1 [In the cellular tissue the pain is acute and throbbing; in the pleura, sharp and lancinating; in the lungs and glandular organs, obtuse and heavy; in the skin, prurient and smarting; in the bones, dull and gnawing. Sometimes it is persistent, sometimes intermittent, sometimes periodical; and occasionally, again, it is felt at parts very remote from the one originally and mainly affected. Of the latter variety we have a familiar instance in the hip-joint disease of children, in which the earliest symptom complained of is pain in the corresponding knee. In hepatitis, the right shoulder is often the seat of the suffering; in cystitis, the head of the penis.—ED.]

2 [Mr. Hunter endeavoured to settle this point by experiments on the inferior animals. With this view, he made a wound in the right side of the chest of a dog, and placing the thermometer in contact with the diaphragm, ascertained that the temperature was 101°. A large dossil of lint was then thrust into the opening, when the edges were drawn together with adhesive strips. On the following day, when the parts were in a state of inflammation, the foreign substance was removed, and the instrument being again introduced, no difference of heat was found to exist. Similar experiments were made on the rectum and vagina of an ass, with like results. Hence Hunter concluded that there was no real increase of temperature. From more recent researches, however, it is obvious that this inference of the great English surgeon is at variance with facts. Thus, in erysipelas, furuncle, and anthrax, the thermometer has been observed, in numerous instances, to rise as high even as 107°, being an increase over the average heat of the blood of eleven degrees. Results of a similar nature have been noticed in tetanus, acute rheumatism, and other maladies.—ED.]

3 [Leeches may be applied to almost any region of the body, excepting such as are abundantly supplied with loose cellular substance, as the eyelids and scrotum; or traversed by large subcutaneous veins. Parts in a state of high inflammation must also be avoided, otherwise gangrene may be induced, an effect which I have several times witnessed in hospital practice: in a case of this kind they should be placed in the immediate vicinity of the disease.

Previously to applying them, the skin should be thoroughly cleansed with a wet sponge, and moistened with a few drops of milk, blood, or sweetened water. Dipping the leeches in table beer is very effective in rendering them lively and active. Having been withdrawn from the water in which they are kept for a quarter of an hour before, they should be held to the part by means of a glass tube, a roll of pasteboard, or a piece of linen. When there is plenty of space, as on the abdomen, chest, or back, and it is designed to use great number, they may be confined by an inverted tumbler or a wire-gauze cage. They should not, however, be crowded too closely together, as erysipelatous inflammation is apt to arise when this is done; and they ought not to be touched until they drop off of their own accord. If they remain on too long, their separation may be facilitated by sprinkling them with a little salt or vinegar: pulling them away is painful and liable to occasion irritable sores. The subsequent flow of blood, which is generally considerable, especially in children, is to be promoted by cloths wrung out of warm water, and reapplied every ten or fifteen minutes for several successive hours.

If the bleeding be profuse or continue longer than is desirable, it may be arrested by some styptic powder or lotion, either alone or assisted by a compress and roller. In obstinate cases, it may be necessary to apply the nitrate of silver or chloride of zinc; or, what is better, because more effective, to use the twisted suture made with a very fine needle and ligature passed through the sides of the little wound.—ED.]

4 [Scarification is a very efficient mode of abstracting blood, and one which, in my own hands, has often been attended with the happiest results. It is performed by drawing a sharp thumb-lancet rapidly and lightly over the affected surface, in as many places as may be deemed necessary, and afterwards encouraging the bleeding either by means of a wet sponge or by immersing the part in warm water. Scarification is mainly used in chronic ophthalmia, attended with great vascular turgescence of the lower lid, in scrofulous swellings of the joints, in chronic enlargement of the testicle and epididymis, in irritable ulcers of the leg, in tonsilitis, and in erysipelas.—ED.]

