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THE
AMERICAN JOURNAL
OP THE
MEDICAL SCIENCES.
No. IX.— Nov. 1829.
1
COLLABORATORS.
Jacob Bigelow, M. D. Professor of Materia Medica in Harvard Univer- sity, Boston.
Walter Channing, M. D. Professor of Midwifery and Legal Medicine in Harvard University, Boston.
N. Chapman-, M. D. Professor of the Institutes and Practice of Physic and Clinical Practice in the University of Pennsylvania.
John Redman Coye, M. D. Professor of Materia Medica and Pharmacy in the University of Pennsylvania.
William C. Daniell, M. D. of Savan- nah, Georgia.
E. De Butts, M. D. Professor of Che- mistry in the University of Mary- land.
William P. Dewees, M. D. Adjunct Professor of Midwifery in the Univer- sity of Pennsylvania.
S. Henry Dickson, M. D. Professor of the Institutes and Practice of Medicine in the Medical College of South Caro- lina.
Benjamin W. Dudley, M. D. Profes- sor of Anatomy and Surgery in Tran- sylvania University.
Gouverneur Emerson, M. D. of Phila- delphia.
Thomas Fearn, M. D. of Alabama.
John W. Francis, M. D. Professor of Obstetrics and Forensic Medicine in Rutgers Medical College, New York.
E. Gedbings, M. D. Lecturer on Patho- logical Anatomy and the Practice of Physic and Surga-y, Charleston, S.C.
William Gibson, M. D. Professor of Surgery in the University of Pennsy l- vania.
John D. Godman, M. D. late Prof essor of Anatomy and Physiology in Rutgers Medical College, New Yoi-k.
It. E. Griffith, M.D. of Philadelphia.
E. Hale, M. D. of Boston.
Robert Hare, M. D. Professor of Che- mistry in the University of Pennsyl- vania.
Isaac Hays, M. D. one of the Surgeons of the Pennsylvania Infirmary for diseases of the Eye and Ear.
George Hayward, M. D. of Boston.
Thomas Henderson, M. D. Professor of the Theory and Practice of Medi- cine in the Columbian College, Dis- trict of Columbia.
William E. Horner, M. D. Adjunct Professor of Anatomy in the Univer- sity of Pennsylvania.
David Hosack, M. D. Professor of tliz Institutes and Practice of Medicine in Rutgers Medical College, New York.
Ansel W. Iyes, M. D. of New York.
Samuel Jackson, M. D. Assistant to the Professor of the Institutes and Practice of Medicine and Clinical Practice in the University of Pennsylvania.
Samuel Jackson, M. D. of Northum- berland, Pennsylvania.
W. J. Macneyen, M. D. Professor of Therapeutics and Materia Medica in Rutgers Medical College, New York.
C B. Matthews, M. D. of Philadelphia.
Valentine Mott, M. D. Professor of Surgery in Rutgers Medical College, Neiv York.
James Moultrie, Jr. M. D. of Charles- ton, S. C.
Reuben D. Mussey, M. D. Professor of Anatomy and Surgery in Dart- mouth College.
James M. Pendleton, M. D. Lecturer cn Midwifery and Diseases of Women and Children, New York.
Philip Syng Physick, M. D. Profes- sor of Anatomy in the University of Pennsylvania.
Nathaniel Potter, M. D. Professor of the Theory and Practice of Medicine in the University of Maryland
Thomas Sewall, M. D. Professor of Anatomy and Physiology in the Co- lumbian College, District of Columbia,
John Ware, M. D. of Boston.
John C. Warren, M. D. Professor of Anatomy and Surgery in Harvard University, Boston.
J. Websteb, M. D. lecturer on Ana- tomy and Surgery, Philadelphia.
N. W. Worthington, M. D. Professor of Materia Medica in the Columbian College, District of Columbia.
Thomas H. Wright, M. D. Physician to tlte Baltimore Aims-House Infirmary.
THE
AMERICAN JOURNAL
OF THE
MEDICAL SCIENCES,
VOL. V.
PHILADELPHIA:
CAREY, LEA AND CAREY—CHESNUT STREET.
1829.
\
TO READERS AND CORRESPONDENTS.
Drs. Hoptox's and Garden's Communications have been received.
The plan communicated to us by a Correspondent at Maracaybo, for dissolv- ing Urinary Calculi within the Bladder, by means of a new instrument, is that which originally suggested itself to M. Civiale, and which he was compelled to abandon as impracticable. M. Civiale's first design was to destroy the stone by chemical agents, for which purpose he proposed to introduce a purse into the bladder by means of a tube, through which, on securing the stone in the purse, he was to pour in the proper solvent? and it was not until he found this was not practical, that the idea of grinding down the stone occurred to him.
Our notices of articles contained in the American Journals, have been ex- cluded by the press of original communications.
We have received the following works —
Rapport lu a FAcademie Royale de Medecine dans les Seances des 15 Mai et 19 Juin, 1827, au nom de la Commission Chargee d'Examiner les Documents de M. Chebvix concernant la fievre jaune. Publie textuellement d'apres l'edi- tion de FAcademie, et accompagne de Remarques. Par le Docteur Chebvik. Paris, 1828. (From Dr. Chervin.)
Examen des Principes de FAdministration en Matiere Sanitaire, ou Reponse au Discours Prononce a la Chambre des Deputes, le 31 Mai, 1826, par M. Db Boisbebtrajtd, Directeur de FAdministration Generale des etablissements d'Utilite Publique. Par N. Chebvis, Docteur en Medecine, &c. &c. &c. Pa- ris, 1827. (From the author.)
Reponse au Discours de M. le Docteur Aue-ouabd, contre le Rapport fait a FAcademie Royale de Medecine de Paris, le 15 Mai, 1827, sur mes Documents concernant la Fievre Jaune. Par N. Chebvix, D. M. P., &c. Paris, 1827. (From the author.)
De la Nullite des Pretendus faits de Contagion observes a Barcelone en 1821, ou Deuzieme Reponse a M. Attdotjabd, D. M. M. Par N. Chebvik, D. M. P., &c. Paris, 1827. (From the author.)
Reponse aux Allegations de M. le Dr. Gebabdix, contre le Rapport de la Commission de FAcademie Royale de Medecine, chargee de FExamen de mes Documers sur la Fievre Jaune. Par N. Chebvin, D. M. P., &c. Paris, 1828. (From the author.)
Traite General d'Anatomie, Comparee. Par J. F. Meckel. Traduit de FAi- lemajtd et Augmente de Notes. Par M. M. Riesteb et Alph. Sanson, Docteur en Chirurgie de la Faculte de Paris. Tome troisieme — BE. Partie. Paris, 1829.
A Dissertation on Intemperance, to which was awarded the premium offered by the Massachusetts Medical Society. By William Sweetsek, M. D. Pro- No. IX.— Nov. 1829. 2
6
TO READERS AND CORRESPONDENTS.
fessor of the Theory and Practice of Physic in the University of Vermont. (From the author.)
Instructions and Observations concerning" the Use of the Chlorides of Soda and Lime. By A. G. Labarbaq.ue. Translated by Jacob Pobteb. New Haven, 1829. (From the translator.)
Traite de Petite Chirurgie. Par M. Bourgebt, M. D. Paris, 1829. Rouen freres. (From the publishers.)
Traite d'Hygiene Appliquee a 1'Education de la Jeunesse. Par le Dr. Simoit, de Metz. Rouen freres. (From the publishers.)
Precis Physiol ogi que sur les Courbures de la Colonne Yert£brale, ou Expose des Moyens de Prevenir et de Corriger les Difformites de la Taille, Particu- lierement chez les Jeunes filles, sans le secours des lits Mechanique a Exten- sion. Par C. Lachaise, D. M. P. &.c. &c. Avec six planches. Paris, 1827- Rouen freres. (From the publishers.)
Traite des Maladies du Foie. Par Auguste Bojtxet, D. M. P. Paris, 1828. Rouen freres. (From the publishers.)
Journal der Chirurgie und Augen-Heilkunde, herausgegeben von C. F. V. Gbaefe und Ph. V. Walther. Zovvolfter Band. Yiertes Heft. (In exchange. )
Bibliothek des Practischen Heilkunde. Herausgegeben von C W. Hufe- ea^d und E. Osann. September, October, November, December, 1828 — Janu- ary, February, March, April, May, 1829. (In exchange.)
Journal der Practischen Heilkunde. Herausgegeben von C. W. Hufela:xd und E. OsAjrjf. September, October, November, December, 1828 — January, February, March, April, May, 1829. (In exchange.)
Litterarische Annalen der Gesammten Heilkunde. Herausgegeben von Dr. J. F. C. Heckeb, Professor der Heilkunde au der Universitat Berlin, &c. June, July, August, 1829. (In exchange.)
Journal des Progres des Sciences et Institutions Medicales en Europe en Amerique, &c. Vols. XIV., XV., and XVI. (In exchange.)
Annales de la Medecine Physiologique. April, May, June, 1829. (In ex- change.)
Revue Medicale. June, July, August, 1829. (In exchange.)
Bulletin des Sciences Medicales. November, December, 1828 — January, February, March, April, May, 1829. (In exchange.)
Journal Universel. May, June; July, 1829. (In exchange.)
Journal General de Medecine. May, June, July, August, 1829. (In ex- change.)
Nouvelle Bibliotheque Medicale. March, April, May, July, 1829. (In ex- change.)
Archives Generales de Medecine. May, June, July, August, 1829. (In ex- change.)
Journal de Chimie Medicale de Pharmacie et de Toxicologic Redige". Par
TO READERS AND CORRESPONDENTS.
1
Ies Membres de la Societe de Chimie Me"dicale. January, February, March, April, May, June, August, September, 1829. (In exchange.)
La Clinique des Hopitaux et de la Ville. From January 1st to July 16th, in- clusive. (In exchange.)
La Clinique, Annales de Medicine Universelle, par une Societe de Medecins Frangais et Etrangers. Nos. I. to X. inclusive.
The Edinburgh Medical and Surgical Journal. July, 1829. (In exchange.)
The Medico-Chirurgical Review, for July. (In exchange.)
The London Medical and Surgical Journal, for July and August, 1829. (In exchange.)
The London Medical and Physical Journal, for July, 1829. (In exchange.)
The London Medical Gazette, for June, July, and August, 1829. (In ex- change.)
The Boston Medical and Surgical Journal, Vol. II., Nos. 22 to 36 inclusive. (In exchange.)
The Transylvania Journal of Medicine, and the Associate Sciences, for Au- gust, 1829. (In exchange.)
The North American Medical and Surgical Journal, for October, 1829. (In exchange.)
The New York Medical and Physical Journal, for July, 1829. (In exchange.)
The Maryland Medical Recorder, conducted by H. G. Jameson, M. D. Pro- fessor of Surgery in Washington Medical College, Baltimore. Vol. I., No. I., 1829. (In exchange.)
For the gratification of our contributors we continue the references to the works, in which they will find notices of their communications; these references are, of course, restricted to the Journals received during the preceding three months.
Professor Phtsick will find his Case of Obstinate Cough occasioned by Elon- gation of the Uvula, noticed in the Annales de la Medecine Physiologique, for April, 1829.
Professor Mott's Operation for Excision of an Osteo-Sarcomatous Clavicle is noticed in the Journal des Progres, Vol. XVI.; and his Case of Calcareous Degeneration of the Scrotum in the Bulletin des Sciences Medicales, for May, 1829.
Professor Dewees's paper on Ergot is noticed in the Annales de la Medecine Physiologique, for April, 1829; and his Case of Puerperal Fever is copied into the London Medical and Surgical Journal, for July, 1829.
Professor Bigelow's Method of Affording Respiration to Children in Re- versed Presentations, is noticed in the North American Medical and Surgical Journal, for October, 1829.
Professor Horneii's Observations on some points of Pathology, are notice in the Annales de la Medecine Physiologique, for April, 1829.
s
TO READERS AND CORRESPONDENTS.
Professor Coxe's paper on Wounds of the Heart is noticed in the Boston Me- dical and Surgical Journal, for September, 1829.
Professor Godsta^'s Communication on the Use of Tobacco in Croup, is co- pied in the Journal des Progres, Vol. XIV.
Professor Hestderso^s Case of Cough from Elongated Uvula, is quoted in the London Medical Gazette, for June, 1829.
Professor Sewall's paper on the Use of Turpentine in Hernia, is noticed in the Boston Medical and Surgical Journal, for August, 1829.
Professor Hake's Analysis of Swaim's Panacea is noticed in the Boston Me- dical and Surgical Journal, for August, 1829; and the North American Medical and Surgical Journal, for October, 1829; and his Mode of Detecting Minute Quantities of Laudanum, in the Bulletin des Sciences Medicales, for January 1829.
Professor Jacksoit's Case of Mercurial Irritation, is copied into the London Medical and Physical Journal, for July, 1829; his Case of Tetanus is given in the Archives Generates, for June, 1829; and the Journal des Progres, Vol. XV. His first Clinical Report is noticed in the Annales de la Medecine Physiolo- gique, for -April, and inserted entire in the No. for May, 1829. His Case of Malignant Intermittent is copied in the Medico-Chirurgical Review, for July last; and his Case of Amnesia is copied into the Medico-Chirurgical Review, for July; the London Medical Gazette, for June: the Archives Generates, for June.- the Journal des Progres, Vol. XV.; La Lancette Francaise; and the Journal Universel, for July, 1829.
Dr. Daxiell's Method of Treating Fracture of the Thigh Bone is noticed in the Boston Medical and Surgical Journal, for August, 1829.
Dr. Hettstis's Case of Hernia Cerebri is noticed in the Archives G£ne>ales, for June; the Journal des Progres, Vol. XL; and the London Medical and Phy- sical Journal, for July, 1829.
Dr. Wright's Case of Arthrosia Atonica is analyzed in the Medico-Chirur- gical Review, for July, 1829; and his paper on the Use of Pressure in Ununited Fractures, is noticed in the Journal des Progres, Vol. XV. ; and the Revue Me- dicale, for August, 1829.
Dr. Jackson's paper on the Use of Ergot in Placental Cases, is noticed in the London Medical Gazette, for June, 1829; and his Remarks on Entropion are noticed in the North American Medical and Surgical Journal, for October, 1829.
Dr. Mitchell's paper on Dysentery is noticed in the Annales de la Medecine Physiologique, for April, 1829.
Dr. Callaghan's Account of an Epidemic Small-pox is noticed in the Boston Medical and Surgical Journal, for September, 1829.
Dr. Griffith's Case of Salivation produced by Tartar Emetic, is copied in the Bulletin des Sciences Medicales, for March, 1829.
Dr. Drake's Experiments on Respiration of Cool Air in Pulmonary Diseases, are noticed in La Clinique, for June 23, 1829.
TO READERS AND CORRESPONDENTS.
9
Dr. Dakin's Account of a Cutaneous Disease is noticed in the Western Jour- nal of the Medical and Physical Sciences, for July, 1829; and the Boston Medi- cal and Surgical Journal, for May, 1829.
Dr. Howe's Case of Tracheotomy is copied in the London Medical and Phy- sical Journal, for July, 1829.
Dr. Pierce's Case of Perforation of the Stomach, is noticed in the Boston Medical and Surgical Journal, for August, 1829.
Dr. Peknock's Experiments on the Effects of Cupping Glasses in Poisoned Wounds, are noticed in the Annales de la Medecine Physiologique, for April; and the Bulletin des Sciences Medicales, for January, 1829.
Dr. Robbigue's Experiments on Ligatures in Poisoned Wounds, are noticed in the Annales de la Medecine Physiologique, for April, 1829; and the Journal des Progres, Vol. XIV.
Dr. Heiskeel's Case of Extra-Uterine Foetation, is copied into the Nouvelle Bibliotheque Medicale, for May; La Clinique, for May 16th; and the Bulletin des Sciences Medicales, for January, 1829.
Dr. Levebt's Experiments on Metallic Ligatures, are noticed in the London Medical and Surgical Journal, for August; the Western Journal of the Medical and Physical Sciences, for July; the Archives Generates, for August; and La Clinique, for August 26, 1829.
Authors of new medical books, desirous of having them reviewed or noticed in this Journal at the earliest opportunity, are invited to transmit to the Editors a copy as soon after publication as convenient, when they will receive prompt attention. Under ordinary circumstances, very considerable delay is caused by the circuitous routes through which they are received.
Papers intended for publication, should be sent, free of expense, as early after the appearance of the Journal as possible, in order to be in time for the ensu- ing number. Such communications should be addressed to "Cabey, Lea & Cabet, Philadelphia, for the Editors of the American Journal of the Medical Sciences." All letters on the business of the Journal to be addressed exclu- sively to the publishers.
QCj* Our Subscribers who receive their Journals by Mail, will observe that the postage is one-third less than formerly, in consequence of the enlarged size of the paper upon which the Journal is at present printed.
a*
CONTENTS,
ORIGINAL COMMUNICATIONS.
ESSAYS.
Abt. Page,
I. Case of Amputation of the Lower Jaw affected with Osteo-Sarcoma. By
J. Randolph, M. D. [With a plate.] - 17
II. Fcetal Bones coloured with Madder. By R. D. Mussey, M. D. Profes- sor of Anatomy and Surgery in Dartmouth College, Hanover, N. H. [With a plate.] 20
III. Parodynia Perversa, complicated with Hydrops Ovarii. By Jesse W, Mighels, M. D. of Minot, Cumberland County, Maine ... 22
IV. Account of a Contagious Purulent Ophthalmia that prevailed at Fortress Monroe, in Virginia, in the years 1826-27. By Dr. Robert Archer, United States' Army ----------- 29
V. Remarks on Otitis. By George F. Lehman, M. D. Lazaretto Physi- cian of the Port of Philadelphia - 34
VI. On Gangrenous Erosion of the Cheek. By Samuel Webber, M. D. of Charlestown, New Hampshire - 41
VII. Remarks on the Climate and Vegetation of the Fortieth Degree of North Latitude. By Richard Sexton, M. D. of Baltimore, Maryland 45
VIII. Case of Disease of the Bones successfully treated by the Internal Exhibition of Arsenic. By John Henderson, M. D. President of the Hun- tingdon County Medical Society. (Published by request of the So- ciety) - - - - - - ... - 58
IX. On the Rhus glabrum as a Remedy for Ptyalism. By William M. Fahnestock, M. D. - 61
X. On Phlegmasia Dolens. By W. P. Dewees, M. D. Adjunct Professor
of Midwifery in the University of Pennsylvania .... 66
XI. Some account of a Case of Paruria Inops, (Good,) or Paralysis of the Kidneys. By George Hay ward, M. D. of Boston .... 89
XII. Remarks on the use of Spirit of Turpentine in Incarcerated Hernia. By C. B. Hamilton, M. D. Late Surgeon of the Marine Hospital at Wash- ington City 94
XIII. Remarks on the Excision of Cartilago-bony Substances from the Knee Joint, with a Case. By Samuel C. Bradbury, M. D. of Bangor, Penobscot county, Maine ........ 96
XIV. Case of Gun-shot Wound, with Remarks. By J. W. Heustis, M. D.
&c. of Cahawba, Alabama 99
XV. Case of Immobility of the Jaw, successfully treated. By Valentine Mott, M. D. Professor of Surgery in Rutgers Medical College. New York 102
12
CONTENTS.
MEDICAL EDUCATION AND INSTITUTIONS. .
XVI. Account of the Hopital des Veneriens at Paris. By Elisha Bartlett, M. D. of Lowell, Massachusetts - - - - - - 105
REVIEWS.
XVH. The Influence of Climate in the Prevention and Cure of Chronic Diseases, more particularly of the Chest and Digestive Organs: Compris- ing an Account of the principal places resorted to by Invalids in Eng- land and the South of Europe; a Comparative estimate of their Re- spective merits in Particular Diseases; and General Directions for In- valids while Travelling and Residing Abroad. With an Appendix, con- taining a Series of Tables on Climate. By James Clark, M. D. Mem- ber of the Royal College of Physicians of London; Corresponding Mem- ber of the Royal Medical Society of Marseilles, of the Medico-Chirurgi- cal Society of Naples, of the Medical and Physical Society of Florence, of the Academy of Sciences of Sienna, &c. &c. - 111
XVIII. De la Percussion Mediate et des Signes Obtenus a l'Aide de ce Nouveau Moyen d'Exploration, dans les Maladies des Organes Thoraci- ques et Abdominaux. Par P. A. Piorry, D. M. P. &c. Paris, 1828. 8vo.
pp. 336. Pis. lithogr. 2. - 130
BIBLIOGRAPHICAL NOTICES.
XIX. D. Francisci Caroli Naegele, Professoris Heidelbergensis, Epistola ad Theodorum Fredericum Baltz, M. et C. D. qua Historia et Descriptio Aneurysmatis quod in Aorta Abdominali observavit, continetur, addita tabula aenea. Heidelb. 4to. pp. 18. Pi. 1. 145
XX. A Treatise on Pathological Anatomy. By William E. Horner, M. D. Adjunct Professor of Anatomy in the University of Pennsylvania, Sur- geon at the Infirmary of the Philadelphia Alms-house, Member of the American Philosophical Society, &c. Philadelphia, 1829, 8vo. pp. 456.
Pis. III. of which II. are exquisitely coloured 148
XXI. A Treatise on the Cutaneous diseases Incident to Childhood; com- prehending their Origin, Nature, Treatment, and Prevention. By Wal- ter C. Dendy, Surgeon to the Royal Infirmary for Children, &c. 8vo.
pp. 289. London, 1827 149
XXII. Traite de Petite Chirurgie. Par M. Bougery, M. D. Octavo, pp. 520. Paris, Rouen freres, 1829 161
XXIII. Hints for Examination of Medical Witnesses. By John Gordon Smith, M. D. &c. Professor of Medical Jurisprudence in the University
of London. London, 1829, pp. 138, 12mo. 162
XXIV. A Manual of Materia Medica and Pharmacy, comprising a Concise Description of the Articles Used in Medicine; their Physical and Chemi- cal Properties; the Botanical Characters of the Medicinal Plants, and the Formulae for the Principal Officinal Preparations of the American, Pa- risian, London, Dublin, Edinburgh, &c. Pharmacopoeia; with Observa- tions on the Proper Mode of Combining and Administering Remedies. By H. M. Edwards, M. D. and P. Vavasseur, M. D. Translated from
CONTENTS.
