calom., Calomelas—Calomel.
Cath., Cathartieus—Cathartic.
Cue. cru., Cucurbitula cruenta—Clipping glass.
Cochleat., Cochleatim—By spoonful.
Coch. ampl., Cochleare amplum—A tablespoonful, half
  fluid ounce.
Coch. mag., Cochleare magnum—A tablespoonful.
Coch. med., Cochleare medium ) A medium sized ordes-
Ooch. mod., Cochleare modicum J sert spoonful, 2 fid. dr.
Ooch. parv., Cochleare parvum—A teaspoonful, 1 fluid
  drachm.
Col., Cola, colatus—Strain, strained.
Colet,  Coletur or colatur—Let it be strained.
Coiaturse—To the strained liquor.
Colent, Colentur—Let them be strained.
Color., Coloretur—Let it be colored.
Comp., Compositus—Compounded.
Cong.,  Conglus—A gallon.
Cons., Conserva—A conserve (also conservo, keep).
oont. rem vel med., Continuentur remedia vel medica-
_ menta—Let the remedies or medicines be continued.
Cop., Coptosus—Plenteous.
Coq., Coque boil, coquantur—Let them be botled.
  .'^.■me   corns,,mP1-. Coquatur ad  medietatis con-
  on™h^l'    ~    "        d '° lhe consumption Vf
Coq. s. a., Coque secundum artem—Boil according to art
Coq. in s. a., l.oque in suffieiente quantitate aqua-Boil
  insufficient quantity of water.            H      °"
Cort, Cortex—Bark. 
LATIN  VOCABULARY.
913
flrast, Crastlnus—For to-morrow.
C. n.,  Cras. nocte—To-morrow night
C. m., Cras. mane—To-morrow morning.
C. v.,  Cras. vespere—To-morrow evenine.
Cuj., Cujus—Of which.               6
Cujusl., Cujuslibet—Of any.
Cyath. the,  Cyatho these—In a cup of tea.
Cyath. vin., Cyathus vinarius—A wineglass (about twc
  fluid ounces.)

Deaur. pil., Deaurentur pilulas—-Let the pills be gilt
Deb. spiss., Debita spissitudo—A  proper consistence.
Dec,  Decanta^Pour off.
Decub. hor.. Decubitus hora—At bed-time.
De d. in d.,  De die in diem—From day to day.
Deglut, Deglutiatur—Let it be swallowed.
Dej. alv.—Dejectlones alvt—Stools.
Det, Detur—Let it be given.
Dieb. alt, Diebus alternis—Every other day.
Dieb. tert,  Diebus tertiis—Every third day.
Dep.,  Depuratus—Purified.
Dex. lat, Dextra lateraUs—The right side.
Dig., Digeratur—Let it be digested.
Dil., Dilutus—Diluted.
Diluc, Diluculo—A break of day.
Dim.,  Dimidius—One half.
Det. in dupl, Detur in duplo—Let it be given in twice
  the quantity.
Div. In p. e. (or ae), Divide In partes equates—Divide
  into  equal parts.
Dir. pro., Directione propria—With proper directions.
Donee alv. bis dej., Donee alvus bis dejecerit—Until the
  bowels have been twice opened.
Donee alv. sol. fuer., Donee alvus soluta fuerit—Until the
  bowels have been loosened.
Donee dol.  neph. exulav., Donee  dolor nephriticus ex-
  ulaverit—Until the nephritic pain has been removed.
Dos.,  Dosis—A dose.
Dis., DistiUata—Distilled.
Diuturn., Diuturnus—Long continued.
Div.,  Divide—Divide.
Dr., Drachma—A dram.