5 [All practitioners are aware how much the formation of the buffy coat is influenced by extraneous circumstances. Of these the most important are the shape and capacity of the receiving vessel, the degree of motion to which the blood is subjected, and the size of the orifice in the vein. Dr. Belhomme, of Paris, who has minutely investigated this matter in a series of one hundred and fifty experiments, has come to the conclusion that a narrow basin, a large orifice, and a full, rapid stream, in the form of an arch, are the external conditions most favourable for producing the buffy coat. The results of these researches have since been verified by those of Gendrin and other observers, and they are well worthy of recollection, as they are calculated to exert an important bearing on the practice of our profession. See my Elements of Pathological Anatomy, Vol. I., p. 207. A cupped state of the blood most commonly occurs in association with inflammation of the serous membranes and parenchymatous organs, and may generally be regarded as evincive of a high degree of vascular excitement. Still, not too much stress should be placed upon this appearance, as it is sometimes present in states of the system the very reverse from that just mentioned, in persons, for example, who have been repeatedly bled or whose strength has been otherwise very much reduced.—ED.]

6 [Throughout the Elements, the edition of Practical Surgery referred to is that of 1842. Philadelphia.]

7 [To prevent mortification blisters have long been a favourite means with American surgeons. The practice originated, I believe, with the late Dr. Physick, of Philadelphia, early in the present century. To do good, they should be large enough to cover, not only the whole of the inflamed part, but a considerable portion of the surrounding surface, and to be kept on until they have produced thorough vesication. Blisters are scarcely less serviceable to arrest mortification, after it has made some progress, but in this case they should be placed in contact with the sound skin, not with the dead, as they cannot, when this is done, be productive of any good.

To expedite the sloughing process, allay the unpleasant fetor, and promote the formation of healthy granulations, I know of no remedy that will answer so well as the nitric acid lotion. It should vary in strength, according to the exigency of the case, from four to twelve drops of the acid to the ounce of water, and a cloth wet with it should be constantly kept in contact with the affected part, taking care to wash it occasionally to rid it of the foul discharges with which it becomes from time to time impregnated. If necessary, a poultice can be placed over the rag. Under this treatment, particularly when aided by the liberal use of carbonate of ammonia, wine, brandy, and other cordials, I have often been astonished to witness the rapid changes that have taken place, in cases apparently of the most desperate character.—ED.]

8 [In this country no remedy is perhaps more frequently employed in the treatment of erysipelas than blistering. In my own practice I have constantly resorted to it for the last fourteen years, and in no instance has it disappointed my expectations. Not only do I consider it as perfectly free from danger, an objection which has sometimes been alleged against it, but I know of no measure so well calculated to afford prompt and effectual relief. My practice is to apply the blister directly to the inflamed surface, together with a small portion of the healthy skin, and to keep it on until it produces thorough vesication. The vesicles are then opened with a needle, and the part covered with a light emollient poultice or the warm-water dressings. In children, and persons of a nervous delicate constitution, or whose health has been previously much impaired, the blister must be removed in from three to six hours, otherwise serious local mischief may be induced. This treatment, although applicable to every species of erysipelas, is particularly valuable in the phlegmonous form, no matter where situated, whether in the face, eyelids, scalp, trunk, or extremities.

Another remedy which has been extensively employed in this country, is the mercurial ointment, first recommended to the notice of the profession by Dr. Dean and Dr. Little, of Chambersburgh, Pennsylvania. My own experience, however, does not enable me to offer anything in its favour. Indeed, if at all useful, it can only be so, it seems to me, in the milder forms of the complaint: in the more severe grades it should never be resorted to, as it is far inferior to blistering, or scarification, as practised by Mr. Liston. The ointment should be perfectly fresh, and be applied upon soft linen, at least twice a day. Professor Velpeau has recently recommended methodical compression by means of the roller, and from some cases which he has published in illustration of his method it would seem to be entitled to further trial.—ED.]

9 [Dr. Physick (American Journal of the Medical Sciences, Vol. VII., p. 304) was always in the habit of commencing the treatment of hip-joint disease by the administration of a mercurial purge. The preparation which he commonly used was calomel, of which he gave to a patient from six to ten years two or three grains at bedtime, followed the next morning, unless it should have previously acted well, by a dose of oil. If, after having kept the patient perfectly quiet for a few days, he found the parts inflamed, swollen, and tender to the touch, he abstracted from six to eight ounces of blood, by the application of a sufficient number of leeches. Unless the inflammation was very acute, with a good deal of febrile disturbance, he did not prescribe much reduction in the diet, which was generally of a light wholesome character. His next object was to institute a course of steady and systematic purging, which he regarded as far superior to emetics, fomentations, blisters, setons, and caustic issues, so much employed by other practitioners. The articles which he selected were cream of tartar and jalap, which were given every other day in sufficient doses to procure several copious evacuations. These medicines were occasionally changed, either as they lost their effect, or as the patient took a dislike to them.