1 3
the French, with numerous Additions and Corrections, and adapted to the Practice of Medicine and the Art of Pharmacy in the United States. By Joseph Togno, M. D. Member of the Philadelphia Medical Society, and E. Durand, Member of the Philadelphia College of Pharmacy. Phi- ladelphia, 8vo. pp. 523 166
XXV. De Hydrorrhea Uteri Gravidarum; commentatio inauguralis. Auc- tore Joannes Baptista Geil. Heidelburg. 8vo. pp. 54 - 168
XXVI. Traite d'Hygiene Appliquee a l'Education de la Jeunesse. Par le
Dr. Simon, (de Metz.) Paris. Bouen freres, 1829. pp. 444, octavo 170
XXVII. Precis Physiologique surles Courbures de la Colonne Verte'brale, ou Expose des Moyens de Prevenir et de Corriger les Difformites de la Taille, Particulierement chez les Jeunes filles, sans le secours des lits Mechanique a Extension. Par C. Lachaise, M. D. P. 8cc. &c. Avec six planches. Paris. Villeret & Co. 1827, pp. 200 - - - - 171
XXVIII. Eliae Bujalsky Tabulae Anatomico-Chirurgicae Operationes Li- gandarum Arteriarum Majorum Exponentes. St. Petersburgh, Elephant folio, pp. 32. Plates 14 - 173
XXIX. Traite des Maladies du Foie. Par Auguste Bonnet, M. D. de la Faculte de Paris, Associe Resident de la Societe Royale de Medecine de Bordeaux, &c. &c. Paris. Villeret & Co. 1828. pp. SOI. 8vo. - 174
XXX. Methodes de Traitement proposees pour guerir la Fistule Urinaire Vesico-Vaginale. Par M. le Professeur Naegele, de Heidelberg. Paris, 4to. pp. 8. Pis. liths. II. --------- 176
XXXI. Medico-Chirurgical Transactions. Published by the Medico-Chi- rurgical Society of London. Vol. XV. Part I. London, 1829 - 177
XXXII. Journal der Practischen Heilkunde. Herausgegeben von C. W. Hufeland und E. Osann.' Berlin. Small 8vo. in Nos. of 8 sheets - 187
XXXIII. Bibliothek der Practischen Heilkunde. Herausgegeben von C.
W. Hufeland and E. Osann -------- 187
XXXIV. Handbuch der Anatomie des menschlichen Korpers, zum Ge- brauch der Vorlesungen, ausgearbeitet von Johann Christian Rosenmul-
• ler, M. et C. D. Professor der Anatomie in Leipzig, 8cc. &c. Vierte vermehrte Auflage Herausgegeben von D. Ernst Heinrich Weber, Prof. &c. Leipzig, 1828. 8vo. pp. 564 - - * - - - - 188
QUARTERLY PERISCOPE. FOREIGN INTELLIGENCE.
ANATOMY.
Page.
1. Anomalous Muscle. By Dr. We- demeyer .... 189
2. On the Supposed Muscularity of the Larger Arteries. By Dr. Wedemeyer - - - ib.
Page.
3. Anomalous Vertebral Artery. By M. A. Meckel - - 189
4. On the Anatomical Structure of the Epiglottis in New-born Chil- dren. By M. Maingault - ib.
14
CONTENTS.
Page.
5. On the Capacity of the Lungs in the Healthy and Diseased State. By Dr. Herbst - - 189
6. Case of Double Uterus and Va- gina in the Human Subject. By M. Jolly - 191
Page.
7. Description of the Auricular Ganglion. By Dr. Arnold - 192
8. On the Structure of the Minute Vessels. By Dr. Wedemeyer 193
9. On the Termination of the Mi- nute Arteries. By Dr. Wede- meyer - - - 194
Physiology.
10. Mechanism of Vomiting. By M. Hediard - - - 196
11. Anatomical and Physiological Researches on Emphysema of the Lungs. By M. Piedagnel - ib.
12. On the Supposed Irritability and Vital Contractility of the Ar- teries. By George Wedemeyer,
M. D. - - - - 198
13. Influence of the age of the Pa- rents on the Sex of their Off- spring. By Professor Hofnacker 199
14. Gestation prolonged beyond the Ninth Month. By Dr. Albert 199
15. Experiments on Endosmose and Exosmose. By G. Wede- meyer, M. D. - - - ib.
16. Vaccine Disease Transmitted from the Mother to the Foetus 200
17. Communication between the Uterine and Placental Vessels. By Dr. Biancini - - - ib.
18. Case in which the Summit of the Bladder was Deficient. By M. Nespoli ... 201
Pathology.
19. Affection of the Mind from In- jury of the Brain. ByJohnEpps,
M. D 202
20. Case of Extraordinary Growth. By Dr. Bedor - - - ib.
21. Remarkable Predisposition to Haemorrhage. By Dr. Screyer ib,
22. Cases of Gonorrhoea and Chan- cre. By M. Gibert - - 203
23. Disease of the Frontal Sinus. By Professor Jager - - ib.
24. On Hypertrophy of the Brain. By M. Mc. Laennec - - 204
25. Foetus affected with Fungous Hsematodes. By Dr. Tonnele ib.
26. Periodical Hemicrania, termi-
nating by the Evacuation of a Calculus through the Nose. By Dr. Axmann - - - 204
27. Case of Disease of the Eye supposed to be Produced by In- flammation of the Jugular Vein. By James M. Arnott, Esq. - 205
28. Case of Intermittent Tetanus. By Dr. Schiitte - - ib.
29. Curious Case of Ischuria. By Dr. Hastings ... ib.
30. Case of Emission of Urine by the Umbilicus. By M. Falaschi 208
31. Induration of the Valve of Vieussens. By Professor Heu- singer - - - - ib.
Materia
32. Animal Charcoal. By Dr. Wag- ner - - - _ - - 208
33. New and exceedingly active Alcaloid substance discovered in Peruvian bark. By Dr. Fr. Ser- tiirner - - - 209
Medica.
34. On the Bark of the Root of the Calotropis Mudarii. By Andrew Duncan, M. D. - - - 210
35. Vesicating Plaster. By Dr. Th. W. C. Martius - - - ib.
Practice of Medicine.
36. On the Utility of Camphor in Puerperal Mania. ByDr.Berndt 210
37. On the Means of Recovering Persons Drowned. By M. Leroy d'Etioles - ib.
38. On the Application of Lunar Caustic in the Early Stage of Angina. By M. Toirac - 211
39. Treatment of Herpes Zoster by Cauterization. By M. de Beau- voys 212
CONTENTS.
15
Page.
40. Tetanus cured by Bleeding-. By M. Lisfranc - - - 213
41. Tannin in Monorrhagia. ByM. Cavalier .... ib.
42. Intermittent Fever cured by Levigated Mineral Charcoal. By Dr. Pierquin - - - 214
43. On the Extract of Male Fern Root for the Cure of Taenia. By Dr. J. J. Ebers - - - ib.
44. Means of Suspending the Se- cretion of Milk. By M. Ranque ib.
Page.
45. Mixture of Quinine and Digi- talis Purpurea in Phthisis Pul- monalis. By Dr. Gunther - 214
46. Combination of Lactuca Ve- rosa, and Digitalis Purpurea in Hydrothorax. By Dr. Joel - ib,
47. Pyroligneous Acid as a Gargle
in Angina Maligna. By Dr. Barth ib.
48. Treatment of the Cholera of India. By M. Gravier - - 215
OPHTHALMOLOGY.
49. Case of Purulent Ophthalmia, following Suppressed Leucor- rhoea. By Dr. Gibert - - 215
50. On the Functions of the Great
Sympathetic Nerve, and the Il- lustration it Affords of the Patho- logy of Amaurosis. By Professor Langenbeck - - 215
SURGEBY.
51. Case of Hydatid Tumour simu- lating a Crural Hernia. By M. Pigeotte - - - - 216
52. Lithotomy. By M. J. M. Viri- cel - - - - - 217
53. Case of Ununited Fracture of the Os Femoris, cured by the In- troduction of the Seton. By Mr. Henry Lyford - - - ib.
54. Cases of Diseased Larynx in which Tracheotomy was Suc- cessfully Performed - - ib.
55. Extirpation of the Ovaries. By Dr. Chrymer - - - 218
56. Excision of Enlarged Nymphs. By Dr. Wagner - - 219
57. Abscess between the Vagina and Rectum, opening into the latter. By M. Roux - - ib.
58. Pseudo-caries. By Mr. Syme ib.
59. Vertical Fracture of the Pa- tella. By M. Dupuytren - ib.
60. Operation of Applying a Liga- ture on the distal side of Aneu- risms. By M. Dupuytren - 221
61. Lithotrity. By M. Civiale ib.
62. Lithotrity. By M. Huerteloupe ib.
63. Lithotrity. By Professor Watt- man ib.
64. Spontaneous Cure of Femoral
Aneurism assisted by Pressure. By Mr. Lyford - - - 221
65. Fracture of the Os Calcis. By Mr. Costance - - 222
66. Case of Strangulated Hernia, in which six inches of the Intes- tine were removed. By John Simpson, M. D. - - - ib.
67. Extirpation of a Cancerous Pa- rotidian Tumour, and Ligature of the Primitive Carotid Artery. By M. Larrey - * - 223
68. Coxalgia treated by Mercury. By Professor Fritz - - 224
69. Prolapsus Ani. By Dr. Von Ammon .... ib,
70. Enlarged Scrotum Successfully Removed. By E. Barcome, Esq. ib.
71. Case of Amputation of the Lower Jaw. By Dr. Anderson 225
72. Removal of Naevi. By Mr. Bro- die 227
73. On Excision of Carious Joints. By James Syme, Esq. - 228
74. Case of Inflammation of the Mucous Membrane of the Sto- mach and Large Intestines, mis- taken for Hernia, and Terminat- ing Fatally. By P. M. Hoskins, Esq. 229
MlDWIFEBY.
75. Caesarian Operation. By Dr. J.
N. Engeltrum - - - 231
76. Caesarian Operation. By Dr. Busch .... ib.
77. Expulsion of the Placenta four Months after Delivery - ib.
78. Case of Twins. By M. Ryan,
M. D. - - - - - 232
79. Pregnancy with Cancer of the Cervix Uteri. By Dr. Laubreia ib.
L6
CONTENTS.
medtcal jurisprudence.
Page. Page.
80. Poisoning1 by Acetate of Mor- 82. On Arsenous Acid, considered phia 232 in a Medico-legal View. By M.
81. Infanticide by Omission - ib. Orfila 233
83. Death from Phosphorus - ib.
Chemistry.
84. ' OnAdipocire. ByDr.Bostock 234 i 86. Mode of Preparing Animal
85. Analysis of the Bark of the Charcoal .... 234 Root of the Calotropis Mudarii. | 87. On Detection of Corrosive Sub- By Professor Duncan - - ib. I limate. By M. Orfila - - ib.
MISCELLANEOUS.
88. Influence of Temperature on 90. Statistics of Mental Derange- the Mortality of New-born Chil- ments, Suicides, and Sudden In- dren. By MM. Milne Edwards voluntary Deaths in Paris. By and Villerme - - - 235 Dr. Falret - - - - ' 236
89. Innocuous Nature of Putrid Exhalations ... ib.
AMERICAN INTELLIGENCE.
Case of Supposed Poisoning with Arsenic. Reported by Samuel Jackson, M. I). of Northumber- land 237
Case of Punctured Wound of the right side of the Chest, penetrat- ing deep into the Right Lung, in which the usual symptoms of In- jury of the Lungs were absent, followed by Mania a Potu and Death. By Henry S. Levert, M. D. House Surgeon to the Penn- sylvania Hospital ( - - 248
Case of Severe Lacerated Wound of the Rectum and Bladder. By Charles Hall, M. D. of St. Albans, Vermont - 249
Case of Ephidrosis Olens. By George F. Lehman, M. D. 250
Sulphuric Ether in a Case of Poi- soning with Laudanum. By Wil- liam M. Fahnestock, M. D. ib.
Datura Stramonium in Retention of Urine. By William M. Fahne- stock, M. D. 251
Case of Poison by Stramonium. By R. E. Griffith, M. D. - - ib.
Notice of two Children whose Bo- dies were united anteriorly, and Lived some time after Birth. By J. Wilson Moore, M. D. (Com- municated in a letter to Dr. Hays) 252
An Account of the Siamese Twin Brothers united together from their Birth. By J. C Warren, M. D. Professor of Anatomy and Surgery in Harvard Medical Col- lege. (With a plate) - - 253
Ligature of the Carotid for Anasto- mosing Aneurism in a Child three months old. By Professor Mott 255
Statement of Deaths, with the Dis- eases and Ages, in the City and Liberties of Philadelphia, from the 1st of January, 1827, to the 1st of January, 1828 - - 256
Statement of Deaths, with the Dis- eases and Ages, in the City and Liberties of Philadelphia, from the 1st of January, 1828, to the 1st of January, 1829 - - 259
Mercury detected in Swaim's Pa- nacea. By Richard Emmons, M. D. of Great Crossing, Kentucky 262
Solution of the White Oxide of Arsenic and Tartar Emetic in Herpes, &c. By Dr. Richard Em- mons, of Kentucky - - ib.
Bark of the Root of the Lynn or Wahoo, (Ulmus alata, Mich.) as a Poultice. By Dr. W. F. Luckie, of Clinton, Mississippi - ib.
Necrology - ib.
'it' I \
s
THE
AMERICAN JOURNAL
OF THE
MEDICAL SCIENCES.
Art. L Case of Amputation of the Lower Jaw affected with Osteo- sarcoma. By J. Randolph, M. D. [With a plate.]
MAY 20th, 1829, I performed the operation of excision of a portion of the lower jaw, affected with osteo-sarcoma, on Mr. Parke Shee, of Chester, Pennsylvania, aged fifty-three years. Mr. Shee applied to Dr. Physiok, for the first time, in the beginning of this month, for advice on account of a large tumour which occupied his lower jaw bone, and occasioned so much deformity as to excite the curiosity, and arrest the attention of almost every person who saw him. He was unable to assign any very satisfactory cause for the existence of this tumour; he recollects to have had several teeth roughly extracted, and thinks, perhaps justly, that this was the origin to which it may be attributed.
The tumour had existed for six or eight years; he first perceived a small lump of the size of a hazle-nut on the external face of the bone, just below the right cuspidatus tooth: it was not attended with much pain, and increased for a long time but slowly. He had been frequently advised to apply for proper relief, but in consequence of being ac- tively engaged in business, he neglected to do so until he became alarmed by the rapid increase in its size, which had taken place in the last few months. The disease at this time appeared to extend from the first bicuspid tooth on the left side to within a short distance of the angle of the bone on the right, No trace of the teeth or alveo- lar processes could be found on the right side beyond the second in- cisor tooth; the bone here was expanded, and presented a large, smooth, convex surface, covered by the lining membrane of the mouth. It completely filled up the cavity of the mouth on the right
No. IX.— Nov. 1829. 3
18
Randolph's Case of Osteo-Sarcoma.
side, and occupied the space under the tongue of the same side, nearly as low down as its attachment to the os hyoides. The tongue was consequently thrown out of its natural situation, and rested upon the surface of the tumour, this occasioned considerable diffi- culty in deglutition. Externally, the tumour was pretty regularly convex, and seemed to be principally composed of osseous structure, an evident fluctuation, however, could be felt at the extremity of the chin, and lines could also be perceived denoting several distinct cells or cavities to exist in it, which were afterwards found to contain a thick, inodorous, serous fluid. The size and weight of the tu- mour was so great as not only to occasion considerable difficulty in mastication and deglutition, but also caused great inconveni- ence by its continual tendency to draw the lawer jaw downwards and keep the mouth open, from which there was a constant flow of saliva. The patient had, however, entire controul of the motions of his jaw, and could move it freely in all directions.
Mr. Shee having been made fully aware of the particular circum- stances of his case, and of the necessity which existed in our opinion for the removal of the diseased mass, promptly expressed his willing- ness to submit to any operation which we deemed necessary. I ac- cordingly proceeded to its performance, on Wednesday, the 20th of May, in the presence of Drs. Physick, Horner, Tucker, Hays, Gillingham, &c. The patient being seated on a high chair, I made an oblique incision through the lip, commencing at the right angle of the mouth, and carrying it down over the tumour, just in advance of the masseter muscle, I terminated it about half an inch below the base of the jaw. The right coronary artery, which was divided by this inci- sion, was then secured by a ligature. I was now able to dissect off" the skin and integuments from the whole external surface of the tumour, as far back as the first large grinder on the left side, at which place hav- ing exposed the bone, I divided it with great ease by means of a com- mon key-hole saw, properly sharpened. I now dissected off the in- teguments from the right side of the bone, as far back as the last mo- lar tooth, at which place I also sawed through the bone, but I expe- rienced some difficulty in doing this, in consequence of the tumour extending so far on this side as to interfere with the motions of the saw. Previously to sawing the bone on this side, the fascial artery, which had been necessarily divided, was taken up and tied. I now completed the removal of the tumour, by dividing the mucous mem- brane of the mouth, and separating the bone from the mylo-hyoid and its other muscular connexions. This was soon done, as the adhesions between the tumour and the surrounding parts were so slight, that
Randolph's Case of Osteosarcoma.
10
when the diseased part of the bone was entirely detached from the sound part, I was able to draw out the morbid mass and finish the dissection with but little difficulty.
Throughout the whole dissection I took particular care to cut close upon the surface of the tumour, in order to avoid wounding important parts lying adjacent to it. After removing the tumour, not being satisfied with the appearance of the extremity of the bone on the right side, it was deemed proper to remove another portion of it; I accord- ingly cut off half an inch of it with great ease, by means of a meta- carpal saw, there being no lump now to retard the motions of the saw. The time occupied by the operation was twenty minutes; the patient did not loose more than six or eight ounces of blood. After carefully securing such of the small vessels as bled, I brought the integuments together on the right side, and retained the edges in contact by means of the interrupted suture. A compress was then placed under the chin, and the relaxed integuments were supported by a roller passed round the chin and head. The patient was a good deal prostrated by the operation; in the evening his pulse rose to 85, he however fell into a fine sleep, perspiration came on, and he passed a good night. In the morning I found him with a pulse of 70, since which time he has not had any fever. For the first four or five days he could neither swal- low nor speak, excepting with great difficulty; he can now articulate nearly as distinctly as he could do before the operation, and swallows with much ease and satisfaction his nourishment, consisting of whey, milk, eggs, oysters, soup, &c» On the seventh day from the time of the operation, the patient was able to get up and walk about his room, and in four weeks he returned home quite well.
Several saws have been recommended by different surgeons for the purpose of dividing the lower jaw; at the suggestion of Dr. Phy- sick, I used a common key-hole saw; it answered perfectly. I had a saw made similar to the one used by Mr. Syme, of Edinburgh, having a straight blade six inches and a half long, and half an inch broad; but after a trial with each,. I prefer the former. As regards the propriety of tying the carotid artery previous to commencing the extirpation, I would observe, that in this ease I consider such a pro- cedure would have been highly improper and altogether unnecessary.
The Plate accompanying this paper represents accurately the ap- pearance of Mr. Shee before and after the operation.
With respect to the nature of this tumour, I would observe, that its formation appeared to me to be perfectly independent of any con- stitutional diathesis. Mr. Shee is the father of thirteen healthy chil- dren, he himself in other respects seemed to enjoy excellent health,
20 Mussey on Foztal Bones coloured with Madder.
and did not exhibit the slightest marks of a scrofulous habit. The disease appeared to me to be strictly local, inasmuch as the external integuments and internal parts, with which it was in contact, were quite sounds and not at all implicated with it; his countenance was natural and good. The disease evidently originated in the cancellat- ed structure of the bone, and while at the same time the tumour was enlarging considerably externally, in consequence of new bony depo- sition, absorption was also taking place within, and this to such an extent that in several places the bone which covered the tumour be- came as thin as the shell of an egg, and in other parts it was entirely removed, and its place supplied by a dense fibrous structure. I can- not agree with the French and German surgeons in supposing that all osteo-sarcomatous tumours necessarily possess a malignant character, and are identical with cancer and fungus haematodes, diseases so con- nected with a morbid state of the constitution, and so liable to con- taminate the adjacent parts, that their removal seldom enables us to calculate upon a cure. Had this tumour, which originated in my opinion from common inflammation, been excited in a constitution im- paired and predisposed to morbid actions, I can readily imagine that it should have possessed a highly malignant character, with which the constitution should have become deeply involved, and that its re- moval would not insure the patient from a return of the disease.
But, inasmuch as the inflammation attacked a healthy constitution* and the patient was not subjected to any adequate treatment for its removal, it was suffered to progress until it occasioned the alteration in the structure of the bone which I have described, and which I do not believe possessed a malignant character, but was so entirely local as to warrant me in hoping that my operation would be permanently suc- cessful.
PI. I. fig. 1. represents the appearance of the patient before the, operation; fig. 2.. after the operation.
Philadelphia, July 27, 1829.
Art. II. Foetal Bones coloured with Madder. By R. D. Mussey, M. D. Professor of Anatomy and Surgery in Dartmouth College, Hanover, N. H. [With a plate.]
The nature of the communication established between the blood- vessels of the mother and those of the foetus, is, perhaps, still a pro- blem. From the almost uniform failure in attempts to inject the one
Edwards del .
Mussey on Foetal Bones coloured with Madder. 21
set of vessels from the other, it has been inferred that no direct com- munication exists between them; and some physiologists have been emboldened to doubt even the existence of any communication what- ever.* In a French periodical,! however, it is stated, that Le Cat, in 1752, and again in 1754, succeeded, by injection, in fully demon- strating to the Acadamy and to the commissaries of that institution, what was considered to be a direct communication between the ves- sels of the fcetus and those of the mother, in cases where the placenta remained attached to the uterus after death.
The following experiments, which, in so far as I am informed, are new, will serve to show, that, with one of the tribes of lower animals, whatever be the nature of the communication between the vessels of the uterus and those of the ovum, it does not forbid the passage of a foreign substance from the one to the other.
I caused a sow, during the last eight weeks of gestation, to be fed with madder, by mixing daily about three or four ounces of it with the food of the animal. On the day the farrow was produced, seve- ral of the pigs were killed, and their bones inspected. Every bone was strongly tinged with red. The teeth were stained of a delicate pink colour. The engraving exhibits tolerably well the effect of the madder upon the teeth, and upon one of the large bones.
Explanation. — PI. II. fig. 1. A cuspid tooth. Fig. 2. Concave part of a partially formed grinder. Fig. 3. Convex part or grinding surface of the same specimen; the enamelled points white. Fig. 4. Interior of the thigh bone, cut longitudinally.
In another experiment, more recently made, a sow within a month as nearly as could be ascertained of bringing forth her farrow, was made to eat four ounces of madder daily, for twenty days, and was then bled to death. The urine of the animal was very high coloured, but was much deepened by the addition of a small quantity of the so- lution of potash. The serum of the blood too, after the red particles were allowed as much as possible to subside, was of a red colour, which was suddenly heightened by the addition of the alkali. Half a dozen of nearly full grown pigs were found in the uterus.
The liquor amnii was repeatedly tested. It yielded a distinct tinge of red when the potash was applied to it. The proportion of madder, however, in the liquor amnii must have been small, for when
* I have heard a lecturer of eminence declare life strong" doubts of the exist- ence of any sort of communication between the foetal and maternal vessels.
fRecueil Periodique d' Observations de Medecine, Chirurgie, Pharmacie, &c. 1754. Tom. I. p. 253.