E. g.,  ExempU gratia—For example.
Eburn., Eburneus—Made of ivory.
Ed., Edulcora—Edulcorate.
Eft'erv., Effervescentia—Effervescence.
Ejusd.,  Ejusdem—The same.
Elect, Electuarium—An electuary.
Emp., Emplastrum—A plaster.
Enem.,  Enema—A clyster.
Exhib.,  Exhlbeatur—Let It be administered.
Ext. sup. alut,  Extende super alutam—Spread upon
  soft  feather.
Extr., Extractum—An extract

F., Fac, fiat, fiant—Make, let it be  made, let them  be
  made.
F. pil., Fiant pilulae—Let pills be made.
Fasc., Fasciculus—A bundle.
Feb. dur., Febre durante—During the fever.
Fem. intern., Femoribus laterals—To the inside of the
  thighs.
Ft venaas., Flat venaesectio—Let  venesection be per-
  formed.
P. h.,  Flat haustus—Let a draught be made.
Fict,  Fictilis—Earthen
Fil., Filtrum—A filtre.
Fist, arm.,  Fistula armata—A clyster pipe or bladder
  fitted for use.
Fl., Fluidus—Fluid.
F. 1. a.,  Fiat lege artis—Let It be made according to the
  rules of art.
F. m., Fiat mistura—Let a mixture be made.
F. s. a., Fiat secundum artem—Let It be made accord-
  ing to art.
Flor.,  Flores—Flowers.
Fol., Folium—A leaf.
Fontic. Fonticulus—An Issue.
Fot, Fotus—A fomentation.
Fruct, Fructus—Fruit.
Frust, Frustillatlm—In small pieces.

Gel. quav.,  Geltlna quavis—In any jelly.
Gr. Granum, grana—A grain, grains.
Gtt., Gutta, aa—A drop.
Gtt. quibusd., Guttis qulbusdam—With some drops.
Guttat, Guttatim—By drops.
Garg., Gargarisma—A gargle.
Gum., Gumml—Gum.

Har. pil. sum.  iii., Harum pilularum sumantur tres—
  Of theso pill let three be taken.
Hor. decub.. Hora decubitus—At bed-time.
Haust. purg., Haustus pnr^ans—A purging draught.
H. s.,  Hora somrti—At the hour of going to sleep.
Hor. un. spa.,  Horaa uuius spatio—At the expiration of
  an hour.
Hor.  Interm.,  Horls intermedils—In the intermediate
  hours.
Hb., Herba—The plant
Hebdom., Hebdomina—A week.
Hestern. Hesternus—Of yesterday.
Hirud., Hirudo—A leech.

Inc., Incide—Cut
Ind., Indies—Daily.
In pulm., In pulmento—In gruel.
Inf?, Infunde, infusum—Infuse, infusion.
Inj. enem., Injiciatur enema—Let an enema "be given.
Inj. Injecto—Injection.

Jul., Julepus—A julep.

Lat. dol., Lateri dolenti—To the affected side.
Lb., Libra—A pound weight
Lim.,  Limones—Lemons.
Liq., Liquor—Liquor, liquid.
Lot., Lotio—Lotion.

M.. Misce—Mix.
Mac,  Macera—Macerate.
Man.,  Maniplus—A handful.
Mane pr., Mane primo—Early In the morning.
Mass.,  Massa—A mass.
Mass. pil., Massa pilularum—A pill mass.
Mist,  Mistura—A mixture.
Mic. pan., Mica panis—Crumb of bread.
Mitt, Mittle send, mittantur—Let them be sent
Mod. praasc, Modo praescripto—In the manner directed.
Mor. die, More dicto—In the way ordered.
Mor. sol., More solito—In the usual way.
Medioc,  Mediocris—Middle sized.
Min., Minimum—A drop 60th part of a dram measure.
Muc,  Mucilago—Mucilage.

Narth., Narthecium—A gallipot.
Ne tr. 8. num., Ne tradas sine nummo—Do not deliver
  it without the money.
Noct.,  Nocte—By night
No., Numero—A number.

0., Octarlus—A pint
01., Oleum—Oil.
Omn.  hor. Omni hora—Every hour.
Omn.  bid., Omni biduo—Every two days.
Omn.  bih., Omni bihorio—Every two hours.
Omn.  quadr. hor., Omni quadrante horsa—Every quar-
  ter of an hour.
Omn.  man.,  Omni Mane—Every morning.
Omn.  noct, Omni nocte.—Every night
Ov., Ovum—An egg.
Ox.—Oxymel.
Oz.—The ounce avoirdupois.

