WB AdT37n ■j •.•,:-.,"*,,i~-"«; :-£^5igfi :'if'.!^;;-«; '£:; ■.••'.V •.•A,v-> .»v .i.-.'-^r-i'-"^.-. UNITED STATES OF AMERICA WASHINGTON, D. C. GPO 16—67244-1 MEDICAL AND SURGICAL CASES v-r---."''i»ic=s^v^B-.w OBSER Y AT IONS, WITH PLATES; BY DUDLEY ATKINS, M. D. .\ E W YOl! K P W T K H H ILL. D4 B K <• .-\ D W a > M DCCC XXXIV A^73; |£3^ SLlllQHT AND VAN NORDKN, HIM". To JAMES JACKSON, M. D. professor of the theory and practice of medi cine, in harvard university, etc. etc. My dear sir, I should have been unmindful of the kindness experienced during nearly twenty years, had I selected any other person than yourself, to whom to send this little volume. I should have most unworthily requited the care with which you endeavored to aid my labors as a student, had I not brought to you this small tribute, the gleanings of a few years of professional labor. But I must confess, to use the words of a great man, that it cannot but look like a design in me to borrow your name, and beg your patronage to my book, that if there were no other worth in it, I might shew that though unknown to the world, I am known to you. And I cannot but say that I am very fortunate in being attracted by private obligation and regard to the very person, whom, of all others, my reason would have chosen for this, 1 trust, not unworthy purpose. iv DEDICATION. I beg you, therefor*3, my dear sir, (<> .necpt as n token of my respect the little volume to which I have thus endeavored to attach your name, and it will not be wholly in vain, if it may be permitted to testify the sincerity and esteem, With which I am, My dear sir, Your very obliged friend, DUDLEY ATKINS, M. D PREFACE. The following collection of cases is thrown together without method, for it was not easy to fix upon any prin- ciple of arrangement, when scarcely two were alike. They are published from a variety of motives, which it may not be amiss briefly to state. In the first place, I thought some of them were worthy of record from their singularity, and others from the importance of their subjects. [n the second place, T thought there were many of them which were of a character very much to encou- rage the young physician, in his attempts to relieve cases apparently desperate in their circumstances. Some of them exemplify the power of nature in effecting cures almost beyond hope, and others, the reward obtained by perseverance, which, however, is not the less for being often unexpected. In the third place, I recollected that most of them occurred in places remote from my present residence, and thnt any reputation they might have tnven me, vi P R E F A C V, whether deserved or not, could only he regained by thei r publication here. And as very many of them occurred among the poorer classes, 1 thought it not unworthy of my profession to seek any praise they might justly deserve, as a portion of my legitimate and fair compen- sation. F therefore leave it to the kindness of my professional brethren, to whom I am already under so great obliga- tions for unmerited courtesy and attention. If this publication shall have the effect of leading others, whose stores are far greater, and upon whom the profession has a demand proportionably great, to favour us with the results of their labors and experi- ence, I shall find in that circumstance alone an abun- dant reward. (.; O N rr E ft T S l'AGE Dedication, ------ - - - o Preface, -.....- ° MEDICAL CASES. Acute Rheumatism Treated by Percussion only, - - 9 Chronic Rheumatism Cured by the Vapour Bath, - - 12 Cases of Curved Spine,......15 Remarkable case of Mollities Ossiuin, ... - 23 Remarks upon Symptoms characteristic of an exhausted Nervous System, - - - - - -26 Treatment and Diet of such persons, ... - 29 Pulmonary Abscess, terminating by a Spontaneous External Opening, ........3o Remarks upon the treatment of Chronic Complaints of the Lungs by alterative doses of Medicine, 37 Case of Procidentia Uteri, with remarks upon Pessaries, - 42 Remarkable case of Inversion of the Uterus, 46 Cases of Chronic Inflammation of the Uterus, - - 48 Cases illustrative of the importance of Alcoholic Medicines, 54 Cases of Delirium Tremens, ------ 58 Watery Cough,........6a Remarks upon Influenza, with a remarkable case, - - 6o Case of Ileus cured by true doses of Croton Oil. 69 viii CONTENTS. SURGICAL CASES. An undescribed affection of the Eye, - Operation for the Stone upon a child of three years, - Treatment of a case of Paraplegia in a child, - Cases of Compound Fracture of the Leg, - Bandage for Transverse Wounds of the Extremities, Remarks upon Hemorrhoidal Tumors, OBSTETRICAL CASES. Cases of Embryulcia,....... Remarkable case of Convulsions with Instrumental Labor, MISCELLANEOUS OBSERVATIONS. Scirrhous Tumor of the Mesentery,.....109 Case of attempted Suicide by Laudanum, - - - 111 Death from swallowing a solution of Pearlash, - - - 113 Chronic derangement of the bowels cured by sweet oranges, 115 Operation of large doses of Calomel, - - - - 117 Remarkable effect of a large dose of Oil of Turpentine in Fever,.........119 Singular crisis in a case of Yellow Fever, - - - 120 Case of Lethargy,........ 