3*
22
Mighel's Case of Parody nia Perversa.
a small volume of it was tested with the alkali, the appearance of a red tinge was not satisfactory; but when tried in the following man- ner, the change was very manifest. About two drachms of the co- lourless, or nearly colourless liquor amnii was put into an ounce phial, and as much into another phial of the same size. These were placed side by side, and the solution of potash dropped into one of them; the red tinge was immediately acknowledged by a number of gentlemen, before whom the liquor amnii was thus repeatedly tested.
The colourless liquor in the stomachs, and the pale urine in the bladders of the foetal pigs, were found in too small quantity to admit of a satisfactory application of the test. In this last experiment with the sow, the teeth and other bones of the foetal pigs exhibited the red colour quite as strongly as did those of the first experiment, in which the mother was fed eight weeks upon madder, instead of twenty days. The bones of the sow, in the last experiment, were dyed of a fine red approaching scarlet. Thus it appears that the colouring mat- ter of madder is capable of existing not only in the serum of the blood, in the urine, but also in the liquor amnii, and of circulating harmlessly through the delicate organs of the foetus, in different stages of their development and growth.
Hanover, New Hampshire, May 19th, 1829.
Art. III. Parodynia Perversa, complicated with Hydrops Ovarii. By Jesse W. Mighels, M. D. of Minot, Cumberland County, Maine.
In February, 1827, Mrs. Campbell, set. about thirty, of sound con- stitution, above the middling stature, sanguineous temperament, strong, athletic, and of a cheerful temper, consulted me on account of a tumour in her side. On examination, I found in the left hypogas- tric region, an indolent, insensible, globular, moveable tumour, ap- parently about as large as an ostrich egg, occasioning no inconveni- ence but from its weight.
I had attended her twice in parturition. With her first child, which was now about three years old, she was in labour twenty-four hours, and although she had the advantages of a natural presentation and well-developed pelvis, she was extremely sick. With her second, at this time about a year old, the presentation was natural, and labour comparatively easy. She stated that she discovered the tumour a few
Mighel's Case of Parodynia Perversa.
23
weeks subsequent to the birth of her second child, that it was then about as large as a goose egg, and that it had gradually and almost imperceptibly attained its present dimensions. She also stated that she had had her menstrual discharges regularly for a number of months, although she still nursed her child.
I did not hesitate to pronounce it an enlarged ovarium, and, as her health in other respects was perfect, advised her to forego the use of all active medicines, to accustom herself to moderate exercise, and diet abstemiously.
In about six or seven weeks I was requested to visit her again. The increase of the tumour had been truly astonishing. It now ex- tended to the epigastrium, filling almost the whole peritoneal sac. She was nearly as large as formerly at her full period of utero-gesta- tion, complained of great pressure, sour eructations, loss of appetite, and costiveness; had menstruated a few weeks previously. I request- ed the attendance of Dr. Tewkesbury, who concurred with me in opinion that it was ovarian dropsy. We directed her to keep her bowels pervious with rhubarb and carbonate of magnesia, to wear a suspensory bandage, and anoint the abdomen with a liniment com- posed ot spt. terebinth, one part 5 olive oil and spt. ammon. aa. two parts.
I saw her again in about a week, when the above symptoms had generally disappeared. No apparent change in the tumour. Ordered blue pill, ten grains, every other night at bed time; a tea-spoonful of spirit of ammonia in infusion of chamomile twice a day; to keep her bowels free with elixir proprietatis or rhubarb; light nourishing diet and moderate exercise. In June she consulted me on account of amenor- rhcea. She had increased considerably; informed me she had consult- ed an empiric, who had given her drastic cathartics, but that she was convinced it had done her no good. She had not menstruated since I last saw her. She was evidently in a state of pregnancy. I direct- ed her to use such palliatives as her case might from time to time de- mand.
She was taken in labour, November 29, 1827. I saw her at seven o'clock, P. M. She had pretty strong expulsory throes. On exami- nation per vaginam, the os uteri was not to be found. In sitting? standing, or lying upon her side, the uterus was evidently in front of the tumour, and in sitting she literally held her child in her lap. Her size was enormous, and in order to avoid exaggeration, I mea- sured her with an accurate scale, and found, that from the sacrum to the utmost extent in front, she measured two feet and three inches; in circumference, five feet and four inches.
24
MighePs Case of Parody nia Perversa,
Lying upon her back, the uterus would fall alongside of the tu- mour, which gave her the appearance of having two gravid uteri, resting upon the rings of the ilium, one upon the right and the other upon the left. The depression or fossa lying betwixt them com- menced a little to the right of the symphisis pubis and run upwards in a line, about half way betwixt the linea alba and linea semilunaris, and terminated at the scrobiculus cordis.
Apprehensive that it might be necessary to lessen the tumour by paracentesis, and that the case might be attended with difficulty and danger, I requested advice and assistance, which 1 was denied. Till twelve o'clock her throes were very severe, from which time till 2, A. M. there was a slight recess; os externum rigid; os uteri out of reach; slight pain in the head. Bled her twenty ounces, and gave one hundred drops of laudanum, which rather increased the force and frequency of the pains. At three o'clock the membranes gave way spontaneously, and gave exit to a large quantity of liquor amnii. I then made an effort to introduce my hand, but failed, in consequence of the great rigidity of the parts. From this time till seven o'clock the pains were tremendous, but produced no apparent change. From seven till ten o'clock she had but little pain; slept some. At eleven o'clock the pains were truly terrible, and on examination I found that the os externum began to yield. I directed her to be placed upon her back, the nates resting upon the edge of the bed, and her trunk considerably elevated.
In this position I readily introduced my hand, found the os uteri above the brim of the pelvis, very far to the right of the centre and considerably dilated ! The tumour occupied at least two-thirds of the bony circle. I could not recognise a space of more than an inch and a half betwixt the tumour and ilio-pubic juncture. I was about to withdraw my hand, with the determination to evacuate the con- tents of the sac by an operation, when a violent pain came on, which evidently caused the tumour to recede, and taking advantage of the recess of pain passed my hand by it, and ascertained that the breech presented. I found but little difficulty in bringing down the feet, in doing which the sac burst, and its contents issued into the cavity of the abdomen, the uterus took its natural situation in the centre, and the labour was finished in a few minutes, child still-born.
During the four or five subsequent days, she discharged enormous quantities of high-coloured urine; in one night five quarts ! In three weeks she was up, doing her work, in perfect health, and no larger in circumference than before she had the tumour.
MigheFs Case of Parody nia Perversa.
25
It began to exhibit itself again, in January, 1828, increased gra- dually till June, when it burst spontaneously, and disappeared again with great celerity through the kidneys* It very soon reappeared, progressed with great rapidity, burst in August, and passed off' as be- fore. She remained feeble for a number of weeks, exercised with considerable pain about the abdomen, and some hysterical symptoms, but recovered perfectly.
January 12/A, 1829. I was called in the morning, and learnt that she had been indisposed for five days, and that she had been exer- cised with strong expulsory throes during all the preceding night. Externally, she appeared much as in 1827, but broader laterally. In sitting or standing, the abdomen appeared smooth and regular, but lying upon her back there was a much more distinct fossa betwixt the uterus and tumour than before. In circumference she measured five feet On examination per vaginam, the os uteri was not to be found. The pains continued very severe till twelve o'clock, from which time till 1, P. M. there was a slight recess. In passing my hand partially through the os externum, I could plainly recognise the bottom of the tumour, which appeared to fill the whole of the up- per part of the bony cavity.
In view of all the circumstances of her case, I could not conceive it possible for the child to pass without lessening the tumour by giv- ing exit to its contents, which opinion I communicated to her friends, and desired counsel, which they objected to, believing that I might succeed as before, and desired me to do whatever I should deem ne- cessary for her relief. As, however, the operation of paracentesis was unusual, perhaps unprecedented in her situation, I did not feel at liberty to do it unadvised.
At three o'clock her throes were very powerful, and finding the external parts well dilated, introduced my hand and found the os uteri jammed in betwixt the distended sac and ilio-pubic juncture, and considerably dilated in the form of a crescent. The tumour was stationary, and although I could make considerable pressure upon it, I could not obtain a space of more than an inch for the passage of the child. During this examination the membranes gave way, and allowed exit to the liquor amnii, accompanied with the funis umbilicalis, which pulsated feebly. I again represented her case to her friends, and re- quested them to procure assistance, but Dr. Tewkesbury did not ar- rive till the next day at noon. By venesection and opium she was kept pretty comfortable during the night. On examination at eleven o'clock of the 13th, I found the left arm protruding through the os uteri. Dr. Tewkesbury arrived at twelve o'clock, and advised an attempt
26 Mighel's Case of Parody nia Perversa.
at turning, but on further investigation he concurred with me, that lessening the tumour by paracentesis was the only alternative. We accordingly perforated it with a pretty large trocar, in the linea semi- lunaris about five inches above the crista ilia, and evacuated eighteen pints of bloody water resembling dirty claret, perfectly limpid and in- odorous. This afforded great relief, the uterus resumed its natural situ- ation in the centre of the abdomen, and there can be no doubt, had the presentation been favourable, the child would have been expelled in a short time.
But, although we had removed one difficulty, we still had before us all the perplexing and discouraging circumstances of a protracted case of preternatural labour of the worst kind. Although naturally possessed of as much firmness and fortitude as a lioness, our patient had become irascible and peevish; the parts, although well dilated, were tender and irritable, and the uterus had contracted with un- yielding firmness about the child; pulsation had ceased in the funis; the head of the child was unquestionably situated in the left side, and the feet at the farthest possible distance from the os uteri; there was no pain. We attempted turning, and, availing ourselves of every possible advantage, persevered in the usual way for two hours, to no effect. So far as I could introduce my hand, the uterus presented the appearance of being encircled with strong inelastic bands, three- fourths of an inch in breadth, drawn around it with incredible force. The cervix was preternaturally elongated, but so well dilated as to admit the hand readily.
Failing to afford relief in this way, we concurred in the expediency of removing the child by embryulcia. We accordingly removed the arm with the scapula and clavicle, penetrated the chest with a perfo- rator, and so far succeeded as to introduce my hand into it and grasp- ed the heart and lungs, when she became impatient, and bounded out of our reach, absolutely refusing any further assistance. One object was to remove the thoracic and abdominal viscera, in order to make room to introduce the hand to the feet, or to enable us to fix a blunt hook upon the pelvis, but we were defeated: we could not prevail on her to suffer another trial. We bled her twenty ounces and gave her a large anodyne, but fearing more trouble and perplexity, we sent for Dr. Carr, who arrived at eight o'clock. She again submitted to the operation, but soon became impatient, and we were obliged to withdraw. We gave her a full dose of laudanum, which procured a pretty comfortable night's rest.
In the morning of the 14th she appeared rather more pliable. The external parts were very little swollen. On introducing my hand, I
MighePs Case of Parody nia Perversa.
27
found that the child had made a partial evolution and presented the right shoulder. With the blunt hook we brought down the arm, which had become so tender by putrefaction that it readily came away with the scapula. She soon became impatient, and sprang out of our reach, requesting us to leave her. At ten o'clock her friends prevailed on her to submit again, but she became discouraged sooner than before, and requested us either to give her the benefit of the Caesarian operation, or leave her to her fate.
She was perfectly sane, pulse a little accelerated, skin rather sal- low, tongue furred, but on the whole no more exhausted than the ge- nerality of women at the close of an ordinary labour. She convers- ed freely, and was evidently perfectly aware of her danger, but she had superstitiously imbibed the impression that she should die unde- livered, and expressed the belief that we were doing violence to an immutable decree to make use of any further means for her relief. We left her at noon, on "Wednesday the 14th.
I visited her again on the 16th, and received the following account: that she was exercised with incessant throes, till Thursday evening, (although during the time she took half an ounce of laudanum,) when it seems that a complete evolution* had taken place, and the child was expelled "head foremost." An old midwife present informed me that as soon as the child was expelled, she introduced her hand and took the placenta. On examination, I found the child in a very putrid state, the head elongated and almost destitute of brain, so that the two parietal bones were almost in contact.
The patient was very feeble; face scarlet; pulse 120, quick, hard, and wiry; tongue dark coloured; unquenchable thirst; head painful and giddy; abdomen considerably distended and extremely tender; uterus appeared unaccountably large; mind sane. Bled her eight ounces, ordered fomentations, and adopted the antiphlogistic regimen to its full extent. No essential change till the 19th; fever much in- creased; abdomen distended, hard, and tender: lochia suppressed; bilious diarrhoea. Ordered calomel and rhubarb, a large epispastic to the abdomen, and an anodyne at bed time.
20th. Has had a very restless night. Cathartic had operated; ab- domen extensively blistered, much distended, and elastic; counte- nance cadaverous; pulse hardly perceptible; respiration rapid and so- norous; hiccups; extremities cold, and the whole body covered with a profuse clammy sweat. She remained in this state about two days,
* See Denman's Midwifery, p. 135, Vol. 2d.
2S
MighePs Case of Farodynia Perversa.
and at some times there appeared to be a complete suspension of the vital functions.
%2d. The lochial discharge reappeared, attended with a mild diar- rhoea and evident symptoms of amendment.
25th. Strong pains supervened in the evening, resembling after- pains in ordinary cases, which terminated in the expulsion of the placenta in a state of putrefaction.
February 4th. The sac had become completely distended, causing much uneasiness. I immediately perforated it with the trocar, and evacuated five quarts of very offensive matter, resembling in colour strong chocolate. She dragged out a miserable existence till the 24th, when, from spontaneous bursting of the sac, she succumbed.
On examining the body, an hour after death, we were almost suffo- cated with the most offensive stench. About two quarts of matter had escaped into the right side of the abdominal cavity, which was perfectly separated from the left by the firm attachment of the great sac to the peritoneum, mesentery, and intestines. The dropsical effusion evidently commenced in the peritoneal covering of the ova- rium. The ovarium itself was but a very little diseased, being only a little indurated and enlarged, and so completely imbecfded in the sac as to appear to make a part of its walls.' We discovered the spon- taneous laceration at the upper part, where it was in contact with the liver. From all we could discover, we were of the opinion that this was the point at which it had burst formerly ; being at all other parts perfectly smooth and regular, but here considerably thickened and hardened, excepting at the centre, where the rupture appeared. The sac itself contained about ten quarts of very offensive pus. The small intestines were crowded into the epigastrium, being firmly at- tached to the vertex of the sac. The liver, spleen, pancreas, and kidneys were sound. The uterus appeared as usual at this period of the puerperal state, but removed from its natural situation and crowd- ed firmly into the right hypogastrium. The peritoneal covering of the bladder and sac had so firmly united as to appear like one membrane.
Reflections.— In view of this case two important practical facts present; 1st. As it regards the expediency of an operation during labour, under circumstances like those above related. I do not re- collect of having ever seen a case recorded precisely like this, but should another occur, I should consider a seasonable operation of primary importance. 2d. It is believed that too much stress is laid upon the importance of artificial interference in cases of malposition.
Archer's Account of a Purulent Ophthalmia.
20
In cases attended with haemorrhage, or when the feet or pelvis may be easily commanded, or when circumstances render turning easy, it may and ought to be resorted to, but not in cases like this. Further, in ordinary cases of presentation of the shoulder or arm, it is believ- ed that it is more expedient, that it is safer to trust the case to na- ture, than to interfere with any degree of violence. Spontaneous evolution will, in nine cases out of ten, take place. With a view to facilitate the evolution, I would merely remove the presenting part, bleed according to circumstances, and allay irritation by the occa- sional use of anodynes.
Minot, Cumberland County, Maine, July, 1829.
Art. IV. Jlccount of a Purulent Ophthalmia that prevailed at Por- tress Monroe, in Virginia, in the years 1826-27. By Dr. Robert Archer, United States' Army.
The ophthalmia which is the subject of this paper, was introduced by a company of artillery from Fort Independence, Boston Harbour, which arrived on the 9th of April, 1826, at Fortress Monroe.
Dr. Mann, the attending surgeon at Fort Independence, has fur- nished me with some important facts in relation to its history. He says it made its appearance at that post in the autumn of 1824$ that between the first of September and last of December of that year, eight cases were reported, and twenty-seven of the most aggravated form in the year 1825, besides many milder ones. More than two- thirds of the company therefore had been attacked before it left Fort Independence.
Four of the company only were affected at the time of its arrival at Fortress Monroe. Of these, two had ulcers and opacity of the cor- nea, and the other two a milder form of the disease. Whether a re- moval from the infected atmosphere of Fort Independence had arrest- ed the disease, or whether the sea voyage and change of climate had destroyed the susceptibility, in those who continued healthy, to re- ceive it, I know not, but after leaving Boston but one new case oc- curred. ,
This company continued to occupy the quarters that had been as- signed to it on its arrival at Fortress Monroe, until the 6th of Decem- ber following, when they were vacated, and another company put in, whose rank entitled it to that position in the order of the battalion.
No. IX.— Nov. 1829. 4
so
Archer's Jiccoiint of a Purulent Ophthalmia.
It may be well to mention, that the only fixtures in the soldiers- barracks are the bunks; when a company moves, it takes with it every moveable article, and it is an uniform practice for the rooms to be thoroughly cleansed and white-washed, before or immediately after they are reoccupied. I am thus particular in noticing this fact, be- cause if the bedding, or any thing else that had been used by this company had been transferred to its successor, we might find less difficulty in accounting for the reappearance of the disease.
In November, 1826, I was relieved from duty in the regiment, and tranferred to another department at the post; the minute details of the cases therefore, which occurred between that period and the sub- sequent November, when I rejoined the regiment, were communi- cated to me by my friend Dr. Everett, the senior surgeon of the post.
About the 4th of March, 1827, the first case in the new company exhibited itself; this, it will be observed, was three months after re- moving into the quarters. The symptoms being very similar to those of ordinary ophthalmia, no alarm was excited, as no suspicion could exist that the contagion had lain dormant for such a length of time after the quarters had been vacated by the infected company; nor was there any reason to suppose that the disease was contagious, for as the company at Fort Independence were all exposed to the same exciting cause, they were all equally liable to contract it^ and the disease might have been considered as epidemic, or rather endemic. The lapse of a few days, however, proved it to be similar in every respect to that brought from Fort Independence, and of a most ma- lignant character. The cases began rapidly to multiply, and in spite of every precaution, such as removing the men on the first symptom of infection, and the strictest attention to police, it pursued its regu- lar course until the 14th day of January, 1828, when the last case was reported.
Of forty-five men who composed this company, twenty-three be- came infected, and it is not a little remarkable that the disease should have confined itself, in the first instance, to a particular spot; for it was clearly ascertained that the first six cases originated in indivi- duals who had slept at some period in the same bunk.
Each company of the regiment occupied one long room, and it may be urged that the disease was promulgated through the medium of the vitiated atmosphere of the room, and therefore that it was not strictly or technically contagious; but, to put this question beyond dispute, it will only be necessary to state, that at a time when there was but one ophthalmic patient in the hospital, the two men of
Archer's Account of a Purulent Ophthalmia. 31
different companies, who occupied the beds on either side of him, both took the disease, and had it in its severest forms.
The progress of this disease may properly be divided into three stages. The first symptom the patient complains of, is a sensation in the eye similar to that produced by the irritation of a grain of sand; the vessels of the conjunctiva are engorged; the inflammation of that portion covering the sclerotica diminishing as you approach the cornea, but unusually severe when it lines the inferior palpebra. This appears to be the part primarily affected, and to constitute the pathognomonic symptom of the disease, for in several cases where I could scarcely perceive a discoloration of the albuginea, the strongest marks of inflammatory action were perceptible on this portion of the conjunctiva. In this stage of the disease the patient experiences rather uneasiness than pain, for although the eye is somewhat sensi- ble to the impression of light, it is not sufficiently so to render a screen at all necessary. Unless you are fortunate enough to arrest the disease here, the most violent symptoms now supervene; the con- junctiva becomes turgid with blood, and frequently protrudes beyond the palpebrse, resembling a lump of raw flesh. You no longer dis- cover the beautiful net-work of vessels that characterized the first stage; the cornea appears sunk; the palpebras so swelled as with diffi- culty to be separated; ectropion; entropion; the pain in the eye excru- ciating, with a large secretion of hot fluid, generally intermixed with purulent matter; the intensity of the heat sometimes so great as to make the patient complain of its scalding his cheek. Opacity of the cornea, ulceration, rupture of the coats, and evacuation of the hu- mours succeed this, and constitute the third stage.
The inflammation in this disease seems to be of a specific charac- ter, for although, as I before stated, the early symptoms are very si- milar to those of simple ophthalmia, a minute examination will at once detect the difference, and render it a very easy matter at the first in- spection to pronounce between them. The conjunctiva in every in- stance exhibited a rough, honey-combed appearance, similar to what would probably result from the application of a strong mineral acid. Mr. Saunders is, I believe, the first writer who has noticed this pe- culiar granulated appearance of the conjunctiva.
In the treatment of this disease, I regret I am not able to add much to the stock of knowledge already in possession of the faculty. Every means that might be supposed, directly or indirectly, to exercise an influence over it, were tried with most determined persever- ance. Venesection, cathartics* fomentations, poultices, scarifica- tions, astringent and emollient collyria, blisters to the temples and
32
Archer's Account of a Purulent Ophthalmia.
nucha were all resorted to, and although the symptoms in one case were partially mitigated, in another they were apparently aggravated. The plan, however, which was most successful, and that on which I would with most confidence rely, should I ever encounter the disease a second time, was the following. In the first stage the patient should be copiously bled, and purged with neutral salts, and subjected to the strictest antiphlogistic treatment. Moderate bleedings appeared to exert no influence over the disease ; blood-letting should be repeated and carried as far as the circumstances of the patient would permit. Sca- rifications of the conjunctiva appeared to have no effect in reducing the inflammation, although, arguing a priori, I should be very loth to dispense with them, more especially when leeches could not be pro- cured, as was the case with us. Emetics of tartarized antimony, frequently repeated, together with nauseating doses of the same, were found particularly appropriate. Collyria of lead and zinc in the first stage were injurious, those of an emollient nature totally inert, but throughout every stage a liniment composed of ol. oliv. and mur. hydr. in the proportion of one or two grains of the muriate to one ounce of oil, was used with decided advantage. The corroded sur- face of the conjunctiva required some lubricating substance to coun- teract the attrition produced by the constant motion of the ball and eyelids, and although the application produced great pain for a few seconds, it soon subsided after a copious secretion of tears, and left the patient in comparative ease.
From the vinous tincture of opium, so strongly recommended by Ware, I do not think any advantage resulted, although I gave it a very fair trial.
Calomel and the blue pill, both as alterants and sialagogues, were employed without effect. In one or^ two instances, blisters to the temples I thought rather aggravated the inflammation, but when ap- plied directly over the eye, their salutary effect was most manifest^ this method of applying them was adopted at an early period by my friend and associate Dr. Everett. It is a practice I can not recom- mend in terms too strong, for if there was any treatment universally and unequivocally successful, it was this.
To relieve the excruciating pain attendant upon the second stage, I found nothing to equal the infusion of the Datura stramonium, ap- plied by means of cloths to the eye. It was continued from one to three hours, according to the violence of the pain, and never failed to relieve it. No evil resulted from its frequent application, although the pupil in every instance was so dilated as to reduce the iris to a delicate ring. This remedy promises to be of considerable importance
Archer's Jiccount of a Purulent Ophthalmia.