P. 89.,  Partes aequales—Equal parts
P. d.,  Per deliquium—By deliquescence
Past., Pastillus—A pastil.
Pond., Pondere—By weight.
P. D.,  Pharmacopoeia Dublinensis.
P. E.,  Pharmacopoeia Edinensis.
P. L.,  Pharmacopoeia Londinensis.
P. U. S.,  Pharmacopoeia of the United States.
Part, vie, Partibus  vicibus—In divided doses.
Per. op. emet—Peracta operatione emetici—The opera-
  tion of  the emetic being  over.
Pocul., Poculum—A cup.
Pocill., Pocillum—A small cup.
Paracent abd., Paracentesis abdominis—Tapping.
Part, aff., Partem affectam—The part affected.
Part dol., Partem dolentem—The part in pain.
Per salt., Per saltum—By leapsk
Pil., Pilula—A pill.            *
Plen.  riv., Pleno rivo—In a full  stream.
Post sing, sed, liq., Past singulas sedes liquidas—After
  every loose stool.
Ppt, Praeparata—Prepared.
Pot, Potio—A potion.
P. r. n.,  Pro re nata—Occasionally.
P. rat. aetat, Pro ratione  aetatis—According  to the age
P. pot. com., Pro potu communi—For a common drink.
Prox. luc, Proxima luce—The day before.
Pug., Pugillus—A pinch.
Pulp., Pulpa—The pulp.
Pulv., Pulvis—A powder.

Q. 1.,  Quantum libet > ,      .       Dieaae
Q. p., Quantum placet $ As mucn as you Please-
Q. s.,  Quantum sufficiat—As much as much as may sixf
  fice.
Quor., Quorum—Of which.
Q. v..  Quantum vis—As much as you will.
Quadribr., Quadrihorio—Every  four hours.
Quamp., Quamprimum—Immediately.

 Rad.,  Radix—Root
VOL.  II.—58 
914
LATLN  VOCABULARY.
 Ras., Rasnrae—Shavings.
 Rect,  Rectificatus—Rectified.
 Red. in pulv., Reductus in pulverem—Reduced to pow-
   der.
 Redig. in pulv., Redigatur In pulverum—Let it it be re-
   duced to powder.
 Reg. umbli., Regio umbilici—The umbilical region.
 Kept.,  Repetatur, repetantur—Let it or them bo  re-
   peated.
 Reg. hep., Regio hep atis—Region of the liver.

 S. a., Secundum artem—According to art
 Scat, Scatula—A box.
 S. n.. Secundum naturam—According to nature.
 Sacch.,  Saccharum—Sugar.
 Scap., Scapula—The shoulder blade.
 Scrob. cord., Scrobiculus cordis—The pit of the stomach.
 Sed., Sedes—A stool.
 Sem., Semen—A seed.
 Semidr., Semidrachma—A half a  drachm.
 Semih., Semihora—Half an hour.
 Sesunc, Sesuncia—An ounce and a half.
 Sesquih., Sesquihora—An hour and a half.
 Sept., Septimana—A week.
 Serv., Serva—Keep or preserve.
 Si n. val., Si non valeat—If it does not answer.
 Si op. sit, Si opus sit—If it be necessary.
 Si vir.  perm., Si vires  permittant—If  the strength
  allows it
 Sign. n.  pro., Slgnetur nomine proprio—Write  the pro-
  per name upon it.
 Signat,  Signatura—A label.
 Sing., Singulorum—Of each.
 S. s. 8.,  Stratum super stratum—Layer upon layer.
 Sol., Solutio—Solution.
 Solv., Solve—Dissolve.
 Spt, Spirltus—Spirit
 Sq.,  Squama—A scale.
 Ss., Semi—Half.
 St., Stet, stent—Let  it stand, let them stand.
 Bub. fin. coct, Sub  finem coctionis—When the boiling is
  nearly finished.
Subtep., Subtepidus—Lukewarm.
Suce, Succus—The juice.
Bum., Sumo, sumendus, take—To be taken.
 Bum. tal., Sumat talem—Let the patient take one such as
  this.
 Summ., Summltates—The tops or summits.
 S. V., Spirltus vini—Spirits of wine.
 S. V. R., Spiritus vini reotiflcatus—Rectified spirits of
   wine.
 S. V. T., Spiritus vini tenuis—Proof spirits.
 Syr., Syrupus—Syrup.