122 Black Vomit from External Inflammation, - - - 124 A Remark upon the dressing of Blisters, - 120 77 81 84 87 94 96 99 104 MEDICAL CASES. RHEUMATISM TREATED BY PERCUSSION ONLY. Case 1. E. T.; an unmarried female, aged about twenty, was affected with acute rheuma- tism of both wrists and elbows, so as to be una- ble to feed herself, or to raise her hands to her head. It had been of two weeks' continuance, The joints were much swollen, and very painful. As there seemed to be very little inflammation, I determined to try the effect of percussion and friction. A stimulating liniment was ordered, but not procured, and she was instructed to make a mallet or beater, with which to beat the joints affected. A silken ball, stuffed firmly with cotton, was fixed upon the end of a short stick, and with this she was directed to beat the parts as often and as much as she could bear. This involved, of course, a constant exercise of the joints affected. By this treatment, perse- veringly continued for two weeks, she was 2 10 MEDICAL CASES. wholly cured. The swelling was removed, the pain subsided, and the joints became moveable, and so free, that in two or three weeks, she could comb and put up her hair behind her head. Case 2. Some time afterwards I was called to see J. M., a connexion of my own, who was said to be very ill. He had been long exposed to a cold north wind, while engaged upon the water-side the day previous. I found him ly- ing upon a sofa, in his parlor, in great pain — unable to move. He complained of severe pain shooting from the small of the back down the buttock and thigh, which, upon farther inquiry, I found to be produced by acute rheumatism of the part. The pain had been only of a few hours' continuance, but was so severe, that upon attempting, at my request, to rise, he fainted. Hardly knowing how to handle so severe an attack, and not liking to wait the slow opera- tion of bleeding, &c, I resolved to test the power of percussion. I turned him with diffi- culty upon his stomach, and commenced the operation. Not having my instrument with me, I used the back or ulnar part of the fist, with which I commenced gently beating the part affected. This at first caused great pain, but the soreness soon became less, and in a few minutes he began to find himself easier. The force of the percussion was gradually increased, and it was applied with both hands. In twenty minutes from the time of commencing it, he MEDICAL CASES. 11 raised himself up, and, with my assistance walked round the room, experiencing compara, tively little pain. I directed the operation to be repeated at short intervals by his family, and ordered him to take the next day, a dose of jalap and cream of tartar, with which remedies he was in a few days wholly recovered. As this mode of treatment gives so immediate relief, I am inclined to recommend it to be used in all cases where the suffering is great. The vulgar use of the same mode of practice, in mild cases, is well known; and I remember that many years since, my father was accus- tomed to place us upon chairs about him, to beat the rheumatism out of his shoulders, which was always effected in a few minutes by our hearty cooperation; but its efficacy in more severe cases is, I believe, less commonly known. The fact being certain, its modus operandi I am inclined to leave to those who have a turn for such speculation. 12 MEDICAL CASES. CHRONIC RHEUMATISM, TREATED BY THE VAPOUR BATH. Case 3. Mr. J. S. came under my eare in the month of September, afflicted to a great degree with what might be termed the sequelae of chro- nic rheumatism. He had recently returned from Havana, where he was for many months dread- fully afflicted with severe rheumatic inflamma- tion in almost every joint. When I saw him his head was almost immoveably fixed upon his neck. He suffered much from pain at night, and was quite stiff in all his joints, moving with great difficulty. I determined to try the powers of the vapour bath in loosening stiffened joints, and with a simple apparatus, which I contrived, I succeed- ed in applying it very efficaciously. I fastened three strips of board about five feet in length, to a large wooden hoop of three feet diameter; — the strips were fixed at the other end, to a wooden triangular frame, which rested upon the floor. In this a chair was placed, and MEDICAL CASES. 