33
In ophthalmias generally, attended with severe pain in the eye, and deserves farther consideration.
In ulceration and opacity of the cornea, the solution of nit. argent, in the proportion of one or two grains to the ounce, applied by means of a camel's hair pencil, was used with advantage, and when the con- junctiva becomes so engorged as to produce eversion of the eyelid, I am convinced that the best practice is to slice it off. By doing so, you take away the principal source of irritation from the cornea, touch the rough granulated surface of the conjunctiva, and I believe pro- duce a new inflammatory action, more manageable and totally dif- ferent from the former.
To what cause are we to ascribe the origin of the disease at Fort Independence? Its extension, we think, we have clearly demonstrat- ed to depend on contagion.
It appears from the statement of Dr. Mann, that sore eyes were more frequent in Boston about this time than usual, although not characterized by any uncommon symptoms. An ophthalmic consti- tution of the air, as Sydenham would have called it, was probably then the remote or predisposing cause of the disease, and to the peculiar locality of the fort, the duties, the habits, and the dress of the soldiers, I think we may with some propriety ascribe the excit* ing cause.
Fort Independence is situated on a small island of ten acres, in the harbour of Boston. The parade ground included within the walls of the fort, comprises an area of about sixty yards by thirty. This, with a view to police, and to render it firm, has been covered with a stratum of coarsely pulverized gray stone of the schistus formation: there is nothing for the eye to rest upon, but these particles of slate, acting as so many reflectors of light and heat, the yellow-washed brick walls of the quarters, and an extensive sheet of water.
The soldier, from the nature of his duties, is necessarily much ex- posed to the direct influence of the solar rays. As a sentinel, he stands on his post for two hours; his fatigue duties are generally, and his drills and other exercises always, performed in the open field, so that I think we may safely say he is exposed, from necessity or choice, at least eight hours out of twelve to the effects of the sun; and when we take into consideration that the only covering to the head worn at that time by the soldiers, except on parade and guard duties, were woollen forage caps, fitting as close as the scalp, and those too with- out visors or screens to protect the eyes, we need look no farther for a cause adequate to produce the effect described, in individuals re- motely predisposed to the disease, by the prevailing constitution of
4*
34
Lehman's Remarks on Otitis.
the air and their too general habits of intoxication. Dr. Mann re- marks that none had the disease severely, except notorious drunkards. There were at this time about twenty women and children at Fort In- dependence, not one of them, or any of the officers, took the disease; which goes very far to prove that the habits of the men, their expo- sure to the sun, and the use of the forage cap, tended materially to the production of the disease.* Fortress Monroe, August, 1829.
Art. V. Remarks on Otitis. By George F. Lehman, M. D. Laza- retto Physician of the Port of Philadelphia.
It has been observed by distinguished authority, that inflammation of the ear is generally limited in its extent, and seated so far out of our reach that bleeding is seldom employed, nor is the constitution so much affected as to render any general remedies necessary.
Several cases of unusual violence having fallen under my notice, which required corresponding measures for their relief, and enter- taining an idea that the pathology and treatment of this affection are not sufficiently elucidated, the following observations are made.
The causes of otitis are generally those which create inflammation in other parts, such as exposure to cold, particularly a current of cold air, or the direct application of snow, ice, or cold water to the ear, mechanical violence, the introduction of exotic substances, as a rag- ged bone, a cherry-stone, or worms, insects, or the larvae of insects, into the ear, many cases of which are on record. I once witnessed a severe inflammation of the ear occasioned by the sting of a wasp.
When inflammation is confined to the meatus auditorius externus, it is characterized by slight pains in the ear, and is relieved by the introduction of a few drops of thebaic tincture, tincture of digitalis, oleum olivee, or oleum amygdalae into the ear, and warmth applied by flannel.
In this state of the disease, the application of a few drops of the tincture of digitalis usually affords as much relief as any other reme- dial agent. Stimulant errhines may be also used with advantage.
* We beg leave to refer our readers to a paper on Purulent Ophthalmia, in the thirteenth volume of the Philadelphia Journal of the Medical and Physical Sciences, in which we have attempted to point out the true character of that disease. — Ed.
Lehman's Remarks on Otitis.
35
The causes of this infection are not to be overlooked in its manage- ment. If it depends on the presence of foreign bodies, they must be extracted; if on insects or the larvae of insects, the proper remedy to suffocate them will be a few drops of olive or almond oil dropped into the meatus externus.
In common cases, indicated by slight pains only, and brought on by the direct application of cold, the disease depends very often sim- ply on the constriction of the excretory ducts of the glandulae ceru- minosse; to relieve which the appropriate treatment is warm fomen- tations, to restore the ducts to their natural action. Sometimes the introduction of tepid water or steam will be sufficient.
If the inflammation extends to the membrani tympani, the pain is sharp, lancinating, and throbbing, reaching to the temporal bone. The brain is often affected, creating delirium, the tongue is furred, and the action of the heart much increased. The disease advancing, suppuration follows, and a discharge takes place.
Sometimes the membranes of the brain are affected, causing phre- nitis, and the temporal bones become carious, and death is occasion- ally the consequence.
Dr. Powell, in the Medical Transactions, Vol. V. page 212, re- lates the case of a lad of sixteen years of age, who had suffered two attacks of otitis preceding the fatal one, in which the pain was in- tense, yet the pulse never exceeded 72, and the operations of the mind were unimpaired.
When we consider that the membrani tympani is stretched very tensely over the tympanum, and is chiefly formed of the periosteum, it can excite no surprise that the pain is so very excruciating in in- flammations of this membrane. Besides, it has an abundance of small vessels, supplied by the stylo-mastoid and temporal arteries.
So extreme is the sensibility of this membrane, and the sufferings of the patient so acute, that his reason is often affected, but the sup^ purative process advances with rapid strides to relieve his agony, and the parts afterwards, in a great majority of instances, heal kindly and in a short period.
No stronger proof exists of the vis medicatrix naturae than the ge- neral tendency of all inflammations to the surface. It is an instinc- tive effort of nature to save her vital parts from the presence of mat- ter, which, from its irritating qualities, would bring about very serious consequences. This observation, indeed, applies to all the great ca- vities of the body; innumerable instances in support of which might be derived from morbid anatomy, which must be familiar to all prac- tical men. If an inflammation attack the peritoneum covering an in-
36
Lehman's Remarks on Otitis.
testine, and adhesions are hereby produced between the two, the in- flammatory action works upwards through the thick walls of the ab- dominal muscles, while the proper coats of the intestines in most instances remain sound. We even find that if abscess form in a frontal sinus from an obstruction in its duct, the matter will rather work its way externally through the frontal bone, than descend into the nose. In like manner, if an inflammation attack the cellular membrane on the outside of the rectum near the anus, although the latter be in contact with the inflamed part, the inflammation will ex- tend to the skin of the buttock, while the gut itself is often but little affected.*
If the inner surface of the tympanum or labyrinth becomes inflamed, the disease assumes a very important character. The pain is conti- nued and most excruciating; coma or delirium is common; the pulse is much excited, and in every instance the constitution is affected; suppuration takes place; the pus finds a lodgment in the labyrinth; the bones become carious, and total deafness follows. The whole struc- ture of the ear is destroyed, even the bones are sometimes discharg- ed through the meatus auditorius, with very fetid matter, and fistu- lous ulcers supervene upon this, which are very troublesome.
In a few rare instances the inflammation has extended to the brain, affecting the membranes and surface of the organ, and coating them with coagulable lymph, pus, or both. As the disease approaches this condition, topical applications are of no avail. We must now have recourse to active and copious depletion, and the first and most bene- ficial is venesection, which may be carried to a great extent.
Active purgatives must always be resorted to, it matters not whether calomel, castor oil, or the saline purgatives are used, so that the doses are liberal enough to act promptly and freely. After this is done, cupping, leeching, and blistering behind the ear, are very salutary. The hot pediluvium is occasionally serviceable.
So soon as the arterial excitement is diminished, the pain is usually relieved, at all events to a certain degree, then the introduction of a few drops of the tincture of digitalis into the ear will be proper.
When, however, the disease does not yield to this treatment, and the pain continues severe, we must depend on narcotic cataplasms, and fomentations to moderate it, until suppuration takes place, and pus is discharged from the external meatus, which usually affords a cessation from pain. Tepid water, or milk and water, are then to be injected repeatedly into the ear to wash it out; or you may syringe
* Good's Study of Medicine, Vol. II.
Lehman's Remarks on Otitis.
37
the ear now and then with gum Arabic water, or any other mucila- ginous infusion, and mild astringent decoctions, and in a short time, the parts will be restored, to their usual healthy condition. The regimen during the continuance of inflammation ought to be cooling and light.
There is a species of ear-ache denominated nervous. It is gene- rally symptomatic, and is almost always the effect of gastric irritation, or some irregularity in the alimentary canal. An active cathartic generally removes it, with the insertion of a few drops of laudanum, ether, or the tincture of digitalis into the ear.
I have attended a lady, the mother of seven children, who is first warned of her conception by a severe ear-ache. It happens occasion- ally until the sixth month of her pregnancy,' when it entirely disap- pears. Twice I applied mustard cataplasms behind her ear, but she has been usually relieved, by the introduction into the external meatus of cotton impregnated with the tincture of digitalis, preceded by a gentle dose of sulphate of magnesia.
If a diseased tooth is the cause of ear-ache, it should be extracted, or remedies applied for the relief of pain to the tooth. For this pur- pose opium and camphor may be applied directly to the tooth, or ether on the cheek of the affected side.
In the decline of malignant fevers, ear-ache sometimes supervenes, which, when severe enough to require medical attention, is overcome by the common topical applications. Sialogogues are recommended by Dr. Good.
Dr. Kennedy of Glasgow has broached a new practice in the treat- ment of acute inflammatory ear-ache.
The following case illustrates his pathological and therapeutical views.
"D. G. a lad of sixteen, of full habit and healthy, experienced a general chilliness, and other feelings of discomfort, in the evening after travelling in a stage coach, the windows of which were occasionally let down during the journey. At the same time the atmosphere was moist and cloudy, while a cold wind blew from the north-east, and his right side was, in consequence exposed to its action. At night he bathed his feet in warm water, had a warm drink, and went to bed, complaining very much of sharp wandering pains in the throat, neck, and right side of the face, with increasing difficulty of degluti- tion, and a stinging, deep-seated pain in the ear. Next morning early, he was roused from an unrefreshing slumber, by a severe pa- roxysm of ear-ache, accompanied with aggravation of all the precursory symptoms. For that day and the following, he was subjected to the
38
Lehman's Remarks on Otitis.
discipline of a domestic treatment, composed chiefly of saline aperients, in defective doses, frictions of the throat, with ammoniated liniment, and the insertion of laudanum on cotton into the affected ear. Such means however proving insufficient, the disease progressively advanc- ed, and late on the third day came under my observation as a true otitis, distinguished by the certain signs, local and general, of inflammatory excitement. On this occasion, slowness of the bowels, loaded tongue, heat and constriction of the skin, hoarseness, head-ache, with throb- bing of the cephalic and cervical vessels, difficulty of swallowing, sense of cold all along the spine, excessive sensibility, and tumefac- tion of the right side of the face, eyelids and neck, and an excruciating pain within the ear, which underwent intense exacerbations, with much disturbance of the respiratory and sanguiferous functions, af- forded the grounds of a therapeutical indication.
Without loss of time, an active emetic, thirty grains of ipecacuanha, and three of the antimonial tartrate, was administered: its effects were powerful but not excessive; and the advantages derived from them were immediate and decisive. Before the last paroxysm of vomiting ceased, all the more urgent symptoms had nearly subsided; and the patient on reclining himself to rest, soon fell into a tranquil sleep, during which a general and profose perspiration supervened. Before midnight three copious alvine dejections were obtained: and he passed the morning in a state of uninterrupted repose."
Dr. Kennedy concludes, from the history of this case and others, that acute, and even complicated otitis, may be subdued by emetics and cathartics without the assistance of blood-letting.
I have pursued the course here adopted in two similar cases, but without the same fortunate result. In both instances bleeding topi- cally, blisters and warm fomentations, eventually overcome the in- flammatory diathesis. Indeed, from direct experience and analogy, it is very doubtful in the acute forms of the disease, simple or com- plicated, whether any other remedial agents would accomplish the cure. The usual characteristics of inflammation on visible parts are heat and pain, redness and increase of the part diseased, and no doubt similar changes exists in all internal inflammations, or those which are not ocular. It is at first limited to a point, but by continued sympa- thy embraces contiguous parts, and sometimes parts so remote as to excite no little astonishment.
Mr. Hunter explains very beautifully the origin of inflammation, by comparing it to a blush, or a simple increase of the diameter of the vessels in consequence of the application to them of the irritant, whatever it may be which originates this new action,
Lehman's Remarks on Otitis.
39
H. S. mate of the schooner Maryland, had a severe attack of bilious fever, June 1827, directly after leaving the port of Tampico*
In consequence of laying under the steerage hatch, on the night of June 27th, in a hard shower of rain, and high wind from the north- west, his left ear being exposed to their combined influence, the next morning he suffered severe pains in his ear and temple. He vomited almost incessantly for several days during the incipient stage of his fever, which afforded no relief to the ear-ache; but on the contrary, increased the paroxysms. Eventually he came under my care in the quarantine hospital, in a very reduced and feeble condition, and the pain in the ear was mitigated, and at last cured, by the repeated ap- plication of blisters behind the ear, and occasional purges.
Nevertheless, it is probable, that when the excretory ducts and vessels of the ear partake of the collapsing influence of cold, in com- mon with the head; and soreness of the face, and stiffness of the cer- vical muscles, prevail in addition to the pains of the ear, relief may be procured by the nauseating effects of emetics, creating an increased excretion of the salivary glands, and Schneiderian membrane; and relaxing the extreme vessels in the meatus externus, and contiguous parts.
My practice is, when called upon to prescribe for otitis, where the general system and brain are not affected, to direct a purgative me- dicine, pediluvium of hot water, and cotton impregnated with the tinc- ture of digitalis inserted into the ear. It has afforded according to my observation, ("casteris paribus,") more alleviation than lau- danum. But to depend upon that or any other medicine wholly, when the constitution is affected, would not be consonant to sound therapeutical views. The general symptoms, idiopathic and sympa- thetic, must not be neglected.
The following cases are offered in illustration of my views and prac- tice, in this painful and sometimes dangerous affection.
Case I.— J. S., seaman, aged twenty-four years, a stout, robust man, slept on the deck of a vessel on the night of September 30th, 1823. The early part of the evening was clear and sultry; during the night the wind hauled round to north-west, and blew fresh for some time, and was followed by a hard shower. At daylight the thermometer was 47°. The rain awakened him, he went below and fell asleep in his wet clothes.
October 1st, P. M.— -I was requested to visit him. Complained of a dull pain in his right ear, which had been exposed, considerable weight in his head, and indisposition to eat. R. Hydr. sub. mur.
40
Lehman's Remarks on Otitis.
gr. xx. ; convol. jal. gr. xx. and a bandage of flannel to be bound round the ear.
2d. — The medicine operated copiously; passed a very restless night; pain in his ear sharp and lancinating, extending to the temples; pulse 96 a minute; tongue slightly furred. Venesection, §xx. R. Sulph. mag. §j. and apply a blister behind the ear. During the day expe- rienced a little relief.
3d— In great agony, and flighty all night. Pain in his ear conti- nues sharp and cutting; pulse full and strong; very irritable. Vene- section, ^xx. Renew the epispastic, and give ol. ricin. §j. Tepid water to be injected into the external meatus. Symptoms much ex- tenuated during the day. At night the pain returned with great se- verity. I dropped ten drops of the tincture of digitalis into his ear, placed in the meatus cotton impregnated with the tincture, and ad- ministered forty drops of laudanum.
4th.~ Slept well the latter part of the night; entirely free from pain this morning. The disease was completely subdued, and he had no return of it.
Case II. — R. B. a shoemaker, aged thirty-one years, was engaged with a companion in a pugilistic affair on the 22d of February, 1825. During the fray his antagonist struck him on the left ear with a large, stone, which, from the violence of the blow, terminated the conflict.
On the 25th, when I first saw him, complained of severe pain in his ear. It was tumefied, and the external meatus filled with coagu- lated blood. I ordered twenty leeches to be applied behind the ear. R. Sulph. mag. ^j. and the coagulated blood washed away with warm water.
26th. — Pain in the ear excruciating, extending to the crown of the head, and stiffness of the cervical muscles. Venesection, §xij. R. 01. ricin. ^j. and a pediluvium of hot water.
27th. — Passed a very uncomfortable night. This morning flighty; incoherent in his observations; pulse 86. Venesection, §xvj. R. 01. ricin. §j. and a common bread and milk poultice applied over the af- fected ear.
2Sth. — No better; pains lancinating through the ear and side of the face. Venesection, §xiv. A vesicatory behind the ear. R. Sulph. mag. ^j. P. M. Much relieved.
March 1st. Passed a tolerable night; pain confined entirely to the ear, and throbbing; general excitement alleviated. Directed warm olive oil into the ear, a pediluvium of hot water, and the blister to be dressed with basilicon ointment.
Webber on Gangrenous Erosion of the Cheek. 41
%d. Pus discharged from the external meatus; violent symptoms all gone. Tepid water injected two or three times a day to carry off the pus. A moderate discharge continued for a few days, and then ceased; all constitutional irritation terminated.
A dull and heavy pain remained for sixteen days, which was me- liorated, and eventually ceased, upon keeping cotton saturated with the tincture of digitalis in the ear.
I do not assert that the tincture of digitalis cured these cases; un- questionably much is to be attributed to the previous reduction of the phlogistic diathesis by venesection, &c. Relief, however, spee- dily followed the application of digitalis, especially in the first case. This medicine, it is notorious, has a direct and powerful sedative in- fluence on the arterial system when taken into the stomach, and why may it not operate externally in a similar manner ? My object, how- ever, is to state facts, and not to theorize.
That digitalis reduces vascular action is indisputable. Some emi- nent physicians have confided so much in its sedative powers as even to make it a substitute for the lancet in the incipient stages of in- flammation. Although this practice cannot be approved, there is strong reason to believe, that like opium, it has been excluded in cases of reduced arterial excitement, when prompt and permanent benefit would have succeeded its administration, both internally and externally.
That the capillaries of the part are always the seat of inflamma- tion, is well established by Bichat, and the physician who has never seen a speedy reduction of topical inflammation by local remedies, after the failure of the most copious and general evacuations, has had a very limited experience, or been culpably negligent in his ob- servations.
Art. VI. On Gangrenous Erosion of the Cheek. By Samuel Web- ber, M. D. of Charlestown, New Hampshire.
In the American Medical Recorder, for July, 1827, there is a paper by Dr. Jackson, of Northumberland, Pennsylvania, containing a number of cases, with remarks, of a disease of children, which he proposes to call Gangrsenopsis, being the same called " Gangrenous Erosion of the Cheek," by Burns and Underwood, in connexion with which Burns slightly notices, under the name of Noma, another and more destructive variety. The complaint, in its severer forms, ap- No. IX.— Nov. 1829. 5
42 Webber on Gangrenous Erosion of the Cheek,
pears to be one of rare occurrence, and is little noticed by medical writers. Milder instances of it, if I may judge from my own limited experience, are not very unusual, but are passed over without parti- cular notice by physicians, in consequence of being considered merely as varieties of aphthous sore mouth with which children are frequent- ly afflicted as a concomitant or sequel of other diseases, particularly bowel complaints. Still they agree so well in every respect, except severity, with Dr. Jackson's description, as well as that of the above- mentioned writers, that I cannot but consider them as modifications of the same disease. It has been my fortune, in the course of two or three years, to meet with four instances, three of the milder kind, and one of the most severe form, answering to the Noma of Burns. These I am induced to make public, with the view of contributing any little in my power to the elucidation of a malady obscure in its nature, and which seemingly has attracted but little notice.
Case I.-— I was requested to see a female child of about two year^ of age, on account as was stated of a bad sore mouth, which had last- ed some days and resisted all common domestic remedies. I found her with the left cheek very much swelled, tense, shining, and white, with a slightly marbled appearance. The swelling on one side extended down on the throat over the submaxillary and sublingual glands, up- wards to the eye, forward over the ala nasi of that side, and the whole of the upper lip. From the pain and soreness it was with dif- ficulty I could get the child to open her mouth sufficiently to let me see any of the internal surface of the cheek, and my view was very imperfect. The gums and inside of the lips were swollen and aph- thous. The swelling of the cheek seemed to project internally, so as to press between the teeth when they were separated, and on the centre of the swelling was a whitish spot about the size of a half dime, seemingly with raised edges and inflamed base. The secretion of sa- liva was profuse, so as to keep up an almost constant dribbling, and the breath had a peculiarly disagreeable smell, like that of putrefying animal matter. The child's general health did not seem much affect- ed; she had previously been troubled with diarrhoea, which had how- ever then ceased. There was a little appetite, but she was unwilling to take any thing but drink, apparently from the pain of swallowing. The tongue was furred, and there appeared to be a little febrile irri- tation, as if arising from the local disease. The treatment pursued was gargling and sponging the mouth, particularly the inside of the cheek, several times a day, with the following mixture. Muriatic acid, alcohol, aa. gut. xv. ; water, §j. a little being swallowed more
Webber on Gangrenous Erosion of the Cheek. 43
diluted after each abstersion. A purgative of four grains each of ca- lomel and rhubarb was given, at first every day, after two or three repetitions every second or third day, till the bowels appeared in good order and the tongue clean, after which rhubarb alone was given as a laxative till the cure was complete, which took place in about three weeks ; the diet was of mucilaginous and farinaceous drinks at first, and afterwards of milk and cracker. The amendment was slow and gradual $ the swelling subsiding, the salival discharge becoming less, the ulcer contracting, and the fetor of the breath diminishing, till they finally disappeared.
Case II.*— In August of the same year, 1827, a much slighter case occurred in a younger subject. This was a feeble child, of eighteen months old, who had suffered greatly all the preceding summer, first with hooping-cough, and then with frequent and troublesome di- arrhoea. The general character was the same as in the preceding case, but the diseased appearances less strongly marked. The cheek was perceptibly but not greatly swelled, and the white spot as large as a small vest button. It gave way to infusion of Statice limonhim with alum and honey as a local application, together with the internal use of cinchona and carbonate of soda, in infusion, for the general health.
Case III. — -This occurred in the succeeding October, and followed a severe erysipelas of the right leg, beginning at the ankle, and ex- tending to the groin before it was finally subdued, and arising from a slight scratch, as was supposed, from a bramble, on the inner ankle. The patient 'was a tolerably healthy girl of twelve years of age. In severity this case was about midway between the two before related, and yielded to similar local applications, with the use of light nou- rishing diet.