 Tabel., Tabella—A lozenge.
 Temp, dext, Tempori dextro—To"the right temple.
 Temp, sinis., Tempori sinistro—To the left temple.
 Tr. tinct, Tinctura—A tincture.
 Trtt, Tritura—Triturate.
 Troch., Trochiscus—A lozenge or troch.

 Ult prsesc. Ultimo praescrlptus—The last prescribed.
 Umb., Umbilicus—The navel.
 Ung.,  Unguentum—Ointment
 Utend., Utendus—To be used.

 Vent, Ventriculus—The stomach.
 V. O. S., Vitello ovi solutus—Dissolved in the yolk of an
  egg.
 Vom. urg.,  Vomitione urgente—The vomiting  being
  troublesome.
 V. s.,  Venaasectio—Bleeding.

 Zz., Zingiber—Ginger.

      SYMBOLS USED  IN  PRESCRIPTIONS.

 1$., Recipe—Take.

 Or.,  Granum—A grain.

 J), Scrupulus—A scruple.

 3 , Drachma—A drachm.

 § , TJncia—An ounce troy.

 ft, Libra—A pound.

lit, Minimum—A minim.

FZ i Fluidrachma—A fluidrachm.
F"§ ., Flulduncia—A fluidounce.

 0., Octarius—A pint

 C; Congius—A gallon. 
INDEX  TO   VOL.   I.
                                   PAGE
Abaomen.........................  1'
Abdominal Affections..............  18
Abortion........................  20
Abscess..........................  27
Acids and Alkalies................  3?
Aconite..........................  "'
Air..............................  *1
Albumen........................  *2
Albuminuria.....................  "
Aloes.................... .......  ^9
Alum.........._................  ^9
Amenorrhea......................  "0
Ammonia.......................  ®*
Amputation................•.....  °"
Anosmia..............•...........  95
Anaesthesia......................™A
Anaesthetics.......................  103
Anchylosis.......................1"°
Aneurism.......................  1U0
Antimony........................  1^1
Antiseptic.........................  *3*
Anus.............................  ]34
Aperients...................  • • •  142
Aphonia.........................  I43
^A<Aa  .... ....................  146
Apoplexy.........................  JJ6
Arsenic........................... 10^
Arteries......................... 1°*
Asphyxia......................... 1»5
Asthma........................... *''

Boldness.......................... J^5
*««*«............................J$
Bebeerine  ........................ *°'
Bed-Sores........................ ;°?
Benzoic Acid...................... *™
i?ttes............................. 1Q1
JUocftfer........................... JJJ
 Blenorrhagia..................... £
 Bloodletting...................... |Jjjj
 2?oi£s........................     " „11
 Bones.....................       ' 225
 Brain..................   .......
 Bread.............               94r.
 Breast................              244
 Bromine..............           '  245
 Bronchitis..................
                                   PARS
Bunion...........................254
Burns—Scalds..................... 256
Bursal Affections..................266

Cachexia.......................... 2^2
Caesarian Section..................273
Calculi...........................275
Camphor......................... 281
Cancerous Affections...............285
Carbuncle............•...........323
Caries..........................358
Cartilage.......................33°
Castration......................r • 33*
Catalepsy......................•• 33J
Catarrh.......................... 3g
CatheKrism....................... JJJ
Caustics ........................ 339
Chaps and Fissures................ 34d
Charcoal  ........................ 34i
Chilblains........................  34°
 Chloroform......................34°
 Chlorosis........................3°2
 Cholera.........................3J?
 Cholera Infantum.................  6™
 Choking..........................  3J2
 Chordee....................  >.....3J*
 Chorea...........................  3J3
 Cicatrices.........................  ;>°*
 Club-Foot........................  3°1
 Clysters..........................3»°
 Colchicum----...................*°°
 Cold..............•.............  ||J
 Colic.............................  |89
 Collapse..........................fl
 Collodion......................... ^
 Coma..........................IU
 Condyloma................;......*»°
 Congestion........................ ™&
 Conium........................•,•• *^
 Constipation.......................4"3
 Convulsive Affections.-..............409
 Copaiba........................* J*
 <7or«s............................*}?
 Cbwp de  Soleil....................41^
  Coryza ..........................*17
  Counter-irritants.................. 418