13 a stool for the feet, as in the common vapour bath. The patient was placed upon the chair, and his head allowed to project above the hoop, while a large sheet, spread over the whole, and pinned about his neck, and round the upright strips of wood, confined the steam. This was produced by placing the common Jennings' appa- ratus upon a furnace of coals, and the pipe in- troduced under the chair. By urging the heat with bellows, a steam was kept up quite as hot as the patient could bear. The patient was kept in the bath about twenty minutes, when he was found to be covered with a most profuse perspiration. While in this state, I caused all the joints affected to be very briskly rubbed, and when he came out, he was rubbed dry. By persevering in this plan daily, for about two weeks, the joints became perfectly relaxed; a slight stiffness only of the neck remaining : the pains were removed, and he was enabled soon to walk out, and to enjoy the fine weather of autumn; nor did he have a relapse while he remained within my notice. From the very decided success I obtained in this case, I do not hesitate to recommend the vapour bath, as a remedy of great efficacy, in cases of chronic rheumatism of this description; and they are often such as baffle the skill of the physician, while they severely try the endurance of the sufferer. And it may be farther added, that they are cases, which are, for the most part, beyond the 14 MEDICAL CASES. power of internal remedies. Blisters, and sti- mulating embrocations, as oil of Turpentine, Larni, &c, are in the highest degree painful, while their operation in chronic cases is of doubtful efficacy. The vapour bath, on the other hand, presents a more sure remedy, which, at the same time, is decidedly grateful to the feel- ings of the patient, and by an apparatus like the one described, it may be soon applied in any situation or place. MEDICAL CASES. 15 CASES OF CURVED SPINE. Case 4. Mrs. M., one of the poor of the parish, came under my care during the year 1827. She was a widow, aged about forty, who was referred to me rather for the purpose of charitable attentions, than from any expect- ation of a cure. She was regarded, to use a common phrase, as bedridden, and I was re- quested to do any thing that might conduce to her comfort. She presented the following appearances. She was wholly confined to the bed, being affected with a partial paralysis of the lower extremities. She had been quite helpless for many months. She complained of great pain in the back and limbs, very much increased by any attempt to assume the erect position. She could move her legs a little, but was wholly unable to sustain her weight upon them, even with much assistance. This state of things had come on very gradually. There was a consi- derable projection of the thoracic and superior dorsal vertebra1, and pressure upon them caused pain. Her bowels were exceedingly consti- pated, and had been so for a long time, being 16 MEDICAL CASES. moved with difficulty by the most active purga- tives. Her tongue was red, contracted, and pointed ; covered, except at the point, with a close yellowish fur, and her breath offensive. Her pulse was weak and frequent, her appetite almost none, and digestion much impaired. As there was no symptom indicative of an ulcer- ated state of the vertebrae,•! was induced to consider it as one of those cases of diseased spine, to which the attention of the profession has been particularly called, by Doctor Physick of Philadelphia, proceeding from a disordered state of the bowels, and consequent imperfect nutrition, terminating in a softened state of the vertebrae. These bones are the first to exhibit the effects of this state of the system, from their having to support a relatively greater weight than those of any other part. Cases of this description, he has found to be treated very successfully by means of active purgatives, frequently repeated, and continued until a favorable change of symptoms is pro- duced. If my recollection is correct, (for I ne- glected to take notes of his lectures, and in common with the whole profession, I regret that we cannot refer to any thing in print for his practice or opinions,) he has found a similar mode of practice equally successful in many of the common cases of curved spine attended with ulceration. I at once put Mrs. M. upon a course of active purgatives, which was continued without inter- MEDICAL CASES. 17 mission for several months. At first I gave her every other day a large dose of Pil. Cochiae, always giving enough to procure three or four evacuations. As the bowels became more sus- ceptible to their action, the doses were diminish- ed, and the intervals between them lengthened to two, and at last three days. At first there seem- ed no remission of her symptoms ; but by degrees the pain in the back and limbs subsided, and she recovered the use and strength of the lower extremities. The bowels became more free, and the general health improved, and before the end of a year, she could sit up several hours, and with a cane could walk about the house. In this state she continued for several years, moving about with comparative comfort, and her back and limbs gradually recovered their strength. Case 5. C. R., a boy, aged about 6 years, had been for some time affected with a curvature of the thoracic vertebrae, to such a degree, that his head was quite sunken between his shoulders. At the time I first saw him, he spent the chief of his time upon the bed, being unable either to sit up long or to walk. His appetite was not good, and his bowels exceedingly constipated. I put him upon the same course of treatment as the last patient, and when lie was up, had his head sup- ported by a suspensory apparatus attached to