Case IV. — This happened in September, 18£8, in a little girl ten years old. It ensued upon typhus, in which diarrhoea had been a troublesome symptom. About the fourteenth day, when the fever was apparently beginning to abate, she complained of a feeling of sore- ness and pain in the left cheek, not far from the angle of the mouth. The part was slightly swollen, somewhat hard and reddish, like the commencement of a boil. Volatile liniment with laudanum was ap- plied, and the redness disappeared, though the swelling continued, being however less hard and rather more diffuse. A day or two after some aphthae appeared in the mouth and fauces, for which a gargle of diluted muriatic acid was employed. She complained, however, of
44 Webber on Gangrenous Erosion of the Cheek.
the cheek's being hotter and sorer, and the swelling had evident- ly increased. On the inside of the cheek it protruded in a ridge between the teeth. Lead water was used externally as a constant application, in addition to the occasional use of the liniment above mentioned, and the inside of the mouth was frequently touched with honey acidulated with muriatic acid, small quantities of wine were given, and one-fourth of a grain of sulphate of quinine thrice a day, also small doses of Dover's powder to regulate the bowels, still rather too loose, and to procure sufficient rest. The cheek nevertheless continued to swell, and the breath became very foetid with the odour before mentioned. The aphthae nearly disappeared in a day or two, but upon the most prominent part of the internal swelling of the cheek was a kind of flabby pustule or blister, seemingly beneath the whole thickness of the internal integument, which over the swelling was opaque and of a dirty white colour. This broke the same evening, discharging a small quantity of foetid fluid, and leaving a sloughing appearance of its membranous covering. It was repeatedly touched during the night and the following day with a strong preparation of muriatic acid and honey, sufficiently caustic to corrugate the sloughing membrane and make it settle down below the level of the surrounding parts. This it was hoped would put a check to the diseased action, and cause the slough to separate. Notwithstanding, it continued to increase during the subsequent night, and on the next morning had nearly reached the angle of the mouth, which looked dusky, cracked, and approach- ing to a state of gangrene. An eminent practitioner from a distance met me in consultation this morning, and advised carrot and fer- menting poultices with charcoal over the cheek, a small blister ex- ternally across the angle of the mouth, and one on the inside of the cheek, of a size sufficient to cover the slough and the surrounding sound edges, while the internal remedies were continued in increas- ed doses. The disease however proceeded with redoubled rapidity. Gangrene in undisguised blackness passed in a few hours across the external blister, and at the same time came through the cheek oppo- site to the point on the inside first attacked. In spite of the assidu- ous application of fermenting poultices with charcoal, these spots spread so as to coalesce in the course of the night, and by next morn- ing to involve most of the unattached portion of the cheek. The case was now deemed hopeless and dissolution was soon expected. The foetor being excessive, with a view to lessen it, the part was covered with a cloth wet with a solution of chloride of lime, (bleaching pow- der.) This also lessened the rapid spreading of the gangrene so much, that for hours it seemed almost entirely stationary, but did not be-
Sexton on the Climate of the Fortieth Degree. 45
come wholly so, though it went forward very slowly, till it had co- vered the whole of the swelling existing at the time of its commence- ment, reaching almost to the lower eyelid, over the membranous part of the nose on the same side, the septum, two-thirds of the lips, and half of the chin, including all the cheek to below the under edge of the lower jaw, and backwards nearly to the ear.
The parts were completely sphacelated, and had nearly separated, when at the expiration of twelve days from the first appearance of danger, the little patient died, completely exhausted. All the pecu- liar symptoms of the fever had entirely subsided, long before her death,
Charhstown, N. H. August, 1827.
Art. VII. Remarks on the Climate and Vegetation of the Fortieth Degree of North Latitude. By Richard Sexton, M. D. of Bal- timore, Maryland.
Eastw ARD from the most elevated ridge of the Allegany moun- tains, the fortieth degree of latitude embraces land for the distance of about two hundred and fifty miles, comprehending a portion of each of the states of New Jersey, Pennsylvania, Delaware, Maryland, and Vir- ginia. This extensive territory comprises three well defined natural divisions: one, situate east of the falls of the rivers, is known by the name of the low country ; another, placed between the low country and the foot of the mountains, is denominated the high or hilly coun- try; and the third is recognized in the mountains themselves.
The low country within the fortieth degree, is remarkable for the levelness of its surface; being, indeed, chiefly a plain, the undulations of which rarely attain the height of eighty or one hundred feet above the water in the rivers. The tide traverses the whole of this divi- sion, and the streams either partially or wholly contained within it generally diverge into wide, and, when compared with their breadth, shallow expanses of water. The line bounding the low country by passing through the most eastern falls in the rivers, commences near Philadelphia, on the Schuylkill, and thence tends toward the south- west; being found on the Susquehanna at Port Deposit, on the Pa- tapsco west of Baltimore, and on the Potomac at a short distance above Washington. In soil, the low country is generally sandy and unfer- tile, being indeed in some places quite sterile, though productive dis-
5*
46 Sexton on the Climate of the Fortieth Degree.
tricts are interspersed throughout the division, and particularly along the borders of the streams.
West of the low country, the surface immediately runs into hills, the summits of which are elevated from four hundred to one thousand feet above the range of the tide. Here the soil is frequently rocky or stony, and whilst the eminences are barren, the vallies are famed for their fertility. This hilly tract measures, in a western direction, from thirty to ninety miles, ending at the Conewago and Monocasy, which rivers meander along the foot of the mountains. The various ridges of the Alleghany chain, ascend, in this latitude, to the height of from one thousand live hundred to three thousand three hundred feet over the plane of the Atlantic.
Forests are universally acknowledged to exert a powerful influence on the climate of a region. By embracing in one view the three di- visions just described, we presume that the trees and shrubs which originally shadowed almost the whole surface, will be perceived to cover at present less than one-half of it. In the low country, two- thirds of the soil without doubt are cleared and under cultivation, whilst the mountains, both from the nature of their surface, a portion only of which will admit of tillage, and from the paucity of their in- habitants, have undergone but a small change from their primitive condition.
To these prefatory remarks we may add, that since difference in altitude will always cause a variance in meteorological phenomena, each of the natural divisions of the territory under consideration, must, consequently, exhibit certain features of climate peculiar to itself. The general temperature of the atmosphere, is, of course, greatest on the low country, and least on the mountains. On the lat- ter, the weather is generally similar to that which occurs along the sea-coast, two and three degrees to the north. Within one degree of latitude, however, little other variation can be detected in the aerial phenomena, than that produced by diversity of elevation, or that effected by dissimilarity of surrounding surface.
The four seasons attributed to regions in the temperate zones, are well denned in the fortieth degree. Each season nearly or quite oc- cupies its proportionate part of the year. The spring is recognized in March, April, and May, by a steady and gradual increase of the temperature, which averages for the whole period about 54°, and de- velopes the foliage of the whole vegetable kingdom. The summer, evidenced by the extreme heats of the climate, follows in June, July, and August, which months possess a mean temperature of 74° to 75°.
Sexton on the Climate of the Fortieth Degree.
47
The autumn is marked in the three succeeding months by the gra- dual decline of the heat, so that its average becomes about 56°, and by the slow but complete extinction of deciduous vegetable life. The winter, following in December, January, and February, with its train of snows and frosts, offers a mean temperature as low as 35° or 33°. Allusion is here made to the seasons in the low country, to which di- vision all other remarks are to be considered applicable, without the contrary is expressed.
It were a perfection in the climate of any region did the atmospheric phenomena always progress in some regular manner, since all those numerous transactions in society which are more or less influenced by them, could, in that case, be executed with a greater probability of success; and human life itself, constantly jeopardized and destroy- ed from ignorance of future weather and temperature, would be held under a less precarious tenure. The climate of no part of a tempe- rate zone, however, is distinguished by such regularity. In this lati- tude, where the weather is noted for a peculiar inconstancy, we scarcely hope for a similarity in the seasons of two successive years, as experience proves that the same season is constantly varying in its heat, in the quantity of moisture, and in the number, suddenness, and excess of its vicissitudes. The first effects which the vernal at- mosphere produces on vegetables, are usually perceived in the first or second week of March, by greenness commencing on the earlier developing plants. The severe frosts, to which March is obnoxious, nip these early productions, and the month altogether is too cold for a hasty vegetation. But in April, the unfolding of leaves and flowers advances speedily, and after this month meets with no interruption. The range of the dates at which vegetation commences is very wide. February sometimes adorns the fields with the verdure of their miscel- laneous plants. In 1824, the pastures appeared green in January, whilst sprouts two inches in length protruded from the common elder? (Sambucus nigra,) and similar untimely appearances are recorded of January, 1828. On the other hand, all the deciduous organization has been observed locked fast within the bud, until the concluding days of March.*
A period of note in the progress of the year, is that of the display of the blossoms on the fruit and forest trees. The former commonly flower in April, and the latter at the end of the same month, and in
* This was the case in the spring of the present year, 1829. We here re- mark, that all the facts it is found necessary to relate, were obtained either from our own observation, or from authority of unquestionable accuracy.
48 Sexton on the Climate of the Fortieth Degree.
May. The range in the dates at which, in a series of years, any kind of tree commences to bloom, measures in length in an inverse ratio to the quantity of heat necessary to effect this expansion on it. Thus, during the last nine years, the dates of the blossoming of the peach tree include one month, whilst those of the Liriodendron but eleven or twelve days. The peach tree, in 1808, was noticed in the pre- cincts and neighbourhood of Baltimore, covered with flowers on the 28th of February; and in 1828, the same development recurred in the south of New Jersey, during the first week of March; but in 1821, this tree did not blossom until the 29th of April. These dates are offered as the extremes of the period during which efflorescence commences on this extensively cultivated fruit-tree.
The idea of a vernal season is habitually associated with those of a mild temperature and a serene sky, and although an inhabitant of this latitude may occasionally in the spring enjoy the reality of this poetic combination, yet the facts fail to distinguish the chief part of the weather of the season. The atmosphere during March and April, and frequently during May also, is excessively variable in its tempe- rature and perceptible moisture, whilst chilling and wet weather oc- cupy a considerable portion of the time. This character of the spring is principally obtained from the extensive sweep taken by the preva- lent winds: the south-west brings the air from the tropic, and even from near the equinoctial line;* the north-west comes forth from re- gions beyond the mountains and lakes, where the snow and ice are as yet undissolved; and the north-east arrives from the seas about Newfoundland, which at this time in the year are covered with a cold atmosphere, remarkably surcharged with moisture. The change of one of these winds for another, will cause the temperature of one day to differ 20° or 25° from that of the preceding, and the north-west following the south-west often effects a sinking of the mercury 28° or SO0; as much sometimes as 35° between an afternoon and the fol- lowing morning. Such depressions in the thermometer, which before the middle of April ranges commonly between 40° and 60°, and rises but on a few days to 65° or TO0, must consequently at times effect a congelation of the water in the atmosphere and on the ground: less or more of snow and ice is indeed always expected in March. In the last ten years there are recorded three instances of deep snow in April. The first is on the 14th of this month, in 1828, when the earth about the city of Philadelphia was covered six or seven inches deep, and sleighs ran for some hours on the highways.. The second
See Volney's View of the Soil and Climate of the United States,
Sexton on the Climate of the Fortieth Degree.
49
instance is on the 3d of April, 1825. In the third instance, which occurred in the first week of April, 1820, the snow, which fell to the depth of five and six inches, remained on the ground in places for more than a week, whilst the cold succeeding the storm was sufficient- ly intense, on two mornings, to depress the mercury to 18°.* By the same event, the mountains were covered a foot and a half in depth. In the year 1803, the ground was concealed by a fall of snow, on the 8th day of May. At this advanced date, the produc- tion of snow must, without doubt, be analogous to that of the hail fre- quently falling in the middle states in May and June, and to that of the sudden precipitation of water, attended with lightning and thun- der, common to the whole warmer portion of the year. The latter phenomena are indisputably the effect of irruptions of cold currents, from the higher regions of the atmosphere into the warmer and moister stratum of air, lying next the surface of the earth.
April forms the customary limit to frost. During the first ten days we usually observe the last instances of a freezing temperature. In an occasional year, the north-west winds will depress the mercury to 29°, and 28°, as late as the twentieth; and ice on small shallow pools, which may be formed, according to Jefferson, with a morning tem- perature as high as 38|° will be noticed in the first part of May. It is the occurrence of frost after the blossoming of the fruit trees, that renders a profitable cultivation of them so uncertain. To failure in the production of their fruit from this cause, the apricot, the species of Jlmygdalis, and their varieties, are especially liable: but, it is a curious fact, that the fortieth degree is more propitious to the culti- vation of these fruits, than the latitudes adjoining on the south, for in them the trees blossom earlier, whilst the" severity of the frosts of April and May appears to be very slightly diminished. t
The extreme heats of the climate usually commence in the begin- ning of June. During this month, July, and August, the daily fluc-
* Since the thermometer is affected variously in different situations, it is ne- cessary to state, that throughout this paper wherever reference is made to the indication of the instrument, its position invariably was in the open air, eight, twelve, or fifteen feet above the ground, where it was freely exposed to the wind, and in the middle parts of the day surrounded by an extensive shade. Without a particular hour of observation is specified, but two kinds of tempe- rature are ever alluded to; the minimum and the maximum of each twenty-four hours.
f At Richmond, Virginia, on the 25th of April, 1823, tubs of water exposed through the night were found frozen over. This city is in the latitude of 37£°.
50'
Sexton on the Climate of the Fortieth Degree.
tuation of the mercury is customarily embraced by points between the sixty-fifth and eighty-fifth degree: and, on averaging the highest temperatures of the whole number of days, there will commonly be obtained a result of from 80° to 82°. May and September, with the summer months, contain all the hot weather; and when these import- ant five months exhibit ordinary warmth, they include sixty or se- venty days, with a heat in the afternoon as great as 80° or more.
The coolest summers are almost always those that are most rainy. Their coolness obviously results from the frequent communication of the temperature of the higher,* to the lower strata of the atmosphere, by the descent of the rain, from the subsequent evaporation of the water, and from the frequent canopy of cloud, which prevents the earth from receiving its usual amount of heat from the sun. The summer of 1814 is memorable for uncommon wetness; and its cool- ness was proportionate, since, according to a statement in the Medi- cal Recorder, of 1818, the mean heat, at S P. M., of June, July,^ncl August, collectively, was lower in 1814, than in any other year, from 1793, to that of the date of the publication. Coolness throughout a summer is, however, occasionally attended by dryness, as was in- stanced in 1816. During a considerable part of the remarkable sum- mer of this year, a haze was diffused in apparently the superior re- gions of the atmosphere; and which at times intercepted so many of the sun's rays, that he could be attentively viewed without inconve- nience to the eye. What subjected this phenomenon to general re- mark, was, that the sun's disc, at a part of the time, contained seve- ral dark spots, which, being visible without the aid of glasses, excited universal attention. White frost was observed on five successive mornings, terminating on that of the 11th of June; also on the 21st of the same month, and even in the first week of July. At the latter part of August the ground was again sprinkled with frost; the mer- cury having fallen to 46°. Many districts suffered by drought during this summer; and the frosts of June, with the general coolness of the season, were so unfavourable to the maize, that in some places not half the usual crop was produced: the later ripening varieties failing entirely to mature.
The most intense heats of the summer are designated on the ther- mometer by 90, 93, 96, 98, and 100 degrees. The mercury arrives
* On the morning1 of the 4th of May, 1827, frost and ice were observed, and the tender garden plants were quite destroyed, even as far south as at Cheraw, in South Carolina.
Sexton on the Climate of the Fortieth Degree.
51
among these points, on at least three or four days of every summer, and in some seasons on ten or fifteen days. The frequency of the elevation to these extremes is not always proportionate to the gene- ral temperature of the season.
Among the summers of the present century, those of 1819 and 1827, are the most distinguished for extreme heat We are inform- ed from the observations of Mr. Brantz,* that during the five warm months of the former year, the mercury, even as early in the after- noon as at two o'clock, stood at or over 80° on eighty-one days; on thirty-three of which number the temperature exceeded 89°.
In 1827, from the first of May to the 30th of September, the ther- mometer rose to or over 80° on ninety days. Twenty-two of these exhibited the instrument above 89°. The extraordinary heats of 99° and 100° were indicated in all cool out-door situations, on the 5th and 6th of August.
The higher situations on the mountains are never visited by heats of that intensity, remarkable in those experienced on the plains. In- valids and fashionables, who, in the summer, retire to Bedford, situ- ate near the most elevated ridge of the Alleghany chain, find thick clothing, with fires in the mornings and evenings, necessary to their comfort in July and August. White frost is occasional in these months, and even ice has been gathered from small pools of water in July.
The autumn is, to the majority of the population of this parallel, the most agreeable of the seasons. During the latter part of Sep- tember, and quite the whole of October, the weather is most com- monly serene, and the temperature usually remains in that condition which neither produces a sensation of unpleasant warmth, nor, to the healthy, sufficient coldness to render fires necessary for their com- fort This period has been declared by Americans of observation, who have spent years in Italy and southern France, to excel the most pleasant seasons of those countries, so famed for the beauty of their climates. Slight white frosts are noticed on low grounds in the lat- ter half of September, and general white frosts, caused by a morning temperature of 42° and 40°, appear in the first ten days of October. These expedite the change and fall of the leaf on the delicate forest trees, though they injure but slightly the verdure of the hardy trees, and that of the tender field and garden plants, as all these vegetate
* This gentleman has recorded the meteorology of several yeays. His very accurate and instructive observations were published, in monthly tables, in the Baltimore Gazette.
52
Sexton on the Climate of the Fortieth Degree.
until the latter part of October, when a series of heavy frosts, pro- duced under a temperature near or below the freezing point, destroys almost the whole of the deciduous vegetation. *
The variation in the dates of the occurrence, and in the severity of the first autumnal frosts, is considerable. September sometimes passes away without a temperature lower than 50°, which is a depres- sion scarcely great enough to effect the slightest congelation of the dew. In 1822, the tobacco, palma christi, and plants of a similar tenderness, were seen in open places, but little injured, as late as on the 25th of November. In 1823, on the contrary, the same plants were destroyed in the last week of September. But although we view occasional irregularities in the weather of the autumn, it is, nevertheless, distinguished in successive years by a greater similarity in its meteorology than appertains to any other season.
The winter is characterized by excessive variability. This portion of the year consists entirely of a continued alternation of snow and severe frost, with storm, rain, and occasional temperate and serene weather. The average heat of any of the months, when compared with that of the same month in another year, may be found to differ 20°, or even more, and the more remarkable phenomena of the sea- son, the ice and snow, constantly vary in different years, both in their quantity and in their duration.
The falls of snow are commonly under six inches in depth, and they occur at five, seven, or ten times during the three winter months. It is unusual to see the surface of the ground entirely or nearly co- vered with this emblem of the season for more than a week at once, for the sun, with a clear sky, dissolves it in open places, whenever the temperature of the air rises even near to the freezing point. But in some years, falls of snow happening in quick succession will keep the surface in exposed places, if they be level, quite covered from three to five weeks together. Thus, in 1817, the snow lay from two to six and eight inches deep, from the 19th of January to about the same date in February, and in 1820, the surface was hidden by it during nearly the whole of January. In the winter of 1820-21, snow concealed the ground, with the exception of a few of the eminences, from the 26th of December to the first week of February, and at a part of the time measured, on a level, eighteen inches in depth.
* Similar to the course of the late frosts in the spring-, the early frosts of the autumn extend themselves far to the southward. The first and only ice that was made at Baltimore, in October, 1827, was formed, one-tenth of an inch in thickness, on the 27th of the month. At the same date, as the public prints informed us, ice as thick as a dollar, was noticed at Charleston, South Carolina.
Sexton on the Climate of the Fortieth Degree. 53
As instances of that class of winters which are most deficient of snow, may be offered these seasons in 1825-26 and 1827-28. In the former, snow fell but once, to remain on the ground more than a day; its depth was then four inches, and it had disappeared in a week after its fall. No snow was perceived on the ground, either in the preceding autumn or in the following spring. During the months of December, January, and February, 1827-28, snow was noticed on the earth but thrice, and the surface was never covered for tv/enty-four hours together.
The following is a statement of the extreme depression of the mer- cury in the last thirteen winters. One fact relative to the extremities of the temperature of this climate may here be remarked. In the last thirteen years, the degree of the greatest heat of each summer has occurred within the space of 8°, whereas the degree of the greatest cold of each winter has fluctuated among 27°, as the succeeding table evinces.
1816- 17, — 4° in February. 1823-24,
1817- 18, — 2 on the 10th of Feb. 1824-25,
1818- 19, . . 5 on the 18th of Dec. 1825-26,
1819- 20, —2 on the 1st of Jan. 1826-27,
1820- 21, —11 in Januaiy. 1827-28,
1821- 22, . . 1 on the 5th of Jan. 1828-29,
1822- 23, . . 6 in February.
In conclusion of these remarks on the course and variations of the seasons, we adduce the mean temperatures of the chief part of the months of six late years. The two columns of observations, formed from noting the minimum and maximum temperatures of every day, were added up at the end of the month, and the amounts divided by the number of their respective observations. From averaging two results formed by this method, each of the numbers which follow were obtained.
8° on the 5th of Feb. 9 on the 4th of Feb. 4 on the 1st of Feb. 4 on the 28th of Dec. 6 on the 22d of Jan. 1 in Jan. and Feb,
|
YEARS. |
January. |
February. |
March. J |
April. |
May. |
June. j |
*-> |
August. |
September. |
October. |
November. |
December. |
|
1823 |
33.3° |
27.5° |
39.7° |
54.2° |
62.7° |
70.2° |
75.6° |
|||||
|
1824 |
36.3 |
34.2 |
40.4 |
52.6 |
62.2 |
71.8 |
77.2 |
74.5° |
66.0° |
57.1° |
46.3° |
40.1° |
|
1825 |
36. |
36.6 |
45.8 |
53. |
62.7 |
75.1 |
79.1 |
73.8 |
66.6 |
33.8 |
||
|
1826 |
34.2 |
36.9 |
45.3 |
50.1 |
70.2 |
75.2 |
77.3 |
|||||
|
1827 |
30.4 |
40.9 |
46.7 |
59.6 |
65.5 |
72. |
78.3 |
76.8 |
66.1 |
56.3 |
42. |
41.5 |
|
1828 |
37.6 |
43.7 |
That an important change has taken place in the climate of this latitude since the early periods of its settlement by Europeans, will not at present admit of dispute, although fifty or sixty years back.
No. IX.— Nov. 1829. 6
54 Sexton on the Climate of the Fortieth Degree.
when the opinion was first agitated, there were many who did not give it credence. The meteorological history of the last twenty or twenty-five years is quite deficient of those relations of long-continu- ed cold, and deep and durable snows, which are recorded in close succession in the histories of the last century. A similar ameliora- tion in the temperature of the colder portion of the year has happen- ed in all the higher latitudes, when the countries which they traverse had become thickly peopled, and their soils had been subdued to a correspondent cultivation. It is now no longer doubted but that clearing the surface of the forests produces this effect. The ground being freely exposed to the rays of the sun, by the destruction of the shrubs and trees, becomes in consequence more intensely heated, and its incumbent air is immediately supplied with a greater quantity of caloric, for the earth is the grand reservoir whence the atmosphere receives its warmth. By this simple and readily explicable process, Italy and France now afford a congenial atmosphere to the orange and the olive, where the winters, one thousand eight hundred years ago, exhibited the rivers bound with ice, and the earth deeply and permanently covered with snow.