  CW*.........................ois4"2 
916
INDEX.
                                   PAQH
Cramp..........................  424
Creasote..........................  426
Croup  ..........................427
Cupping........................433
Cynanche........................434
Cysts............................435

Deafness.........................436
Deformities................  .....441
Delirium.........................  441
Delirium Tremens.................444
Dentition.........................450
Diabetes...........................451
Diaphragm........................  461
Diarrhoea.......................  461
Digitalis.........................477
Diphtheritis......................478
Disinfectants...................483
Dislocations......................484
Diuresis.........................494
Diuretics.........................495
Dropsy.........................496
Drowning........................  510
Dysentery........................  516
Dysmenorrhcea...........♦.........524
Dyspepsia........................  533

Ear.............................551
Ecraseur.........................561
Electricity........................ 562
Emmenagogues...................  568
Emphysema.....................568
Empyema........................570
Enuresis.........................576
Enteritis......................... 580
Epilepsy........................ 581
Epistaxis.........................589
Ergot............................ 591
Erysipelas........................ 592
Ether............................ 602
Eye.—Amaurosis................... 604
     Cataract......................605
     Cornea........................ 612
     Entropion..................... 622
     Iris..........................623
     Artificial Pupil................. 629
     Lachrymal  Affections."......... 630
     Ophthalmia................... 633
     Venereal Disease of the Eye..... 642
     Ptosis......................... 645
     Strabismus.................... 646
     Miscellaneous.................. 649
 Eyelids........................... 653

 Feet.............................. 656
 Fever............................. 657
     Enteric,  or Cornmon  Continued
         Fever.................... 663
     Infantile Gastric Fever......... 6i»6
     Nervous  Fever................ 667
     Intermittent Eever............. 668
     Typhoid Fever................ 674
     Typhus...................---677
                                    PA OK
    Remittent Fever............... 691
    Yellow Fever.................. 694
Finger........................... 697
Fire.............................. 698
Firing........................... 700
Fistula........................... 701
    Fistulse in Perineo.............707
    Recto-Urethral Fistula.......... 709
    Recto-Vaginal Fistula......  ..... 709
    Urethral Fistula..............710
    Urethro-Vaginal Fistula.........711
    Urethro-Vesical Fistula.....---712
    Vesico-Vaginal Fistula.......... 713
    Fistulous Openings............. 717
Flatulence........................718
Food.............................719
Fractures......................... 7i0
Frozen Persons....................740

Galactagogue......................740
Gallic Acid.-........'.............. 742
Ganglion.........................742
Gangrene......................... 743
Gastralgia........................ 7-54
Gastrodynia....................... 754
Glanders......................... 756
Glandular Affections............... 757
 Gleet............................. 760
 Glycerine......................... 761
 Gonorrhoea....'.................... 764
 Gout.............................773
 Gravel...........................  780
 Guarana......................... 782
 Gums............................. 783
 Gum Resins........................ 785
 Gutta Percha..................... 787

 Hcematemesis......................788
 Hcematuria ....................... 790
 Hemorrhagic  Diathesis............795
 Hemoptysis.........................798
 Hemorrhage....................... 8^2
 Hemorrhoids....................... 805
 Hair............................. 822
 Hand............................ 824
 Hanging.......................... 827
 Harelip........................... 829
 Hay Asthma...................... 832
 Headache.........,............... 833
 Hematocele........................ 836
 Hemicrania....................... 838
 Heart............................839
 Hemiplegia....................... 861
 Hepatic Affections................. 863
 Hernia.......................... i # 869
 Hiccough....................     # gg*
 Hoarseness....................... ggg
 Hooping-Cough.................... ggg
 Hydatids.......................  * ggg
 Hydrocele......................   ' ggg
 Hydrocephalus........,.........\  ' gn4
 Hydrophobia...................\  " gi q
 Hypochondriasis,...............     gin 
INDEX  TO   YOL.   II.
                                  PAGB
Hysteria...,....................    3