Having pursued the above plan for a few weeks, and accustomed the patient to his confinement, the next object was to insure perfect rest to the diseased joint, the most essential item of the whole treatment. To this end, a carved splint, long enough to extend from the middle of the side of the chest nearly to the external malleolus, and sufficiently wide to reach nearly one-half round the parts into which it was to lie in contact, was adapted to the shape of the limb, carefully padded on the inside, and secured by two rollers, one of which was passed round the trunk, the other round the limb from the ankle to the top of the thigh. When the limb is much bent or distorted, it should by no means be forced into a straight position in the first instance; on the contrary, the splint should be angular, to accommodate itself to hollows and projections of the parts, and, as the cure progresses, another less crooked should be substituted. It is rarely that more than two splints are required, though Physick was sometimes obliged to use as many as three or even four in the same case. During the whole treatment the patient should lie upon a hair mattrass, and the apparatus kept steadily applied until all the symptoms of the disease have vanished, which is seldom under twelve months.—ED.]

10 [The treatment of this affection must be chiefly of a local nature, although it may sometimes be necessary to resort to constitutional means, especially mercurial purgatives. When dependent upon a gouty or rheumatic state of the system, the different preparations of colchicum may be exhibited with a prospect of advantage, as also the hydriodate of potash in large doses. As a local remedy, blistering is by far the most prompt and effectual, and worth all the liniments and unguents that have ever been devised. The discharge from the vesicated surface may be maintained by savin or tartar emetic ointment; or, what is preferable, the fly may be reapplied as soon as the sore becomes dry. The operation of the blister should be aided with a bandage and a piece of oiled silk, or strips of adhesive plaster, to support the distended ligaments. Should these means fail, or the accumulation be so great as to impede the motions of the joint, and render it probable that absorption cannot take place, a small valvular incision may be made into the most dependent situation of the swelling, to draw off the fluid. Such a step, however, although justifiable under the circumstances here indicated, should not be taken without due reflection.—ED.]

11 [Rachitis is emphatically a disease of infancy, being most frequently witnessed from the eighteenth to the twentieth month; it is occasionally congenital, and sometimes, though rarely, it takes place after puberty. Of three hundred and forty-six cases examined by Mons. Guerin, of Paris,12 three occurred before birth, ninety-eight during the first year, one hundred and seventy-six during the second, thirty-five during the third year, nineteen during the fourth, ten during the fifth year, and five from the sixth to the twelfth. Of these cases one hundred and ninety-eight were observed in the female sex, the remainder, or less than one-half, in the male.—ED.]

12 Memoir on the General Characters of Rachitis, translated by Dr. T. W. Colescott, of Louisville, and published in the Western Journal of Medicine and Surgery, for January, 1841.

13 [The symptoms which characterize this affection are generally well defined. The face has a yellowish, sallow appearance; the eyes are large and brilliant; the nostrils unnaturally expanded; the lips, especially the upper, tumid and everted; the head big, and sunk between the shoulders; the chest narrow and contracted; the curvature of the clavicle increased; the articular extremities of the bones unusually prominent; the muscles thin and flabby; the motions constrained and difficult; the whole body has a short, stunted appearance, and the little patient exhibits all the marks of premature decay or old age. The respiration, short and laborious, is performed chiefly by the diaphragm; the abdomen is tense and tumid; and the skin, which is constantly moist, is often bathed during the night with acid perspiration. The appetite is weak, the digestion difficult, the thirst considerable, and there is nearly always diarrhœa, or diarrhœa alternating with constipation. The alvine evacuations are of a thin, watery character; the urine is copious, but not high coloured; the pulse is small and frequent; the action of the heart feeble, the sensibility remarkably keen, and the mind uncommonly active. The child feels averse to use his limbs, and the bones are so soft as to be bent with the greatest facility.