The more remarkable particulars of the change, which the climate of this latitude has undergone, appear to be as follow: — 1st, the wind is more variable; 2nd, the winds from the western semicircle have declined in number; 3rd, snow and ice are formed in smaller quantities, and are less durable, and the general temperature of the winters has increased.
1st. On referring to the causes, which are known to influence the motions of the atmosphere, the conclusion is obvious, that the aerial currents Would move with less regularity and steadiness, after large portions of surface, cleared and thereby rendered disproportion- ately hot, had become new powers in effecting motion in the atmos- phere, than when acted on solely by those causes, which permanently belong to the continent. There are but few facts preserved from the oblivion of former ages, which relate to this subject A late volume of the Transactions of the American Philosophical Society, contains the translation of the diary of a Swedish clergyman, who noted the courses of the wind on the Delaware, in the seventeenth century. I have not the work now before me, but from recollection, I state, that the tenacity of the wind to a few neighbouring points of the com- pass, as described by the Reverend observer, for exceeds that exhi- bited in journals of the winds of present years.
The Swedish professor, Kalm, who travelled in North America, in the years 1748 and 1749, has formed some valuable records of its
Sexton on the Climate of the Fortieth Degree.
d5
climate. In his register of the courses of the winds at Philadelphia, and at a situation in New Jersey a few miles southward of that city, we find the currents occasionally flowing from three or four adjacent points of the compass, for five and seVen days together: and, in the tabular observations of the celebrated Bartram, which were taken in the summer and autumn of 1749, and are appended to the work of Kalm, the wind is marked at several times to have blown from one direction five or six days in succession, and once, in the latter part of July, from the west for the space of eleven days. But the incon- stancy of those winds of longest continuance, the N. W., N. E. and S. W. is now so increased, that, allowing to each an eighth part of the circle for its vacillancy, its duration is rarely over two and three days. Tables of the winds for five years, offer not a single instance, when currents from within any eighth part of the compass, existed more than five days together.
2nd. Jefferson, in his Notes on Virginia, remarks relative to the east and south-east breezes, which commence in the afternoons, of the warm months especially, "that they have advanced into the coun- try very sensibly, within the memory of people now living, as they formerly did not penetrate far above Williamsburg, but are now, (1782, ) frequent at Richmond, and occasionally reach the mountains. " There is no reason to suppose, that this increase of the easterly winds was the effect of any other cause than the cultivation of the soil; from which similar changes in the motions of the atmosphere has doubt- less been produced in the whole maritime region, at least of the mid- dle latitudes of the United States.
Dr. Williamson, writing in 1770, observes, "that seamen, who are deeply interested in the subject, informs us, that in the winter sea- son they have been beating off our coast, three, four, or five weeks, not being able to put in by reason of the north-westers: they are now seldom kept off twice that number of days. *
In the ten months, between the first days of August, 1748, and June, 1749, Professor Kalm has recorded four hundred and seventeen ob- servations on the course of the wind. Of these, forty-six are marked with the cardinal points N. and S. : of the remaining three hundred and seventy-one, two hundred and seventy-three, or three-fourths, are on winds from the western, and ninty-eight, or one-fourth, on those from the eastern semicircle. Easterly and westerly winds occupy, at the present time, each about the same number of days in the year. Hence, we infer, that the decline of the westerly winds in eighty
* Transactions of the American Philosophical Society, Vol. I.
56
Sexton on the Climate of the Fortieth Degree,
years, equals one-third of their number at the commencement of that time.
The greater frequency of the winds of the eastern semicircle, most of which receive the abundant evaporation from the Gulph stream, may be offered as a sufficient explanation for that increased damp- ness in our atmosphere which has been noticed by Dr. Rush and others.
3rd. All accounts concur in the assertion, that for many years after the first settlement of the middle colonies, the earth, in this lati- tude, was partly or entirely covered with snow for three or four months annually. Forty or fifty years ago, when the decline of this conspicuous phenomenon of the winter had become a subject of gene- ral remark, the usual depth of the snow, in this season, was according to Rush, from six to nine inches, though sometimes between two and three feet: and, in uncleared districts, it occasionally lay until the first week of April.
We are informed by the same author, that in the year 1740, the river Delaware was crossed on the ice in sleighs at Philadelphia, on the 16th of March, and that the navigation to that port, did not open until the 24th of the same month, and that in the winter of 1779-80, this river was frozen across, at the same place, for nearly three months. In the year 1705, snow is related to have fallen a yard in depth= During the winter of 1697-98, the Delaware was passable on the ice for- sledges below Christiana creek; and the author, from whose work this fact is extracted, also states, that the same river is seldom frozen across at Newcastle.* Messrs. Mason and Dixon, whilst engaged in astronomical observations, about thirty miles west of Philadelphia, in the month of January, 1767, saw the mercury, in the open air, fall to 22° below zero. In the winter of 1783-84, the snow lay in many places in the south-eastern part of Pennsylvania, from two to three feet deep during the chief part of the season, and all the rivers, which were frozen up in December, continued bound until the middle of March, with the exception of a short time in January, when the ice was broken, but not destroyed. These are a few of the many in- stances to be gathered from history, which testify to that abundance of snow, and durability of cold, which, if not constant, was formerly very frequent in a series of winters in this latitude.
The season of 1820-21, exhibited more intense cold, and deeper snow, than any other winter of the last twenty or twenty-five years9 and, probably, than any other within the present century. The navi-
* Kalm's travels, Vol. L
Sexton on the Climate of the Fortieth Degree.
gation to the cities of Baltimore and Philadelphia, was closed from the 24th of December, to the 16th of February, a space of nearly eight weeks. A north-east storm on the 6th of January, buried the surface fourteen and sixteen inches deep with snow. The same month con- tained the whole of the very intense cold of the season. The mercury was observed below zero on three mornings: yet one circumstance is remarkable in comparing the temperature of January of 1820-21, with that of the same month in 1779-80: in the latter, the mercury, ac- cording to Rush, rose to the freezing point but on one day, whereas in the former, fourteen days are marked by Mr. Brantz above that point. The river Delaware was frozen over, in this winter, for twenty or twenty-five miles below Philadelphia.
There are handed down to us, however, a few memorable instances in ancient winters, when a remarkable mildness usurped the place of their customary severity. Swedish records state, that flowers were seen in the woods in February, 1714.* In or about the year 1756, apple trees were noticed in full bloom, and bearing young fruit, in December. But we are assured, from the unanimous assertion of aged persons, as well as from the Indian adage, "winter never re- mains in the sky," a conclusion founded of course on long experi- ence, that such untimely mildness, was either preceded or followed by a full measure of wintry severity.
The extreme degree of cold to which the fortieth degree is liable, is, perhaps, still as great as it was one hundred years or more ago. This extremity attends north-western winds, and according to the received opinion, that increase of the general temperature, follows solely from the clearance of the surface, since the countries north- west of the lakes, have not undergone such a change, the atmosphere cannot have been altered in temperature at their sources. And, although in passing to the sea, the cultivation which the mountains and lands eastward have received, may usually mitigate the coldness of these winds, yet, they must disseminate their original temperature along the sea-coast, whenever they are of long duration, whilst the country over which they proceed, is continuously covered with snow: for snow receives but little heat from the rays of the sun, whilst it refuses to conduct the caloric of the soil beneath. Within this cen- tury, the mercury has been seen at 14|° below zero, in the hilly coun- try, a few miles from Philadelphia, and at 11° below the same mark,
* Some plants require but a low temperature for the production of their blos- soms. The red maple flowers at almost the commencement of the vegetating season: as also Pothos foetida, Sanguinaria canadensis, Anemone nemorosa, and many others.
6*
it
Henderson's Case of Osteo-Sarcoma.
m the immediate neighbourhood of that city. But there will doubt- less be an amelioration in this particular, when Canada and the United States shall become thickly peopled, and generally cultivated: in this latitude, then, like the same parallel in Europe at present, snow and ice will become rare phenomena, and the orange, the olive, and other vegetables of the same class, now strangers to the soil, will become objects of the labour and solicitude of the agriculturist.
Baltimore, August 1829.
Art. VIII. Case of Disease of the Bones successfully treated by the Internal Exhibition of Arsenic. By John Henderson, M. D. President of the Huntingdon County Medical Society. (Published by request of the Society.)
On the 10th of June, 1818, Miss Martha M'Elheny, aged seventeen years, was brought to Huntingdon, by her friends, in this neighbour- hood, with a view of obtaining my advice and assistance in a deplo- rable affection of the bones. On enquiry, I learned that the disease was first noticed about eighteen months before, when two tumours were observed, of the size of a nutmeg, about the middle of the ra- dius of the left arm; that these soon ulcerated, and from them nine spi- culse of bone were thrown off at different times; and that others were forming on other parts. For the removal of these tumours, she had placed herself under the care of a respectable neighbouring physician, who put her under a severe mercurial course, and continued the sali- vation for near two months ; which reduced her so low that, (to use her own expression,) "she could not raise her hand," with no other good effect, than that, during the mercurial action, the disease was kept at bay. Her debilitated situation precluded any further trial of the medicine, and the treatment was abandoned, after which the dis- ease resumed its course, and she was left to her fate. As soon af- terwards as she had regained sufficient strength to bear a ride of a few miles, she was brought to me.
She was then labouring under extreme debility ; countenance very pallid; dyspnoea and palpitation of the heart, to a distressing degree, upon the slightest exertion; constant irritative fever with night sweats; the catamenial discharge had never appeared. Her father and mo- ther's family had been remarkably healthy, no scrofulous or other he- reditary disease had ever appeared in either of them, as far as
Henderson's Case of Osteo-Sarcoma.
could be ascertained. Osseous tumefactions, of an oval form about the size of a small plum, had been formed around the second pha- langes of two of the fingers and thumb of the left hand, as well as on three of the right. The fingers appeared as if they had been insert- ed through the tumours, (which were of a pale white colour,) retaining their usual size immediately above and below them. The toes and metatarsal bones of each foot were similarly affected, and there were deep ulcerations of the ossa calcis and ankle joints, one os mala, one of the spinous processes of a dorsal vertebra, and one os femur and tibia also partook of the disease, and from all that were ulcerated there exuded a very foetid sanies, containing occasionally small pieces of bone.
Previous to this period I had met with but one case of an osteo-sar- comatous character, appearing to affect the whole osseous system; this was in the first year of my practice as a physician, and occurred in the neighbourhood of Chambersburg, in a child of Mr. Samuel Nicholson, about one year old. It being a disease entirely new to me, I requested the father of the child to obtain the advice of Dr, Physick, and I would carry his prescriptions into effect. Dr. Phy- sick directed a small portion of the oxymuriate of mercury, in solu- tion, to be given to the child daily, with a well-regulated diet; but upon a fair trial, even with very minute doses, we found that the sto- mach and intestines of the. child would not bear the medicine, it bring- ing on distressing vomiting and dysenteric symptoms, to an alarm- ing degree. It was then laid aside, and the child left to the opera- tion of nature. In a few months the bones of the toes, as well as those of the fingers, separated and fell off, the ankle joints were dislo- cated, and it sunk under the disease.
This case, of course, showed no safe precedent by which I could be guided in the present one; neither had I ever met with a similar one in the course of my reading, (which I must acknowledge has not been sufficiently extensive,) that had been relieved by the internal use of medicine ! It is true, I had met in my own practice, and also found in our books, a number of cases of a local nature, generally depending on local injury, in which amputation was the only remedy that held out a chance of relief; but when tumour after tumour arises in sue- sion on various parts of the osseous frame, involving so many bones, as in the present case, shall we remain spectators of the ruin of joint after joint, and calmly view its inevitable tendency to the destruction of the sufferer, without making a powerful effort to arrest its pro- gress? But, on the contrary, ought we not for that purpose rather push to the fullest extent any remedy that holds out the least pros-
60
Henderson's Case of Osteo-Sarcoma.
pect of relief? Here was a* constitutional disease, a general affection of the whole osseous system, and requiring general internal remedies to correct it, and I was left alone to judge of what those remedies should consist.
From the effect of the mercury formerly given in arresting the progress of the disease for a time, and the idea I then entertained of its substituting its own peculiar action for that of the disease, until a more healthy one should be resumed by the system, and the inability to bear it for a sufficient length of time to accomplish this purpose, I was induced to turn my attention to the selection of a medicine of the tonic class, whose action could be kept up, if properly adminis- tered, to an indefinite length of time; and I accordingly fixed on the white oxide of arsenic. With the use of this medicine I had long been familiar, in cutaneous affections, chronic rheumatism, scrofulous ulcers, and diseases of the intermitting form, and well knew that un- der proper regulation it could be so administered as to run no risk of the constitution being injured by a judicious application of it. The preparation I used was a saturated solution, made by boiling any quantity of the oxide in common water, in a Florence flask, for fifteen or twenty minutes, and after it had subsided, and the solution become clear, it was fit for use. I commenced giving it in doses of five drops, combined with a little camphorated tincture of opium, three times a day; but, least it should not be sufficiently expeditious in its effects, I also gave in conjunction with it, for a few weeks, a vinous tincture of cinchona, and the red oxide of iron; however, the latter was soon laid aside, as being deemed unnecessary, and the arsenic alone de- pended on.
After the medicine had been taken about three months, the tumours that had not ulcerated ceased to enlarge; and those that were open began to close up; and many appeared to be entirely healed; when my patient was unfortunately seized with the hooping-cough, attended with severe pulmonary affection, which forced me to lay aside my medicine, until the new disease should be overcome; a period of near- ly two month; when I found that all my previous exertions had been to little or no purpose, as the ulcers by this time had all opened out anew, and my patient nearly as ill as when I first prescribed for her. However, I had the satisfaction to know that I possessed a remedy at hand sufficiently powerful to controul, if not to eradicate the dis- ease entirely, and with confidence entered on its use a second time. In my calculation, I was not disappointed, but soon found it produc- ing its former salutary effect. I now gave positive instructions that on no account whatever, should it be laid aside; and fortunately no
Fahnestock on Rhus glabrum.
Si
accident occurred to interrupt us in its further use. From this time all went on well; no new tumours were found; those already exist- ing ceased to increase; and the open ulcers often throwing off some loose bone, soon healed. In about six months after resuming the medicine, the menses made their appearance; the disease seemed to be completely overcome, and I considered the cure confirmed; but through fear of a return, my patient of her own accord, continued long afterwards to take the medicine, which had now become so plea- sant a stimulant, that she compared its effect on the stomach to that produced by a small portion of spirituous liquor. It always gave her an appetite for food, in which she was not restricted, but allowed whatever was most agreeable; no unpleasant effect whatever occurred at any time from its use, but the quantity could never be increased beyond five drops, without producing vomiting, and long afterwards, on trial, two drops were found to produce the same effect.
In November, 1819, a large collection of fluid was discovered high up in the muscles of the right thigh, which, by pressure, could nearly all be forced into the pelvis; no pain attended it; I believed it to be produced by an ulcerated state of some inner part of the os ileum, and it yielded to blistering, camphorated volatile liniment, and a roller.
The medicine was regularly taken, three times a day, (with the exception of the time that the hooping-cough prevailed,) from the 10th of June, 1818, to the 1st of November, 1819, and my patient has been ever since, as healthy as she or her best friends could wish.
Art. IX. On the Rhus glabrum as a Remedy for Ptyalism. By William M. Fahnestock, M. D.
We are not fond of encumbering the materia medica with inert ar- ticles, nor do we feel ambitious of introducing new remedies, but yet it is not proper to reject a new substance without an impartial experiment, and particularly when one of gentle operation is propos- ed as a substitute for those of more irritating qualities.
The medications in use to check inordinate and protracted saliva- tion, are all of a highly stimulating, astringent, and often corrosive nature, as borax, myrrh, bark, alum, nitric acid, &c. which seldom fail to aggravate the sufferings, and create deeper seated irritations. Having seen very alarming, and even fatal effects, from salivation
62
Fahnestock on Rhus glabrum.
and the remedies employed to controul it, our attention was directed to the use of the gentle astringents, as common green tea, &c. and finding much advantage from them, the experiments were continued to the milder articles, as the elm, sassafras, and sumach; from the latter we derived peculiar benefit, and have continued to use it with uniform and unparalleled success.
The first case to which it was applied under our observation, was a patient who had been treated with mercury, both internally and ex- ternally, for typhoid pneumonia, and which affected the system to the most distressing extreme. The face and eyes were very much swol- len; the tongue enlarged and protruded, the internal surface of the mouth denuded, and the fauces in ulcers. A lukewarm gargle of the inner bark of the root of the smooth Pennsylvania sumach was ordered to be used every fifteen minutes, and mucilaginous drinks enjoined: relief was soon experienced, and in a few days the irrita- tion was entirely removed.
The second case we shall mention, was a girl of nine years of age, who, for an attack of simple remitting fever, had the mercury exhi- bited so as to produce profuse salivation, which resisted all the irri- tating compounds of borax, myrrh, &c. and continued until it had effected anchyloses of the jaw, extensive caries of the upper maxil- lary bone, and sloughing of the cheek. She was now put under the care of a second physician, who, after a short time, abandoned the case in despair. She was then directed to the notorious panacea shop of this city, and was dosed with half dozen bottles of the celebrated nostrum, with no other effect than increasing the irritation, and ex- tending her sufferings. In this state of the case we were asked to visit the child, and found her with her jaw perfectly fixed; the angle of the mouth sloughed away; the superior maxillary bone of one side carious, and discharging from four to six ounces of the most fcetid sanies every twenty-four hours; which excoriated the cheek, and ren- dered her extremely offensive to all her attendants. We recom- mended to the patient, as the only prospect of any relief, to sub- mit to an operation, provided healthy action could be produced in the parts; which we anticipated from the correcting quality of the sumach. She was immediately put under treatment — laxative and mucilaginous drinks were ordered, and the gargle of the sumach used every half hour: in the course of a week or ten days the morbid action was changed, and the parts put on a healthy appear- ance. The operation was now performed, in which we removed the whole alveolar process of the affected side; the gums united most gently, the ulcer of the cheek healed up, and the patient recovered
Fahnestock on Rhus glabrum.
!i3
very rapidly, and has remained perfectly well.* The healthy dispo- sition of the soft parts we attribute entirely to the use of the sumach, without which we should not have attempted the operation.
During the time the Dauphin County Alms-house Infirmary was under our charge, we had frequent opportunities of subjecting cases of protracted salivation, sloughed mouths, and ulcerated throats to experiment, which we uniformly found to yield to the infusion of the sumach, and the internal use of mucilaginous drinks and mush diet. The remedy, we think, may be extended with advantage to irritable ulcers of other parts. Its detergent and very soothing qualities, we believe, would contribute very much to healthy action, but we have no instances to support our opinion.
A short time since, we prescribed it in the case of our friend Dr. J. Ross Smith, of the northern liberties, who has suffered much from frequent returns of sore mouth and ulceration of the tongue, which he contracted while in attendance upon the convicts of the New York State Prison some years since, in which it has succeeded admirably well 5 and at our request he used it, with decided benefit, in a case of salivation threatening unpleasant symptoms, which we annex from his pen in a note to us.
" April 25th, 1829. — I was called to see Mrs. A. aged thirty, disease pleuri- tis, for which she was put under the ordinary treatment in such cases. Deple- tion having been carried as far as prudence dictated, on the 28th, she was or- dered, (by our advice,) the following: R. sal. nitre, gj.; calomel, gr. xij.; ipecac, gr. viij. M. Div. in ch. No. viij. one to be taken every hour and half.
" May 1st. — Pulmonary symptoms all subsided, and she complained for the first of her mouth; from this to the 9th she suffered to an astonishing degree from the effects of the calomel upon the salivary glands. The pulse from 76 now run to 90, and the irritation was such as to cause a recurrence of her fits, as she styled them, which she had been subject to ever since the birth of her first child, now three years of age. A tremulous motion would commence in the head, amounting to a smart rigor, and gradually extend to the body and ex- tremities, with the jaws firmly locked; they would last from ten to fifteen minutes, and then, as she expressed herself, go off at her hands and feet, leaving a slight perspiration: during its continuance the mind was perfectly rational, so much so as to enable her to assist herself, but her memory became greatly impaired. Considering my patient as suffering solely from the effects of calomel on an ir- ritable system particularly obnoxious to the effects of this salt, increased by some disorder of the uterine organs, I resorted to opium, oleum ricini, sulphur, blisters behind the ears, and to the whole list of irritating, as I now consider them, gargles, and with the effect of rather increasing than diminishing the suf- ferings of my patient. Under these circumstances you were kind enough to
* The operation was performed December, 1825.
64
Fahnestock on Rhus glabrum.
visit the patient with me, and at your suggestion she was ordered to make use of the infusion of the inner bark of the root of the Rhus glabrum. She com- menced on the evening of the 9th, and on the 10th I found my patient had pass- ed comparatively a comfortable night, and the pain and salivation greatly relieved.
" 11th. — The pulse had fallen to 78, and on the 15th I discontinued my visits. It may be well to remark that I have since treated this patient for prolapsus uteri, according to Dewees's plan, with entire success. "
An infusion of the inner bark of the root of the Rhus glabrum is a very mild mucilaginous refrigerant, and moderately astringent, very cooling and soothing to the irritated surface of the mouth and throat, and can be applied in any stage of disease and at any age. It acts by allaying irritation and obstructing excitement, sheathing the delicate surfaces, and healing abrasions.
There are seven species of the Rhus noticed in Pennsylvania; the Rhus typhinum, R. copallinum, R. glabrum, R. canadense, R. ver- nix, R. toxicodendron, and R. radicans. Some of these resemble each other so nearly that some botanists consider them as varieties rather than distinct species, and distinguish but five species. It is of much importance to discriminate accurately betwixt the species, as some of the other, and particularly the vernix, which resembles the glabrum very much, is very poisonous.
From Dr. Horsefield's dissertation, we cull the following distin- guishing features of the vernix and glabrum. The Rhus vernix, which is known by the different names of poison tree, poison wood, varnish tree, poison ash, swamp sumach, and white sumach, is the largest of all our native species of Rhus; it grows in some instances to the height of twenty -five or thirty feet; its average height, however, may be estimated at ten or fifteen feet. It seldom exceeds five inches in diameter. It occurs near creeks or rivulets, in dark and shaded situa- tions. The common trunk of the Rhus vernix, after arriving at the height of four or five feet, generally divides into two branches, which pursue for some distance a regular oblique course. The bark of the trunk is of a dark gray colour; in the upper branches the colour is lighter. The bark of the young trees is generally smooth, it becomes rough and furrowed as they advance in age. The leaves are com- pound: each leaf consists of four or five pair of pinnse, (is five-feather- ed or winged,) which are placed opposite, on very short petioles, and are terminated by an odd one. Linnseus's specific character of the vernix is— -leaves feathered, most intire, annual, opaque, petiole intire, equal. The flowers are arranged in small separate racemes, which form, at the termination of a long common peduncle, an uninterrupt- ed panicle (of flowers) of considerable length. The peduncles always
Fahnestoek on Rhus glabrum.