Indian Hemp......................   10
Infants...........................   11
Inflammation... %..................   13
Influenza.........................   15
Insanity..........................   16
Intestinal Affections................   33
Intestinal  Obstruction..............   36
Inhstines.........................   39
Intoxication.......................   45 •
Iodic Preparations.................   47
Ipecacuanha.......................   51
Iron.............................   53
Irrigation.........................   54
Issues.............................   55

Jaundice...........................   56
Joints.............'...............   58
    Ankle Joint........'...........   67
    Elbow Joint...................   70
    Hip Joint___.................   73
    Knee Joint....................   82
    Shoulder Joint.................   96
    Wrist Joint..................   99

Kidney Affections.................  100

Labium...........................  118
Labor............................ 119
    Placental Complications......... 145
    Premature Labor..............  149
Lactation......................... 152
Laryngeal Affections............... 155
Larynx........................... 160
Lead...:...:..................... 161
Leeches........................... 161
Leech  Bites....................... 162
Leucorrhoea........................ 163
Ligatures...........  ............. 164
Ligaments........................ 165
Liniments........................165
Lint.............................  166
Lip..............................  ] 66
Lithectusy.........................  169
Litholih'i..........................  i'1
Lithoiomi........................  "2
                                   PAGI
Lithotrity.......................... 184
Lobelia  Inflata.................... 190
Lock-Jaw......................... 190
Loins............................ 192
Lumbago......................... 193

Malaria.......................... 194
Manganese......................... 194
Mania............................ 199
Marasmus .'.......................202
Matico........................... 203
Meajsles........................... 204
Medicines......................... 204
Melancholia....................... 221
Melanosis......................... 221
Melama........................... 223
Meningitis........................ 223
Menorrhagia...................... 224
Menstruation...................... 227
Mercury.......................... 230
Milk............................. 233
Moles............................ 234
Morbus Coxarius.................. 234
Mortification...................... 235
Mouth............................ 237
Moxa............................ 243
Muscles........................... 244

Nccvi............................ 245
Necraimia........................ 251
Necrosis.......................... 252
Needles........................... 253
Nervous Disorders.................254
Neuralgia........................257
Nipples.........................., 261
Nitric Acid....................... 263
Nose..............................264
 Nymphomania.....................269

 (Edema........................... 269
 (Esophagus....................... 270
 Oil................................ 271
 Omentum......................... 272
 Onychia.......................... 273
 Oophoritis, or  Ovaritis............. 276
 Operations......................... 278
 Opium........................... 282
                                  917 
918
IXDEX.
                                     PAGS
  Orchitis........................... 286
  Ovarian Affections. ,...............289
  Ox-Gall.......................... 297

 Palate............................ 298
 Pancreas.......................... 302
 Paracentesis....................... 302
 Paraphimosis....................304
 Paralysis......................... 304
 Paraplegia........................ 313
 Parasites......................... 314
 Paronychia....................... 315
 Pediculi......................... 316
 Penis............................ 316
 Pericarditis........................ 318
 Perineum......................... 319
 Periosteal Affections............... 322
 Peritonitis........................
 Perspiration...........,.......... 330
 Pessaries.........................
 Phlebitis......................... 332
 Phlegmasia Dolens................. 333
 Phthisis Pulmonalis............... 333
 Phimosis.......................... 347
 Pills............................. 349
 Placenta.......................... 350
 Plasters.......................... 351
 Pleurisy.......................____355
 Pneumonia........................ 357
 Poisoning.—Aconite................ 365
     Aconitina..................... 366
     Arsenic....................... 3G7
     Belladonna.................... 372
     Colchicum....................372
     Copper....................... 373
     Corrosive Sublimate............ 373
     Cubebs....................... 378
     Prussic Acid.................. 378
     Lead......................... 384
     Opium----................... 385
     (Enanthe  Crocata..............388
     Strychnine....................389
     Upas Antiar.................. 394
     Yew-Berries...................  394
     Zinc..........................  395
Polypi.—Ear.......................  395
     Nose.........................397
     Rectum.......................402
     Uterus........................403
Pregnancy........................410
Prolapsus  Ani....................414
Prolapsus  Uteri....................416
Prolapsus  Vesica!..................418
Prostatic Affections................ 419
Puerperal Affections...............423
Puerperal Fever...................429
Puerperal Mania..................433
Pulse............................434
Purgatives........................436
Pyrosis........................... 438