The alterations of the osseous tissue have been divided by Mons. Guerin, to whom we are indebted for the most able and elaborate account of this disease that has yet been furnished, into three stages. In the first, the bones seem to be saturated with a reddish, watery fluid; a considerable quantity of which is also interposed between their outer surface and the periosteum, on the one hand, and between the medullary membrane and their internal walls, on the other. At a more advanced period, this fluid is replaced by a sort of gelatiniform substance, that is particularly conspicuous in the situations here specified, becomes gradually organized and vascular, and ultimately adheres with great firmness to the parts with which it lies in contact. The periosteum is thickened and injected, the nutrient vessels are remarkably enlarged, and the medullary membrane is sensibly altered in its character; the changes which it has undergone being similar, though less in degree, to those of the fibrous envelope just mentioned. The lamellæ of the long bones, naturally so hard and compact, are a good deal softened, and the areolar structure greatly rarefied, many of the cells being more than double or even triple the natural size. Similar alterations are observed in the short and flat bones.

In the second stage, a peculiar spongoid substance is formed between the periosteum and the outer surface of the bones, varying from two to three lines, or upwards in thickness; and which, by the pressure which it exerts upon the lamellæ of the compact tissue, sometimes forces them inwards upon the medullary canal, thus greatly reducing it in size, or even entirely obliterating it. Simultaneously with these changes the bones are rendered so soft that they may be easily bent, cut, or even indented with the finger. In the third stage—that of resolution—the recently formed substance in the long bones, as well as in some of the flat and short, assumes a compact character, and becomes gradually identified with the pre-existing tissues, which at the same time regain their primitive solidity. Owing to the presence of this new matter, the bones are much larger than in the natural state, and their firmness—especially in the adult—resembles that of ivory. Hence the term eburnation is sometimes applied to this state of the skeleton.—ED.]

14 [Of sixty-three cases recorded by Mr. Hodgson, in his work on the Diseases of the Arteries, fifty-six were noticed in the male, and seven only in the female. The reason of the more frequent occurrence of aneurism in men than in women is found in the circumstance of the former being more exposed to all sorts of violence and disease than the latter.—ED.]

15 [This disease is much more frequent in old than in young persons. Of one hundred and eight cases, collected by Dr. Bizot, of Geneva, from the writings of Morgagni, Corvisart, Laennec, Scarpa, Boyer, Hodgson, Richard, and S. Cooper, only a single one occurred before the twentieth year. Fifteen were noticed from the age of twenty to twenty-nine; thirty-five, from thirty to thirty-nine; thirty-one, from forty to forty-nine; fourteen, from fifty to fifty-nine; eight, from sixty to sixty-nine; two, from seventy to seventy-nine; and two, from eighty to eighty-nine. Thus it would appear that more persons suffer from this malady from the age of thirty to fifty than during all the other periods of life put together. (Elem. of Path. Anat. vol. i., p. 288.)—ED.]

16 [The following table, extracted from the Cyclopædia of Practical Surgery, will place this subject in a clearer and more accurate point of view. It exhibits the relative frequency of spontaneous aneurism in the different arteries in 179 cases, excluding those of the aorta: it was drawn up originally by Mons. Lisfranc:—

In another table, constructed by Mr. Hodgson, and founded upon sixty-three cases, including, however, twenty-nine of the aorta and innominata, the results are as follows:—

Carotid 2 Subclavian and axillary 5 Inguinal 12 Femoral and popliteal 15.—ED.]

17 [This aneurismal diathesis occasionally exists in an astonishing degree. Thus, Pelletan relates an example in which there were upwards of sixty tumours of this kind; and a still more remarkable one is recorded by Mons. J. Cloquet. In this case the number of dilatations exceeded two hundred, the largest of which were not bigger than a common pea. (Elements of Path. Anat., vol. i., p. 283.) An instance similar to that in the text occurred at Cincinnati two years ago, in a man between thirty and forty years of age, in whom Professor Mussey secured the right femoral artery for popliteal aneurism. Three years previously the same operation was performed on the left limb for the same affection by Dr. Speer, of Pittsburgh.—ED.]

18 [This is commonly called Brasdor’s operation, after the surgeon who devised it. Mr. Wardrop, of London, is its greatest advocate. It has proved successful only in a few cases out of upwards of twenty in which it has been performed.—ED.]