65
originate from the smaller branches, at the basis of a common petiole of the leaves, by which they are surrounded and supplied. The flowers are chiefly produced near the end of the branches, where they exist in great abundance; they are arranged in common with the leaves that support them, circularly around the lesser branches, forming, when the tree is in blossom, a beautiful globular cluster of flowers. They are very small and of a yellowish or herbaceous colour. The flowers are succeeded, on the female plants, by seeds which are arranged on their panicles, in the same manner as the blossoms; they somewhat resemble branches of small grapes. The seeds are not perfectly globu- lar, but a little compressed. They are surrounded in their dry state by a thin, light green corticle covering, which before they become dry, contains a pulpy substance; and the seed contains a small yellow kernel of an oleaginous nature. The Rhus glabrum, common su- mach, or smooth Pennsylvania sumach, grows in a loose, fertile soil; frequently upon vacant and uncultivated fields, and along the sides of roads and fences. It sometimes rises to the height of eight or ten feet; in many instances it does not exceed four or five. The trunk of the Rhus glabrum is seldom erect; after rising in an incurvated or oblique direction, to the height of two or three feet, it divides into several large branches. They are covered with a smooth, light gray or reddish bark, containing a viscid glossy yellow juice, which is not changed on exposure to the air. The leaves, like those of the Vernix, are compound: each leaf consists of nine or ten pair . of leaflets or wings, which are placed opposite, and are terminated by an odd one. The Linnsean specific character is; leaves feathered, sawed, lanced, naked on both sides. The leaves, which in summer are of a deep red colour, change to a beautiful red, in autumn. The flowers are produc- ed in large, erect, compound thryses, at the termination of the superior branches. They are of an herbaceous colour; and after they arrive at maturity, early in autumn, covered with a white tenacious powder, of an agreeable acid taste, and has been called, in various parts of Pennsylvania, Indian salt*
Though alike in appearance, the therapeutic effects of these species are widely different; while the vernix and radicans produce great ex- citement and inflammation, the glabrum is considered innocent and harmless. Dr. Barton informs us,t that it 4 4 is excellent for removing warts, and also tetters. " This shows, says he, 44 that even this species,
* An Experimental Dissertation on the Rhus vernix, Rhus radicans, and Rhus glabrum, published 1808.
f Collection for an Essay towards a Materia Medica of the United States. No. IX. —Nov. 1829. 7
66
Devvees on Phlegmasia Dolens.
which is generally deemed innocent, possesses some active quality." The vernix, radica?is, and toxicodendron, have been extensively and very successfully used by MM. Dufresnoy, Pore, Gouan, in France, and Verdeyen, Van Baerlem, and Burdach of Germany, in para- lysis, herpes, and consumption ; and is said to exert a very active in- fluence on the nervous system: great care therefore should be taken not to mistake the one for the other species.
Art. X. On Phlegmasia Dolens. By W. P. Dewees, M. D. Ad- junct Professor of Midwifery in the University of Pennsylvania.
We have retained the name of phlegmasia dolens, (the phleg- masia alba dolens puerperasum of White,) for a peculiar con- dition of the lower limb, because its pathology is still as unsettled as in the time of Mauriceau, whom we believe was the first that gave any satisfactory account of it; for the description left by Rod- rigues a Castro, can scarcely be tortured, by any partiality for an- tiquity, into the disease of which we are about to treat, though Dr. Hull complacently inclines to the belief, that he was acquainted with it. And we doubt whether the disease of the apothecaries' wife, as described by Wiseman, was really the disease in question, as it is but casually mentioned in his chapter upon 44 Abscesses and Cor- rosive Ulcers arising from Distempers of the Womb in Childbed," and what renders it especially doubtful, is, that he declares, matter form- ed in various places.
There cannot be a question however, that Mauriceau was well ac- quainted with this disease; as his description is still a pretty faithful one, in the main. By this author, and several others, the disease was attributed to some derangement of the lochia, which when not sufficient, was thrown upon the large nerves of the thigh, and thus created pain and swelling, &c. From the time of Mauriceau, to that of Puzos, the disease appears to have been familiar to a number of practitioners, as Manningham, Mesnard, &c.
It was however found, after a time that the appearance of this dis- ease did not obey any particular state or condition of the lochia; and that as it was very commonly accompanied by a diminution, or suppression of the milk, a new hypothesis was invented, and it was made to con- sist, of a metastasis of this fluid. Puzos with a great show of reason, has a prior claim to Levret, for this suggestion; as the latter himself refers to the former's "Memoires sur les dep6ts laiteux," and speaks
Dewees on Phlegmasia Dolens.
67
approvingly of them. These great men were followed by Astruc, who treats expressly upon this subject. Sauvages, fully adopted these notions in his nosology, and treated of them under different genera and species.
Van Swieten, Lieutaud, Raulin, Selle, &c, all seem to have acknowledged the great influence of the milk upon the constitution; and each has treated of its metastasis.
Mr. White of Manchester, was the next to invent a theory of this disease; he made it consist of an obstruction, rupture, or a disor- dered condition of the lymphatics, and he was followed in this opinion by others. Mr. Trye pretty freely criticized the opinion of Mr. W. and said that, though he could not discover any grounds for supposing the trunks of the lymphatics to be ruptured in labour, " yet he could easily conceive, that the obstruction to the return of the lymph may commence in the primary inflammation of a trunk or trunks, and that probably this may be the case more frequently than he had hitherto discovered, or suspected it to be." Mr. Trye was followed by Dr. Hull, in a valuable and highly learned work upon this obscure, and debatable disease. Dr. H. says, "the proximate cause consists in an inflammatory affection, producing suddenly a considerable effusion of serum and coagulating lymph from the exhalents into the cellular membrane of the limb." Dr. Davies, of London, next offered new pathological veiws, of the proximate cause of phlegmasia dolens, and makes it consist in an inflammation of "one or more of the principal veins within and in the immediate neighbourhood of the pelvis, pro- ducing a thickening of their coats, the formation of false membranes on their internal surface, a gradual coagulation of their contents, and occasionally, a destructive suppuration of their whole texture; in con- sequence of which, the diameters of the cavities of these important vessels become diminished, sometimes so totally obstructed as to be rendered mechanically incompetent to carry forward into their cor- responding trunks the venous blood brought to them by their inferior contributory branches."*
Thus, we have five different hypotheses, for phlegmasia dolens; of either of which it would be difficult to make a choice, if we consulted their value, either, in relation to the phenomena this disease pre- sents, or to the pathological condition of the parts affected, as far as has yet been revealed, by dissection. On these several opinions, we shall pass a few remarks; and believing neither to be the true proxi- mate cause, that it is right to give the arguments against each, that
* Lond, Med. Chir. Trans. Vol. XH. p'426.
68
Dewees on Phlegmasia Dolens.
our reading has supplied us with, as well as those, that has suggested themselves to us from attentively having observed the phenomena of this painful affection.
The two first opinions, (namely, that phlegmasia dolens is caused by some derangement of the lochia, or from a metastasis of the milk,) will scarcely require a remark ; as subsequent observation, has abun- dantly proved, that neither has ever had the slightest agency in its production, even as a remote, or as an exciting cause. And further, were either or both, to be admitted as contributing to this affection, the pathological condition of the seat of the disease, as caused by them, would still remain unexplained.
Mr. White of Manchester, must be considered the first writer, who had attempted a pathological exposition of phlegmasia dolens 5 and much credit is due to his industry, and learning upon this subject, though we cannot yield to him the merit of having been satisfactory, or perhaps even clear. He declares this disease,
"Is owing" to the child's head pressing the vessel or vessels which arise from the lower extremities, against the brim of the pelvis during a labour pain, so as to stop the progress of the lymph; that the number of valves will effectually prevent it from regurgitating, and if the head continues any time in tnis situation, while the lymph is driven on through the valves by the peristaltic contraction of the coats of its vessels, by the great exertion of the muscles, and the strong vibration of the inguinal artery, though its coats (the lymphatics) should be al- lowed to be stronger than those of the blood-vessels, it must at last burst and shed its contents. When the orifice made in the lymphatic is heated, and the diameter of the tube is contracted, or totally closed by the cicatrix, the lymph is retained in the lymphatic vessels and glands of the limb, and the labia [labium] pudendi, and distends them to such a degree and so suddenly, as to occasion great pain and swelling, which always begin in the part next to that in which the obstruction is formed, and when the obstruction is in part or wholly relieved, or the lymph has found a fresh passage, the part next to it is consequently re- lieved." pp. 49, 50.
He adds, "If the above hypothesis be true, the predisponent cause may in all probability be a weakness in the coats of the lymphatics in such subjects only, as have these vessels formed into one principal trunk under Poupart's liga- ment." p. 55.
Objections to these conjectures of Mr. White will readily present themselves; for it supposes that some obstructing cause or pressure to be absolutely necessary. Now, if it be even admitted that the child's head affords this pressure, at the brim of the pelvis in some cases, it could not have done so in all the instances, in which this disease has appeared. For, 1st, this pressure cannot take place to the necessary extent, but in a very few instances; for it is notorious to accoucheurs, that for the most part, in a well-formed pelvis, the head may be even
Dewees on Phlegmasia Dolens.
69
larger than it is usually found, and yet pass without difficulty. 2d. The portion of the brim of the pelvis at which, in ordinary circum- stances, this pressure is found to exist, is not that at which the lym- phatics would be subject to its influence; for as a general rule, it would be behind either of the acetabula. 3d. That no other part save the head, could effectually exert this pressure; yet it is agreed on all hands, that no position of the child yet discovered, is more efficient in its production than another. 4th. That a pressure so long conti- nued and so effectual, "as to stop the progress of the lymph," and eventually to cause a lymphatic to burst, must necessarily produce upon the intervening parts, a gangrenous condition; yet this is a ca- sualty, we have never heard of. 5th. Several circumstances connect- ed with the history of this disease would still remain unaccounted for; as the occurrence of the disease in the opposite limb; and this not si- multaneously, but after a considerable interval; and not until after, as a general rule, the first affection is yielding; to the pain and swell- ing first occurring in the calf of the leg, as it sometimes does; for if Mr. White's statement be true, that "pain and swelling always be- gins in the part next to which the obstruction is formed^ p. 51, the pain and swelling must primarily exist in this part of the limb; there- fore is not indebted to pressure exerted on the brim of the pelvis for its existence.
The arguments just urged might appear sufficient for the purpose intended by them; but as several conclusive ones have been employ- ed by Mr. Trye to the same end, we think we should not be render- ing justice to this gentleman did we altogether omit them. He ob- serves, that
"No experiment has shown that the lymphatics can be torn, without doing equal violence to the other vessels of the part. That practical anatomists have ascertained that these vessels will bear a weight of quicksilver, equal in effect to a much greater force than is required to circulate the lymph towards the tho- racic duct. That the force exerted by the child^ head in its passage, cannot exceed that of the pad of a tourniquet on the arm or thigh. That if the trunk of a lymphatic be compressed, its contents are forced inwards towards the tho- racic duct if no obstruction exist;, in this case its sides, are squeezed together, and will consequently occupy so little space, that in cannot be well ruptured at the compressed part. If a rupture then takes place, it must be below the com- pressed part — but no reason can be given for this taking place always in one place, namely, within Poupartfs ligament, rather than in the leg or thigh."
Besides, we have known two instances of this complaint to follow abortions in the early months; and once in a premature delivery be- tween the sixth and seventh month; in this instance, the child had been dead at least one month previously to its delivery. Again, my
7*
70
Dewees on Phlegmasia Dolens.
friend Dr. Chapman informs me of a violent case having occurred in a patient in our Alms-house, labouring under cancer uteri. But above all it has happened to the arm of the male, as recorded by Dr. Ferriar,'* besides an instance, of the same kind, that fell under our own notice in 1788. A gentleman, pretty far advanced in life, received a severe contusion on the point of his shoulder, by the overturning of the mail coach. He however paid but little attention to it, and merely rested it in a sling, as it did not prevent his attention to busi- ness for several days; but at the end of this time, the arm became very painful, and swelled rapidly, considerable fever was excited, and the gentleman was obliged to keep his bed. The controul of the motions of the limb was entirely lost, as every Attempt to move it was attended by exquisite torture. The character of the swelling was precisely that of the milk leg, to which it was compared at the mo- ment, by my preceptor — that is, he declared, had the same affection befallen the leg of a lying-in woman, he would have called it a milk leg. After a tedious, and an active treatment of three months, symp- toms of amendment showed themselves; but it required a long time to restore the limb to its former usefulness — indeed, from what we afterwards learnt, it never became as strong as the other.
This case is not unique; several instances of this kind are upon record; all of which, perhaps, are not entitled to the distinction. Dr. Ferriar's case is perhaps one, that could not be quoted as a genuine instance of phlegmasia dolens; nor do we regard the one related by Littre, under the care of Luminier, to be without exception, as there was well-marked red inflammation. t Yet that related by Dr. Heer- mans appears to have been a genuine instance of phlegmasia dolens in the male.J
Besides, we are informed, that phlegmasia dolens, has happen- ed to women not pregnant; of this we can only speak from the au- thority of others, for we have just said above, that this took place in a patient under the care of Dr. Chapman, in our Alms-house; and Dr. Beck mentions a case where it took place in a woman of fifty- two years of age.
Dr. Moore, of Ipswich,§ makes a singular remark upon the opinions of Mr. White; the force of which we cannot perceive, though it purports to overthrow his doctrine at once. He says, "in refutation of Mr. White's opinion, I will state, that in no
* Medical Histories, Vol. III. p. 92. By Dr. Ferriar.
f Medico-Chirurgical Review, for April, 1829.
$ Dr. Francis' Memoir, p. 9.
§ New England Medical Journal, Vol. II. p. 229.
Dewees on Phlegmasia Dolens.
71
instance that has come to my knowledge, has the disease preceded parturition." Now, how this refutes Mr. W.'s opinion we cannot understand; for in no instance does Mr. W. require that parturition should always happen before this disease can be produced; and in our humble opinion, had Dr. Moore have known an instance of phleg- masia dolens preceding parturition* it would have told very much more against Mr. W.'s hypothesis, as the great agent in producing this disease, in Mr. White's opinion, would have been wanting; namely, pressure from the child's head during labour. But Dr. M. should have not attempted to pass his want of knowledge of such cases for more than it is worth; since many cases of the kind alluded to may have taken place, without his being apprised of them; for cer- tainly it has happened, as stated above, that this disease has occurred to unimpregnated females. Now if this be so, we do not see by what law of pregnancy, the woman is secured against an attack.
By the by, we may remark, that Dr. M. dismisses the hypotheses of Mr. Trye and Dr. Ferriar still more cavalierly, and with still greater brevity. Of the first he says, it "is mere supposition;" of the second, "in reply to Dr. Ferriar, I will adduce the fact, that phleg- masia dolens as frequently follows natural and easy labour, as diffi- cult and laborious."
These assertions of Dr. Moore, purporting to be refutations, were to pave the way for the explanation which he offers immediately after, in the following terms.
" After an attentive observation of cases, and a careful examination of the subject, 1 will humbly offer the following explanation as the most satisfactory to me."
" During gestation, the abdominal muscles, their vessels, and integuments, are in a state of great preternatural distention; immediately after parturition, when the distending cause is removed, these parts powerfully contract in order to regain their natural dimensions. If this effort be unequally exerted, if it be suddenly excited by the application of cold, if the lymphatic vessels be over- distended at the time of plethora, or great debility subsists in the vessels them- selves, an interruption and accumulation of the fluid ensues; the great and long accumulation of which, acting as an extraneous and offending cause, will occa- sion inflammation. In persons of a plethoric and irritable habit, inflammation may quickly supervene; while on the other hand, in a person of a contrary ha- bit, it may be more tardy in its progress." p. 230.
We would now ask, if ever hypothesis was more heavily laden with conjecture, and supposition, than this — it has not even the merit
* Puzos relates two instances of this kind; one took place at the 4th, and the other at the 7th month of utero-gestation. And we have seen two instances in which it followed premature delivery.
72
Dewees on Phlegmasia Dolens.
of ingenuity, much less an imposing probability to reconcile its meager pretensions. The initial postulate is not founded in fact, for we can- not look upon the distention imposed upon 44 the abdominal muscles, their vessels, and integuments," as 44 preternatural," since, in being put upon the stretch by pregnancy, they are but performing one of the offices for which they were designed. His second is no better grounded; for, after parturition has removed the distention, 44 the abdominal muscles, their vessels, and integuments," do not 44 power- fully contract in order to regain their natural dimensions;" for this is performed silently, and gradually, and requires for its completion many days. We have just shown how reluctant Dr. M. is to permit either Mr. Trye, or Dr. Ferriar, to conjecture, or to suppose; yet, he says himself, in the attempt to make out his explanation, 44 if this effort," &c; 44 if it be suddenly," &c; if the lymphatic vessels," &c. ; such and such things will happen. That is, we shall have in- flammation from an accumulation of lymph in the lymphatic vessels; and in what essential point does this 44 explanation" differ from that of Mr. White, or Mr. Trye? in none that we can see, if we except the agent by which the interruption to the circulation of the lymph is effected — in one instance it is the head of the child; in the other it is cold and debility.
We should not have thought it necessary to notice this 44 explana- tion" in an especial manner, did not the doctrine it inculcates lead to a mischievous, and reprehensible plan of treatment; for the doctor observes —
" In the ordinary mode of treatment, much time is lost In the inefficacious use of diuretics; and much mischief and pain produced by the application of blisters, and other stimulating- remedies." " From the view here taken of the subject, 1 am fully disposed to regard it as a local disease, and decidedly re- commend the early application of a large emollient poultice, which, by its re- laxing and resolving power," (recollect the doctor's opinion of the cause of the disease, is, debility and over-distention,) "will, in a great majority of cases," (has he ever seen a sufficient number to determine this important point? the doctor only mentions two cases, and neither of which, was the disease in ques- tion,) " prevent the formation of a distressing and tedious disease. And when it does not produce this most desirable effect, I should recommend its continu- ance, with an intention of producing early suppuration, which I think next to re- solution, the most speedy and safe termination of the disease." p. 231.
Was ever a disease less understood; or a more preposterous re- medy, ever proposed ! The continued application of an emollient poul- tice is every thing that is necessary for the relief of a milk leg!
We have good grounds for believing Dr. Moore had never seen a case of phlegmasia dolens* if we take the two pases he details as spe-
Dewees on Phlegmasia Dolens.
73
cimens. In the first case, the patient complained of a pain in the right hip and back: rigors and watchfulness; a rigidity and soreness of the abdominal muscles; pain in moving the limb; the pulse a little increased, slight thirst, and perfectly clean tongue. For this state of things, antimonials, cathartics, and fomentations were prescribed. These proved ineffectual; bark* guaiacum, and a continued blister to the thigh were employed.
" This course evidently increased the local affection. The upper part of the thigh, the inguinal glands, and right iliac region, become more tumefied, which gradually extended to the hypogastrium and labium pudendi."
" In the early stages of the swelling it appeared in ridges and bunches, occa- sionally assuming- a livid, and at other times a purple hue."
It became more uniformly diffused, tender, hotter than natural, shining, but not much discoloured. The fever kept pace with the local affection; the pulse was small and very frequent. The swelling increased. "With an intention of rousing the action of the absor- bents, a volatile stimulating liniment was applied, and in turn hot vinegar; but these had no better effect than the blistering!!"
Digitalis was now administered; this increased the debility; the in- flammatory appearances became more evident; the pain, heat, soreness, and redness increased, until a discharge took place from a ruptured lymphatic in her side, about an inch from the inferior spinous process of the ilium, p. 228.
The second case is still farther removed than the first, from being an instance of phlegmasia dolens. This occurred in a person of ro- bust constitution; it supervened on natural labour. On the second day after the delivery, the patient experienced a great rigidity of the abdominal muscles, which increased in tenderness, and presented an appearance of 66 ridges and bunches;" the constitutional symptoms high; these increased until suppuration took place from an "opening a little below the navel."
We have italicized such parts of these histories, as show at once, that they were not instances of plegmasia dolens; and also such, that have excited our wonder in regard to treatment. If the cases just related, and others, that we shall have occasion to mention presently, be received as genuine instances of phlegmasia dolens, the pathology of this disease will remain unsettled to the end of time.
We have already cursorily mentioned the opinion of Mr. Trye, of the proximate cause of phlegmasia dolens; we shall now develope it more in detail. He says, p. 70 —
" I have considered the proximate cause of the swelling to be seated in the lymphatic glands. I will not contend that it must be so universally, because
74
Dewees on Phlegmasia Dolens.
there is a probability, that the original seat of obstruction and inflammation may, in some instances, be in the principal trunks of the absorbents within the pelvis, independent of, and abstracted from the iliac glands; in which case the inflammation maybe continued along the absorbent vessels downwards; that is, towards the labia pudendi, leg, &c. as well as upwards, or towards the thoracic duct."
Dr. Ferriar is also mentioned as an inventor of a theory for phleg- masia dolens ; but he does not appear to be entitled to this claim, since he has only adopted the opinion of Mr. Trye upon this subject And were we even to admit he had not seen Mr. T.'s work, he must at least have been familiar with the opinions of Drs. Denman and Latham. The lectures of the former he most probably attended.
We shall make no observations upon the opinions of Mr. Trye and Dr. Ferriar, until we have noticed the hypothesis of Dr. Hull, which we shall now give in his own words. He states, that —
** From an attentive consideration of the whole of the phenomena observable in this disease, and of its remote causes and cure, no doubt remains in my mind, that the proximate cause consists in an inflammatory affection, produc- ing suddenly a considerable effusion of serum and coagulating lymph from the exhalents into the cellular membrane of the limb." " The seat of the inflam- mation I believe to be in the muscles, cellular membrane, and inferior surface of the cutis. In some cases, perhaps the inflammation may be communicated from these parts to the large blood-vessels, nerves, and lymphatic vessek, and glands imbedded in them." ■+
We have united the hypotheses of Mr. Trye, Dr. Ferriar, and Dr. Hull, because they are essentially one and the same; namely, that the proximate cause is an inflammation of the lymphatics and glands of the groin; though as a whole, Dr. Hull's assumes a much broader ground; so much so indeed, that Dr. Davies styles it with much point, 44 a capacious theory."
The objections which present themselves to these explanations, are, first, their incompatibility with one especial phenomenon of the disease, namely, the shining white appearance of the limb throughout the whole course of the disease; and this so notoriously so, as to have it as one of its genuine characters. In all instances of inflammation of either, muscle, skin, lymphatic,* or blood-vessels, redness is a
* In the time of Dr. Hull, the term u lymphatics" was understood to mean the lymphatic absorbents; the researches of Bichat had not then made it neces- sary to distinguish this set of vessels, and those whose office it is to convey the lymph, being either the termination of arteries, or the beginnings of veins. And we beg the reader to keep in mind, that where "lymphatics" are men- tioned in the quotations of either Mr. White, Mr. Trye, Drs. Hull, Ferriar, or Moore, that the lymphatic absorbents are to be understood.