Quinine...........................440
                                     PAGl
 Pedum  ..........................  441
 Respiration.......................  447
 Rheumatism.......................  448
 Rickets...........................462

 Salivation.........................464
 Sarsaparilla......................466
 Scalp............................467
 Scarlatina.........................  468
 Sciatica...........................  47 6
 Scorbutic Affections................480
 Scrofula..........................482
 Sea-Sickness.......................  485
 Sensation.........................  486
 Silver............................486
 Sinuses.................  ........489
 Skin................  ............489
 Skin Disease.—Acne............... 490
     Eczema.........  .............. 493
     Herpes........................ 501
     Impetigo...................... 502
     Ichthyosis.................... 502
     Itch.......................... 502
     Lepra............----,....... 604
     Pemphigus.................... 507
     Pityriasis  ..................... 507
     Prurigo..................... 508
     Psoriasis ....................... 510
     Sycosis Menti.................. 515
     Syphilitic Eruptions............. 517
     Tinea Capitis.................. 519
     Urticaria...................... £27
     Miscellaneous.................. 528
 Sleeplessness ..-....................
 Small-pox........................ 538
 Snake Bites....................... 541
 Soaps..........................543
 Sores  ........................... 543
 Spasmodic Affections .............. 544
 Spermatocele...................... 545
 Spermatorrhoea.................. 546
 Spina Bifida  ..................... 553
 Spine............................ 554
 Spleen............................ 5(51
 Sponge Tents..................... 562
 Sprains.....;..................... 552
 s7uil1............................. 563
 Stammering.....................553
 Sterility....................." " 564
 Stomach....................  '.. ... 666
 Strangury  ..............   ......[ g79
 Stricture of Rectum................ 579
 Stricture of OEsophagus,  etc..'.......".' 581
 Stricture of Urethra...............] 581
 Styptic.^.......................'/'  ggg
 Suppositories.......................  ggg
Sutures. .■...................       "  gQQ
Synovitis...................        "  gQ^,
Syphilis..............'.7.7.7... 7 !  601

 Tabes Mesenterica..............      goa
Tannin..........                 "*  ftQQ
***.............:::::::v.v.:::::.'SS 
INDEX.
919
                                    PAGB
Tendons.......................... 649
Testes............................ 652
Tetanus.......................... 657
Throat............................ 666
Thyroidal Affections............... 669
Tibia............................. 673
Tobacco......................... 673
Toe Nail.......................... 675
Tongue........................... 677
Tonsils........................... 685
Toothache........................ 687
Tourniquet......................... 690
Trachea.................... ---691
Tracheotomy...................... 693
Transfusion....................... 698
Tubercles.........................700
Tumors...........................701
Turpentine......................... 734

Ulcers............................ 735
Umbilical Cord....................753
Urethra...........................754
                                   PAGB
Urine.............................760
Uterine Hemorrhage................ 797
Uterus............................ 805
Uvula............................ 817
Vaccination....................... 817
Vagina........................... 821
Vagitus Uterinus...............• • • 824
Varicocele  ........................ 825
Varicose  Veins.................... 827
Veins............................. 829
Ventilation....................... 833
Vermifuges....................... 833
Vomiting......................... 835
Vulva___.........................838

Warts............................ 839
Water............................ 840
Whey:........................... 840
Whitlow  or Felon................. 841
Worms........................... g44
Wounds.........................• 849
ADDENDA.
Frtnch Measures.................. 859
French Weights.................... 859
Table of the Muscles................860
Incompatibhs...................• • 887
Latin  Vocabulary.................. 9°0
Index............................ 915 
 
 
u 
 
NLM032780783