19 [For some very interesting examples of this hemorrhagic tendency, the reader is referred to Mr. Wardrop’s excellent little work on Bloodletting, and to the first volume of my Elements of Pathological Anatomy. A few years ago a case came under my notice in which fatal hemorrhage was caused by lancing the gums over the two central incisors of the upper-jaw, in a male child between five and six months old. He was labouring at the time under an attack of cholera, so prevalent in our early summer months; and the day after the operation purpuric spots appeared in different parts of the body, the largest being situated on the abdomen and the scalp, just behind the ear. The bleeding was at length arrested by the twisted suture, made by transfixing the gum with three very small needles, the points of which were broken off close to the jaw, and the threads applied in the usual manner. Notwithstanding this, the child died exhausted on the fifth day, hemorrhage having, in the meanwhile, taken place from the stomach and bowels. It may be proper to add, that the infant had been delicate from his birth, and that there was no hereditary predisposition to the singular affection which carried him off.—ED.]

20 [In one instance I succeeded perfectly in effecting a cure with the seton. The tumour, about the size of a twenty-five cent piece, occupied the vertex, and possessed all the properties of the erectile tissue. The child was eighteen months old, and the swelling had made its appearance a few weeks after birth. Half a dozen coarse silk threads were passed, by means of a curved needle, under the base of the tumour, where it was allowed to remain for nearly a month. Considerable suppuration supervened, followed by the complete obliteration of the enlarged vessels. In the hands of Mr. Wardrop, of London, the caustic potash, applied to the surface of the tumour, as in making issues, appears to have been attended with great success. The practice of tying the principal arterial trunks connected with the swelling almost constantly fails, and is rarely resorted to except by ignorant and reckless surgeons.—ED.]

21 [The first accurate account of osseous aneurism was published in 1826, by Mons. Breschet, in the second volume of the “Répertoire Générale d’Anatomie et de Chirurgicale.” It has since been noticed by other surgeons, particularly by Professor Lallemand of Montpelier, and Mr. Bell of Edinburgh, and there is reason to believe that it is of more frequent occurrence than is generally imagined.

The disease is most commonly seated in the head of the tibia. It has been observed also in the scapula, as in the case mentioned in the text, the femur, wrist, and ankle. The male is more liable to it than the female, and it rarely makes its appearance until after the period of puberty. The cause of the disease has not been satisfactorily explained. In some cases it is produced by external violence, as a blow or fall; in others, especially when seated near a large joint, it is traceable to gouty and rheumatic affections.

The enlargement, even in its early stage, is tense and painful; being attended with distention of the superficial veins, swelling of the surrounding structures, and slight discoloration of the skin. In a short time a deep-seated pulsation, or throbbing, synchronous with that of the left ventricle, and similar to what is witnessed in some erectile tumours, may be perceived in the affected part. In the advanced stage of the malady the beating is accompanied by a sort of undulating movement, and is easily interrupted by compressing the main artery of the limb, between the tumour and the heart. The enlargement varies in size. In a case mentioned by Mr. Bell, it was more than nine inches in circumference, by upwards of six in length. In some instances, pressure applied to the tumour with the finger imparts a peculiar crackling sensation, not unlike that of dry parchment or an egg-shell. The soft parts around the disease are generally œdematous, the whole limb is apt to be swollen, and the motions of the contiguous joints are constrained and painful. Towards the last the general health always seriously suffers.

On inspection, the outer table of the bone is found to be considerably attenuated, in many parts destroyed, and in some so flexible and elastic as to be bent with the same facility as cartilage. Frequently the bone is extremely brittle, and may be crushed like an egg-shell. The areolar texture is partially absorbed, and the medullary canal filled with coagula, which are often arranged in concentric layers, as in old aneurismal sacs in other situations. The investing membrane in the immediate vicinity of the disease is thickened, as well as preternaturally dense and firm, and the vessels ramifying through the tumour are greatly enlarged.

The only effectual remedy for this disease, provided its location be favourable, is amputation. In the early stage relief may possibly be afforded by securing the main artery of the limb. Lallemand relates a case in which ligature of the femoral artery completely arrested an aneurismal affection of the head of the tibia; but this must be regarded as an exception to the general rule.—ED.]