Dewees on Phlegmasia Dolens.
15
never-failing attendant, as is well known to all who are familiar with disease. Yet this does not happen in phlegmasia dolens, notwith- standing the numerous tissues Dr. Hull involves in the mischief. 2d. That were all these tissues in a state of inflammation, this inflamma- tion would manifest itself by the ordinary phenomena of this affec- tion; namely, heat, redness, swelling, pain; yet we find redness al- ways wanting in phlegmasia dolens, when this disease is pure and uncomplicated. If muscle be inflamed, redness is sure to be present; if the skin, the same thing occurs; if the trunks of lymphatics, (ab- sorbents,) be the seat, we have frequent opportunities to witness that they become red; and when the lymphatic glands are in this con- dition, redness notoriously attends. And though Dr. Hull does not suppose, that all these parts are simultaneously affected, but succes- sively, yet it alters not the fact, that in phlegmasia dolens redness is always absent during the whole course of the disease.
3d. Besides, this progressive extension of inflammation cannot well be sustained, as the rapidity of the disease is such sometimes, as to involve the whole limb in the course of a very few hours; where- as the transmission of inflammation by contact even, is sure to be much slower; yet it would not fail to betray its progress by all the phenomena of inflammation, were it to exist in such parts.
4th. When the lymphatic glands become inflamed by the absorp- tion of some acrid substance, or specific poison, the venereal poison for instance, they not only become red themselves, but the lympha- tics even that convey the poison, can be distinctly traced in their course, by the vivid red that marks their inflamed coats.
5th. The ordinary inflammation of the several parts declared to be involved in phlegmasia dolens, moreover, do not thus suddenly effuse serum; of this, proofs, in the progress of this affection, present themselves every day, as in rheumatism, wounds, contusions, the in- sertion of poisons, &c.
6th. When the lymphatics are inflamed, together with their glands, it is acknowledged by Dr. Ferriar himself, that 44 the vessel can be distinctly traced in its course by its hardness and enlargement, and frequently by a slight inflammation of the superincumbent skin, forming a red or purple streak, and extending with the affection of the vessel."*
7th. We do not agree with Dr. Ferriar in the assertion, that 44 the violent pressure on the internal iliacs, and the accompanying veins and nerves, which takes place during delivery, must undoubtedly be
* Med. Hist. Vol. III. p. 95.
76
Dewees on Phlegmasia Dolens.
considered as a powerful occasional cause of lymphatic inflamma- tion" p. 120. Now, if this were true, phlegmasia dolens would be of much more frequent occurrence than it is found to be; since this pressure is common to all labours, yet the disease in question is one of very rare occurrence.
8th. Because in phlegmasia dolens, one of its inseparable charac- ters is the exquisite sensibility of the whole limb; so much so in most instances, that the patient cannot bear the slightest pressure, or the slightest motion, yet Dr. Ferriar informs us, that 44 the pain in lym- phatic inflammation is referred to the enlarged glands, and is not re- markably increased by motion; there is more stiffness than actual pain in the whole limb." p. 102.
9th. Because, in the twelve or fourteen cases of exquisitely form- ed phlegmasia dolens, that we have seen, we never were able to trace the "inflamed lymphatics," or to feel the 44 enlarged conglobate glands;" yet, both of these circumstances are declared to be con- stantly present, by those who espouse the pathology under consider- ation.*
10th. Because, Dr. F. furnishes a case himself, which disproves his own explanation, viz. : —
" Jane Waters, aged twenty-five, was delivered by an accoucheur, of her second child, December 26th, 1797, after being- four days in labour. During delivery she lay upon her left side. December 27th. she was affected with pain and swelling of the left knee, which descended to the leg and foot of the same side. On the 28th of December the swelling began to rise from the left knee and to affect the thigh. It extended up to the left groin and labia pudendi. 1 saw her for the first time on the 3d of January, 1798. I found the swelling tense, uniform, not discoloured; that there was a great sensation of rigidity in the limb, and that it was extremely painful on being touched or moved. She felt exqui- site pain in the ham, where I could perceive the lymphatics a little enlarged. The glands of the groin were not affected" p. 127.
In this case there was an exquisitely formed phlegmasia dolens; for it was attended by all the essential characters of the disease; the limb was exquisitely tender to the touch; the swelling was uniform and elastic; it was not discoloured; the glands of the groin were not affected, and the lymphatics in the ham could be perceived to be 44 a little enlarged." Here then was a case of genuine milk leg, without
* Dr. Hull declares the same inability; he says, " I have never met with either enlargement or inflammation of the lymphatics in any stage of the com- plaint; I am therefore convinced that this is a rare occurrence, and by no means essential to the disease." — Essay on Phlegmasia Dolens, p. 116. It will there- fore be perceived that our observations only apply to Dr. Hull, as far as he ad- mits the lymphatics to be involved.
Dewees on Phlegmasia Dolens.
77
inflamed "lymphatics" or " conglobate glands.5' We think we have said enough to prove that this pathology is not well founded; and that, if inflamed lymphatics, or enlarged glands be present, that they are the consequences, and not the cause of the disease called phlegmasia dolens.
The next hypothesis in order, and it is the last with which we are acquainted, is one of late date; it is by Dr. David Davis, a teacher and practitioner of considerable celebrity in London.
Dr. Davis attempts to prove, that phlegmasia dolens is the conse- quence of an inflammation of one or more large veins; ending in the production of an extraneous membrane or other obstructions, within their cavities; and thus offering remorse, to the returning blood from the extremity.
This view of the subject, from its supposed truth, has gained much more notoriety, than can be sustained by facts; though supported by the powerful aid of Velpeau; and we may add that of Bouillaud and Ribes. When we say this, we would not wish to be understood as implying the slightest disbelief of the truth of Dr. Davis's state- ment; on the contrary, we are fully persuaded that neither he nor the gentlemen who, both directly and indirectly, support his doctrine, have set down nothing that they did not see — the only question then is, were the dissections of these gentlemen cases of phlegmasia dolens? this is the point at issue — whether phlebitis and phlegmasia dolens are identical; or in other words, are the cases related as cases of the latter, any other than instances of the former?
Before we proceed further in the examination of this question, it will be proper to determine the absolute character of phlegmasia do- lens from the best accredited practitioners; for to them alone should the appeal be made. And perhaps one of the older writers of this kind, will be the safest guide upon this occasion. Callisen has summed up the characters of this disease most happily in a very few words, making allowance for the introduction of one of its supposed causes in his time, namely, a metastisis of milk. " CEdema puerpe- rarum, aliis lacteum est tumor elasticus, albescens, renitens, calidus, dolens, foveam impressi digiti haud retinens, puerperis haud infre- quenter, gravidis rarissime infestus." He has, however, omitted a very material feature of the disease, namely, fever; for, as far as we have seen, tins condition of the system has always been present, and sometimes to an alarming degree.
The essential characters then of phlegmasia dolens may briefly be stated to consist of the following strongly marked characters. 1st. Fever always to a greater or less degree. 2d. Pain generally corn- No. IX.— Nov. 1829. 8
73
Dewees on Phlegmasia Dolens.
mencing in the hip, groin, and sometimes the back. 3d* Swelling commencing at the seat of pain, and proceeding with more or less rapidity down the whole limb. 4th. The swelling elastic, not retain- ing the impression of the finger. 5th. The whole swoln part white, even more so than natural in some instances, but never red, when uncomplicated. 6th. The whole limb exquisitely sensible to the touch* 7th. Total inability to move the limb, and action always creating great suffering. 8th. The temperature of the whole affected part, much above the natural temperature. 9th. The labium pudendi of the diseased side, almost always participates in the swelling, but never extending to the other labium, unless the other limb be also affected. 10th. After the first leg begins to improve, or is perhaps nearly well, the opposite leg runs through a similar course, and some- times with an aggravation of symptoms. 11th. That the limb thus affected, rarely suppurates. 12th. That this disease is rarely attend- ed by danger. 13th. That after the more violent stage of inflamma- tion is abated, which generally happens, under proper treatment, about the sixth or eighth day, that the swelling abates its elastic cha- racter, and takes on that of a common oedema. 14th. The milk usually diminishes, and sometimes disappears.
We have been thus particular, yet we trust strictly faithful, in enumerating the essential characters of phlegmasia dolens, that the coincidences and discrepancies between it and phlebitis, may be more readily subjected to comparison.
Symptoms and general character of Phlebitis. — In giving an ana- lysis of the symptoms of phlebitis, we have chosen the one condensed in the Medico-Chirurgical Review, Vol* IV. p. 509, from Recherches Cliniques pour servir a Phistoire dela Phlebite; par M. J. Bouillaud, M. D. Revue Med. Avril et Juin, 1825 5 and from Expose succinct des Recherches faites sur la Phlebitejpar M. F. Ribes, M* D. Revue Med* Juillet, 1825. We have done this in preference to other au- thorities, because they are the latest who have written on this subject, though we have no evidence that they consider this affection consti- tutes phlegmasia dolens. We shall give the English version, as con- tained in the above named Review. First, of Dr. Bouillaud.
" Symptoms. — 1. The symptoms of inflammation in the trunk of a superficial or external vein are easily recognised. The member swells, becomes hot, painful, or is even the seat of phlegmonous erysipelas. The vessel itself feels tense, hard, knotty or like a cord. Abscesses not unfrequently form in the course of the vein. The pain, our author thinks, is more dependant on an affection of the neigh- bouring nerves, than on inflammation of the vein itself. (Edema of the limbs is a very common attendant on phlebitis of one or more of the principal veins, and evidently arises from the mechanical obstruction to the return of the blood — the
Dewees on Phlegmasia Dolens.
79
veins being now acknowledged to be the principal conductors of the serous ex- halations, (see note * to p. 74,) that take place into the cellular tissue. Such are the signs of local phlebitis.
"2. When the inflammation extends to the whole, or to a great portion of that vast membrane which lines the internal surface of the venous system, we constantly find that a violent fever is lighted up. Among many of our patients, the fever presented all those characters which are attributed to what are called putrid, adynamic, or typhoid fevers; and indeed the term, putrid \s perfectly ap- plicable, since after, nay before death, there are unequivocal signs of decompo- sition, or a kind of putrid fermentation of the fluids."
Second. Air. Ribes says, " The veins are very frequently inflamed, and this af- fection is a very dangerous one." (Yet phlegmasia dolens is a rare disease, and is very seldom dangerous.) " In incipient phlebitis, the patient experiences a slight pain in the track of the veins affected. These vessels swell and become pro- minent, presenting a light bluish colour, and subsequently a brownish pale hue. The circulation ceases in the vessel, and the blood becomes more or less decom- posed. If the circulation should be re-established, the contents of the vein are carried into the current of the circulation, and dangerous consequences may ensue." p. 512. " Phlebitis is a serious malady, and is often quickly mortal." Ibid.
We have thus brought into opposition the characteristic symptoms of phlegmasia dolens, and phlebitis, which we now submit to the reader's candour to determine the strength of their analogy, or rather how far they are entitled to absolute identity. Let him run his eye over such parts of the description and consequences of phlebitis as are emphasized, and compare them with the general history of phleg- masia dolens, and he will at once, we are certain, perceive their dis- crepancies, and determine their entire want of sameness.
But lest it be thought that we have drawn our conclusions from premises not attempted to be sustained by Dr. Davis, we will pro- duce in a very short compass all the symptoms detailed in his histo- ries, that he may speak for himself.
"Case I. — Caroline Dunn, set. 21; weak constitution; delivered on the 7th of February; severe labour; some haemorrhage after delivery; placenta removed artificially. 8th. Pulse 90; tongue white and moist; no pain in the abdomen from pressure; soreness in vagina. On the 13th, slight fever; pulse full and quick; costive; tongue white and dry; the labia pudendi inflamed and cede- matous; some head-ache; respiration difficult; discharge from vagina resembling cream." 17th, better; 21st, much better; 22d, still better; 26th, worse; leg and thigh much swollen; pain in the groin; no signs of inflammation; no pitting on pressure; 28th, no better; leg pitted on pressure; March 3d, total insensibi- lity; limb equally swollen; 4th, died.
We shall introduce a part of the dissection, as performed by Mr. Lawrence, "which is a sufficient guarantee for its correctness.*' Med. Chir. Review, p. 581.
80
Dewees on Phlegmasia Dolens.
Dissection. — " The left lower extremity presented an uniform oedematous en- largement, without any external discoloration, from the hip to the foot. This was found, on further examination, to proceed from the ordinary anasarcous ef- fusion into the cellular membrane." The inguinal glands a little enlarged, as they usually are in a dropsical limb, but without any sign of inflammation. The femoral, external iliac, common iliac firmly plugged, apparently by a coagulum of blood. The other veins thickened, except the saphena and branches, which were healthy. That the substances occupying the cavities of the vein, were the product of inflammation.
We cannot do better than present the observations on this case contained in a review of Dr. Davis's work on phlegmasia dolens.
" We take the liberty of differing from Dr. D. on the identity of the case de- scribed with that of real phlegmasia dolens. We ground our first doubt on the fatal issue of the case, which is contrary to the general experience of the pro- fession hitherto; for it must be recollected that Zinn's patient died of asthma, and not of phlegmasia dolens. If then there are very few cases on record where phlegmasia dolens in itself proved fatal, we have at least grounds for supposing, (we do not say it amounts to proof,) either that Dr. Davis's case was not phleg- masia dolens, or that its proximate cause was different from the proximate cause of phlegmasia dolens in general." p. 382. Med. Chir. Rev. Vol. V. No. 18. The reviewer asks in a note, "Is it likely that so serious, and generally so fatal a disease as an inflammation of the internal coat of veins, under other circumstances, should be almost invariably devoid of dang-cr in phlegmasia do- lens?" Ibid.
" Our main doubt, however," continues the reviewer, "is grounded on the anatomical, or rather, the pathological difference between Dr. Davis's case, and those described by authors. We have Mr. Lawrence's authority that the en- largement of the limb proceeded from ordinary anasarcous effusion into the cel- lular substance. Does this state harmonize with the description of phlegmasia dolens as given by authors, or as seen by practitioners? It is contradistinguish- ed, by all the writers we have perused, from anasarcous infiltration, (and cer- tainly by our own observation in at least four or five cases,) by the tense, or hard, or at all events, elastic swelling of the limb — not pitting on pressure." p. 382.
Dr. Bateman runs the following parallel between the two dis- eases:—
" The swelling is general and equal over the whole limb; it is much harder and firmer than in anasarca, in every stage "of the disorder; it is not so cold, in any state of the disease, as in the dropsical swelling, nor so much diminished by the horizontal position; neither does it pit when pressed upon by the finger, nor does any water issue from it when it is punctured by means of a lancet." — JRees's Cyclopaedia, Vol. 28. "When these descriptions are compared with Mr. Lawrence's dissection, we think every unprejudiced mind will agree with us that Dr. Davis's case was of a character wholly different from genuine phleg- masia dolens." p. 383.
Dewees on Phlegmasia Dolens. 81
*f Case II. A lady of a sanguineous, irritable temperament, died suddenly in the midst of apparently high and perfect health, on the 20th of September, 1819, six weeks after confinement. She was seized with peritoneal inflamma- tion the day after delivery, which yielded to active measures. Ten days after this she complained of a deep-seated pain in the groin, and along the great ves- sels. Dr. D. found the limb swelled, and very painful, but by leeches and blis- ters, this new inflammation was speedily reduced, and in a week, the swelling had entirely subsided, the patient having recovered the perfect use of the limb. From this period she convalesced rapidly and satisfactorily, but died, as above stated, in the midst of apparent health."
In what possible respect can this case be looked upon as a case of phlegmasia dolens ? Is there a single coincidence between the two diseases ? The only circumstances on which even a re- mote analogy can be based, is "a deep-seated pain in the groin,*' and that 44 the limb was considerably swelled, and exquisitely pain- ful." But will such conditions of a limb, constitute phlegmasia do- lens ?
" Case III. This is a case communicated by Dr. Davis's friend, Mr. Oldknow, A woman was delivered, by an easy labour, in September, 1820. She did well for about three weeks. She was then attacked by a violent diarrhoea, for which she took astringents. Fever continued. On the thirtieth day after delivery the diarrhoea returned, and * the left lower extremity became swollen and painful, with considerable increase of fever.' Four days afterwards she died." p. 435.
In this case, the only pretence for calling this a case of phlegma- sia dolens, during the life of the patient, was the existence 44 of swol- len and painful lower extremity;" and no proof of its having been a case of this kind, is adduced by the examination after death. The whole attention of the operator appears to have been occupied in the examination of the blood vessels; "the femoral vein and iliac veins were much enlarged, and contained adherent layers of coagulated blood. The same appearances, but in a lesser degree, were observed in the cava as far as the entrance of the renal veins. The coats of the veins were highly inflamed, and intimately attached to the sur- rounding parts. The absorbents and glands were slightly enlarged." These morbid changes may perhaps with propriety entitle tkis case to stand with those of phlebitis; but it has no possible right to be ranked with those of phlegmasia dolens.
The sudden death of this patient, we conceive, will effectually pre- vent this case from being acknowledged as one of phlegmasia dolens, *
* It is true, that in the case related by Puzos, the patient died on the fifth day; but she appears rather to have " died of the doctor," than of phlegmasia dolens. He relates another, that took place in the fourth month of pregnancy, and which proved fatal on the ninth day.
8*
82
Dewees on Phlegmasia Dolens.
for we believe from what we have seen and read of this disease, that it is the first instance, if it be one, that has terminated so suddenly in death. Indeed, this termination is so confessedly rare, that phleg- masia dolens has never been looked upon as a disease of danger,* though one for a time of great suffering, and almost always one of tedious convalescence.
Case IV. A lady of a delicate constitution, an irritable habit, was delivered on the 2d of July, 1821. She was doing" well until the seventh day; on this day she was exposed to cold, and was seized with a rigor. During- the forming of the hot stage, she felt a pain in her left side, which increased rapidly, and for which she was bled without much relief. She was afterwards bled, leeched, and blis- tered. The affection of the chest was relieved, but fever continued. In the evening of the 9th " unequivocal symptoms of phlegmasia dolens declared themselves." She died on the 23d of the same month.
"On dissection, there was effusion and inflammation in the chest, 'the left lower extremity, from the hip to the toe, was considerably, but not greatly en- larged, and there was an evident enlargement of the labium pudendi.' The iliac veins on both sides were unusually turgid with blood. When the left was opened, it was found to contain a firm coagulum of blood, not adherent to the vessel at that place. Higher up, however, in the common iliac portion, the co- agulum was adherent to the internal surface of the vessel. The left internal iliac was greatly inflamed, and the diameter so much contracted as to be almost impervious."
"In the above case we have to regret that nothing is said of the state of the limb from the 9th of July, when the ' unequivocal symptoms of phlegmasia do- lens commenced,' till the patient's death. In the dissection, again, nothing is said of the pathological condition of the limb. The whole attention is concen- trated on the vessels. Now it ought to have been Dr. Davis's chief and main object to prove, in all those cases, that the disease was really phlegmasia dolens, by an accurate description of the symptoms and state of the limb, and then to have traced the cause if he could. But it is evident that the first and main object is almost totally neglected — or where it is adverted to, as in Mr. Lawrence's dissection, it makes against the question — and therefore we do not consider ourselves bound to subscribe to our author's etiology, without having the neces- sary documents respecting the symptoms and dissections of the cases."f
We cannot, however, hesitate to believe, that the swelling spoken of was produced by the inflammation and obstructions discovered by dissection, as Ribes tells us it is one of the common symptoms of phlebitis; but we must deny that, that swelling, and the swelling at- tending phlegmasia dolens, are of one and the same kind, as this au- thor expressly calls it, 44 oedematous."
* Dr. Francis relates a case on the authority of Dr. Mann of Boston, in which death took place from sphacelus, in consequence of the limb being punctured with a view to draw off the water supposed to be present.
f Med. Chir. Rev. p. 385.
Devvees on Phlegmasia Dolens.
S3
From all the facts adduced by Dr. Davis in support of his pathology of phlegmasia dolens, sufficient evidence is not afforded, that "the proximate cause of this disease is a violent inflammation of one or more of the principal veins within and in the immediate neighbour- hood of the pelvis," &c. Nor in our opinion is this pathology sustain- ed by the cases related by Velpeau, purporting to illustrate the cause of this disease, though they coincide with the observations of Dr. Davis.
Dr. Velpeau has drawn the same conclusions as regards the proxi- mate cause of phlegmasia dolens as Dr. Davis, though not aware he had been anticipated in this, by the latter gentleman. We will briefly relate his cases — that is, we will mention every circumstance which may bear upon the question.
Case I. Valette, eighteen years old, had a tedious labour; on the third day she was much affected by some melancholy tidings. She now laboured under an acute pneumonic affection. Eleven days after delivery, she had chills and fever, pain in the groins, hypochondria, and left side of the pelvis. On the forty-first day, the left leg was found to be swelled, with pain in the hip and groin, and ultimately in the whole limb. " The whole extremity (edematous." Pressure give pain only in the groin. On the sixtieth day she died.
Dissection. " When the left extremity was cut into, it was found much infil- trated in the cellular tissue. The lymphatic glands of the groin were much swelled and red — the muscles small and pale" — crural vein red externally, and its cellular coat thickened. This was the case in all its deep-seated branches. Purulent matter was found in these veins, and pus in the cava, and purulent deposition in other places. Can any one recognise phlegmasia dolens in the history of this case, or in the details of the dissection ? There was a swelled leg it is true — but it is expressly declared to be " cedematous," and this is the only resemblance.
Case II. Damiens, thirty-five years of age. She had a quick delivery. During the three first days nothing remarkable occurred. Fourth, fever, and deep- seated pain in the pelvis. On the thirteenth day the lower extremities are much swelled and painful, especially the left. Fifteenth, breathing affected, difficulty in passing water, diarrhoea. Twentieth, the lower extremities more swelled and red, (enfiees et rouges,) belly swelled and painful. Twenty-sixth day, died. In the dissection there was nothing to justify the opinion that this was a case of phlegmasia dolens; or perhaps that it was a case of phlebitis.
Case in. Has even less claim to the title assumed for it, than the preceding— the only possible circumstance to rest such an opinion upon is, that "there were pains in the upper and lower extremities — the latter beginning to show oedema."
Such are the kind of cases which of late have been foisted upon the medical public, for instances of phlegmasia dolens; than which, no- thing can be less similar. Dr. Davis has evaded all the difficulties that might attach to a regular history of the appearances of the limb,
S4
Be wees on Phlegmasia Dolens.
by declaring in some instances, that "to-day unequivocal signs of phlegmasia dolens appeared;" we must therefore take his word for the truth of the observation; not, however, that we would insinuate, that he would in the slightest degree misrepresent the appearances which led him to this conclusion, but that he was satisfied with symp- toms which