22 [In this country we have a number of insects, the sting of which is sometimes attended with considerable pain and swelling, or even high inflammatory excitement. Of these, the most common are the bee, wasp, hornet, yellow-jacket, and humble-bee, which all secrete a subtle poison contained in a reservoir in the abdomen, from which it is projected by the barbed dart when in the act of stinging. Severe and even dangerous wounds are occasionally thus inflicted; indeed, in a few instances death has been known to follow, especially in persons of a nervous, irritable temperament. Another insect, from the bite of which a good deal of irritation often results, is the musketoe, which abounds everywhere, during the hot summer and autumnal months, along the water-courses of the western and southern states. The little punctures made by this animal I have known in several instances to degenerate into unhealthy sores, furnishing a thin, sanious discharge, attended with more or less itching, and exceedingly difficult to heal. The late Professor Dorsey mentions a case—that of a lady who previously enjoyed good health—in which the bite of the musketoe terminated in gangrene and death.

Of the great number of serpents inhabiting this country, only two—the rattlesnake and copperhead—are known to be venomous. Both are very active in warm weather, are furnished with long teeth, and secrete an acrid, virulent poison, of a yellow-greenish colour, which is lodged in a bag or reservoir at the roots of two of the teeth of the upper-jaw. When this poison is fairly infused into a wound of the skin and cellular tissue, it often proves fatal in a few minutes; in other cases, the patient either recovers, or death does not occur until a later period.—ED.]

23 [The wounds made by the stings and bites of insects are best treated by stimulating lotions, such as salt-water, vinegar, alcohol, hartshorn, and camphorated spirits. These remedies generally afford prompt relief, and they possess the additional advantage of being always near at hand. Bleeding, purging, and opiates, may become necessary, when, besides much pain and swelling, there is a great degree of constitutional disturbance. When bees and wasps find their way, as they sometimes do, into the œsophagus, causing violent suffering and nervous agitation, almost instantaneous relief may be afforded by making the individual drink large draughts of vinegar or salt and water.

When a person has been bitten in one of his limbs by a venomous serpent, a ligature should be immediately applied, as tightly as possible, at a short distance above the wound, which is then to be carefully excised together with a portion of the surrounding structures. A cupping-glass is next applied, and after this has remained on for several hours, the sore is to be dressed with an emollient poultice or some simple unguent, or fomented with cloths wrung out of warm water and laudanum. The only internal remedy upon which the slightest reliance is to be placed, is arsenic, in the form of Fowler’s solution. It should be administered, as was first suggested by Mr. Ireland, an English surgeon, in doses of two drachms every thirty minutes until an ounce or upwards is taken, or until free vomiting and purging ensue.—ED.]

24 [The above symptoms, together with deep-seated tubercles of the skin and mucous membrane, constitute what Mons. Ricord has lately described under the name of tertiary syphilis. They seldom make their appearance under fifteen or eighteen months after the formation of primary sores, and some cases occur even after the lapse of many years. From two to three years may perhaps be considered as the average period for the development of the tertiary form of the disease. This, however, is still an unsettled point.—ED.]

25 [It is somewhat surprising that the author has made no mention, in connexion with this subject, of the iodide of potassium, so justly lauded by Mons. Ricord and some other French surgeons. For the last two years or more I have been constantly in the habit of employing this article in tertiary syphilis, in mercurial disease of the bones, and in chronic rheumatism, in which, I am convinced, it is as much of a specific as quinine is in intermittent fever and miasmatic neuralgia. The medicine, to produce its full effects, should be administered in much larger quantities than are recommended in our treatises on the Materia Medica. In my own practice, I usually commence with ten grains, repeated three or four times a day, and gradually increased until it amounts to a scruple, or even half a drachm. Exhibited in doses of this size, it is truly surprising how rapidly, in most instances, it affords relief. Patients who have laboured under nodes and nocturnal pains for months, whose health has become greatly impaired, and who have not slept soundly perhaps for weeks together, have often perfectly recovered under this treatment in less than a fortnight. A very decided improvement generally takes place within the first forty-eight hours, the local uneasiness diminishing, and the sleep being rendered more refreshing. The medicine should not be laid aside as soon as the patient experiences relief, but be continued for several weeks after the symptoms of the malady have subsided. By neglecting this precaution a relapse will occasionally occur. The best vehicle for it is distilled water with a small quantity of simple syrup. Mons. Ricord administers it dissolved in hop-tea, made with an ounce of hops to a pint of boiling water; this is allowed to stand for four hours, when thirty-six grains of the salt are added, and the whole drunk during the course of the day. When given in the large doses above mentioned, it is said to be sometimes productive of diarrhœa or gastric irritation; but no such effects have followed its employment in my own hands, and I presume therefore that they are exceedingly rare. Should they take place, the quantity must be lessened, or the medicine entirely suspended for a few days.

In obstinate cases of tertiary syphilis it may be necessary to exhibit along with this medicine the compound decoction of sarsaparilla, or some of the preparations of mercury, such as the proto-ioduret, deuto-chloride, or cyanuret. The first may be given in doses of from one-half a grain to a grain, the second, from one-eighth to a fourth of a grain, and the last, from one-sixteenth of a grain to a grain, twice or three times a day. How the iodide of potassium acts in producing its beneficial effects in the diseases in which it is now so extensively used by our French brethren, as well as by some of the practitioners of our own country, has not yet been explained. That it is a powerful alterant must be admitted, and that it greatly improves the condition of the digestive organs is equally certain.—ED.]

26 [As there are no facts in surgery so valuable as those of a statistical kind, I shall offer no apology for transferring to these pages an abstract of a very able article on hernia cerebri, published by Dr. Gurdon Buck in the fourth number of the New-York Journal of Medicine and Surgery. The paper in question is founded on an analysis of thirty-three cases, all collected, save one which occurred in his own practice, from the writings and reports of different American and European surgeons.

Of these cases only two occurred in the female. The age of the youngest was two years and a half; of the oldest, forty; seventeen were twelve years or under; nine from thirteen to twenty years; and seven, twenty-one or upwards. The seat of the wound giving rise to the disease, occupied, in fourteen cases, some part of the frontal region; in seventeen the parietal; and in two the occipital. In fourteen cases the brain was lacerated, and a portion of its substance discharged; in five it was wounded without loss; in one its surface was simply denuded; in ten there was no exposure; and in three its condition is not noticed. The dura mater was torn in twenty-one cases, and in another perforated; the cranium in all, except one, was broken into several fragments; and in twenty-four the scalp was more or less lacerated; in another it was pierced; in three there was no solution of continuity; and in five no mention is made of its condition.

The period of the appearance of the morbid growth from the occurrence of the injury varied in different individuals. In eleven cases it manifested itself prior to the sixth day; in fifteen between the seventh and twelfth; and in five between the twelfth and twenty-fifth. In one instance it did not begin until the eighth week: in another the time is not specified. The earliest period of its appearance was the third day, and that in two cases only; in more than three-fourths it commenced on or before the twelfth day. The average period was the ninth day from the accident.

In regard to the volume of the tumour, it varied from half an inch in diameter to a mass measuring six, by three and a half inches upon the surface, and two and a half in thickness. In twenty-two cases in which the dimensions are stated, the tumour in five was of the size of a hen’s egg; in eight it exceeded that magnitude; and in nine it fell short of it. The morbid growth was dissected only in eleven of the cases; in nine of these it consisted of cerebral substance, in which the cortical and medullary tissues were distinctly recognised, and in the other two it was composed of coagulated blood of a fibrous texture. In seven cases the tumour assumed a sloughing character; in five it yielded a fetid, sanious discharge; in one it bled freely on the slightest touch; in three it was enveloped by the pia mater; and in three others the surface was coated with a layer of clotted blood. In the centre of the largest tumour a cavity existed, filled with an ounce of limpid serum, and lined by a transparent, glistening membrane.

The general symptoms, indicative of disturbance of the vascular system, and of the cerebral functions, may be next considered. In twenty-three cases there was more or less excitement of the heart and arteries; in four none was apparent; and in the other six the symptoms are not stated. “In fourteen cases some one or more of the following symptoms of disturbance of the brain and nervous system were present: coma, delirium, pain in the head, general irritability, and insensibility. In six paralysis of the side of the body opposite to the injury was superadded to the preceding symptoms; and in two convulsions. Three cases were remarkable as presenting some striking exceptions to the general characteristics, and are, therefore, deserving of more particular notice; one of them, from the circumstance that there was no apparent shock to the nervous system, not even as the immediate effect of the injury, though its severity was so great that several fragments of bone and pieces of coal penetrated the brain, causing a discharge of three or four teaspoonsful of its substance. In another the patient remained in a state of complete insensibility and general paralysis for twenty-three days; the hernia appearing on the seventh day, and no inflammatory symptoms supervening. The third case exhibited a character of most frightful violence. Besides paralysis of one side, there were spasmodic actions of the muscles of the face and of all the limbs; nausea, retching, quivering of the eyelids, fixed eyeballs, strabismus, grinding of the teeth, alternate contraction and dilatation of the pupils, intolerance of light and sound, and other signs of the most alarming nervous commotion, often threatening to terminate life.”

Of the thirty-three cases in question, seventeen recovered, at a period varying from three weeks to four months; and sixteen terminated fatally, on an average, about the twenty-fourth day. More young persons recovered than old. Of the sixteen fatal cases, eleven were examined, and exhibited the following lesions: in eight the portion of the brain subjacent to the hernia was softened, pulpy, more or less disorganised, and sometimes intermixed with clots, while in the account of the other three no notice is taken of its condition. In eight other cases there were signs of acute inflammation of the arachnoïd membrane as indicated by thickening, opacity, adhesions to the dura mater, and deposits of lymph or pus. The portion of the dura mater around the opening through which the fungous mass protruded was thickened, black, and sloughy, in three of the eleven cases in question. In four the ventricles were filled with bloody serum; in one there was a large abscess in the brain full of pus, and lined with a false membrane. In one case a clot of blood was found between the dura mater and the cranium; in four the fracture extended through the base of the skull; and in one of these the edges of the osseous aperture, through which the hernia protruded, were rounded off by absorption.

In respect to the general treatment, it was uniformly antiphlogistic, consisting of the abstraction of blood by venesection and leeching, and the use of purgatives, proportioned to the urgency of the inflammatory symptoms. The local means employed were, excision of the hernial tumour, the application of the ligature, pressure, and caustics, either singly or together. In one of the cases that resulted favourably a spontaneous cure took place after copious hemorrhage from the morbid mass, excited by an accidental attack of vomiting. In another, after the ineffectual use of the nitrate of silver and other escharotics, the ligature was applied and gradually tightened from day to day; in five pressure alone was sufficient; in two the pressure was conjoined with lime-water; and in one with the nitrate of silver. In seven other favourable cases excision was resorted to, either once, or repeatedly, accompanied with pressure; in some dilute nitric acid—twenty drops to the ounce of water—lime-water, or nitrate of silver, were employed in addition. In the sixteen cases that terminated fatally the local treatment was, pressure alone in two; in five excision with pressure; in two the ligature; in one both ligature and excision; and in another escharotics. In five no mention was made of the local means.—ED.]

27 [Dr. Maunoir, of Geneva,28 relates a curious instance, strongly corroborative of the occasional hereditary tendency of this affection. While investigating this subject, he became acquainted with the history of a woman whose grandfather, uncle, two aunts, and two cousins, all on the paternal side, had had cataract, and who had all been operated upon. She herself, at the age of twenty, was attacked with it. Finally, out of four children which she had, one was born with cataract; and, what is remarkable, neither her father, mother, nor sisters, had ever had any affection of the kind. The same writer states that Roux once operated for this disease upon three brothers, whose father and grandfather had suffered similarly. A brother, much younger than themselves, had the affection in its incipient stage. Instances more frequently occur in which several members of a family are affected with cataract, without any traceable hereditary predisposition on the part of either parent. Professor Drake met with a case not long ago, where five out of nine children were blind from this cause; and last autumn I operated on two boys and a girl from Mississippi, who had lost their sight in a similar manner.—ED.]

28 Essay on Cataract, translated by Dr. Bowditch, of Boston.

29 [The two subjoined tables, the one constructed by Mons. Maunoir, and the other by Professor Fabini, demonstrate the immense influence which age exerts upon the production of cataract:—

It has been said that men are more liable to cataract than women; the difference, however, if any, is probably very slight. Thus, in the first table, 61 were males and 60 females; in the second, 268 were males and 232 females.—ED.]