his chair, and constructed from the drawings given by Dr. J. K. Mitchell, in his valuable paper 3 is MEDICAL CASES. upon this subject in vol. IV. of the North Ameri- can Medical and Surgical Journal. After this plan had been pursued a few months there was a rapid improvement in his condition; he was made to walk in one of the suspensory cars described as above, and in the course of six months was able to play in the street. The pur- gatives were continvied in his case about three months, and no external irritants of any kind were applied. He had subsequently a severe pulmonary affection, with copious purulent ex- pectoration, but unattended with any of his pre- vious symptoms, and from which he happily re- covered. Case 6. L. N., a very delicate boy, about 3 years old, was affected with curvature of the lum- bar vertebrae, followed by psoas abscess. He was a slender child, of white skin, with light hair and light blue eyes, the sclerotica of a pearly white. He had a slight curvature in the lumbar region, complained of much pain, was unwilling to move, and limped exceedingly. When stand- ing he was much bent forward, from the con- stant flexion of the thighs upon the pelvis. His bowels were not constipated. From the great pain and difficulty he experienced in moving, as well as from his temperament, I apprehended caries of the spine. His mother being anxious to prolong his life, and consenting to active treat- ment, I made two long issues upon the back with caustic potash, placing them on each side of the MEDICAL CASES. 19 affected portion of the spine. These were kept open for many months, with ultimate success. Two or three months after the issues were open- ed, a painful swelling appeared in the right iliac region, passing down towards the thigh. I had no doubt from this moment, that caries of the spine had terminated in the formation of a psoas abscess. As the tumor increased, it descended lower, until it occupied the whole superior half of the thigh. His strength became much dimi- nished, but was supported by nourishing diet, and frequently repeated doses of the Sulphate of Q,uinia. He was feverish and restless, and could rest only upon pillows in the lap. At last the abscess pointed and was opened upon the out- side, just below the buttock, and a very large quantity of pus discharged. The discharge from the issues was carefully kept up, and that from the abscess was found gradually to lessen. This treatment was continued for the greater part of the year, when he became able to walk and to play about the floor, and finally recovered. From these cases, which I trust will not be found destitute of interest, the young practitioner may find encouragement to persevere in a mode of treatment which he knows to be judicious, notwithstanding the most unfavorable appear- ances; and he may find fresh inducements to the faithful discharge of medical duty, under circum- stances the most disheartening. There is nothing so delightful as the crown of success, earned by constancy in endeavoring to overcome a dis- 20 MEDICAL CASES. ease which time seems to have put beyond the power of remedies. Case 7. The following case is deemed wor- thy of being recorded from the singularity of its mode of termination. It is taken from notes made while I wras House Pupil in the Philadel- phia Alms House Infirmary. Daniel Sullivan, aet. about 35, was admitted in- to the Infirmary, March 26, 1819. He had been sick for several months before the physician in attendance was able to ascertain the true cha- racter of his disease. The first symptoms were pain in the back, after a severe cold and a slight sprain in his loins. He gradually lost the use of his lowrer extremities, and the discharges from his bladder and rectum became involuntary. A great quantity of pus was one day discharged with his urine, which ever after continued to be purulent. Nothing more was done for a long time than merely to support his strength by to- nics and a generous diet, and to meet any un- pleasant symptoms as they occurred. The symp- toms and history of his disease were so obscure, that no efficient treatment could be adopted. About five or six w7eeks before his death, July 13th, Dr. Hewson having satisfied himself that it wras principally a disease of the spine, whatever else might have occurred subsequently, ordered two issues to be made in his back, just at the junction of the lumbar and dorsal vertebra?. They were kept open by Ung. Cantharid. and MEDICAL CASES. 21 for the last two weeks before his death, he be- gan to recover some power over his right leg; which proved satisfactorily that Dr. Hewson's view of the case was correct. After sinking gradually for a week, he died July 13th. Inspection. Upon opening the abdomen, we found the stomach distended with air, but other- wise healthy. The liver and small intestines were also nearly natural, except that the last as well as the large intestines had a slightly in- flamed appearance. The ccecum was very large and distended; the colon to the beginning of the sigmoid flexure was natural and full of faecal matter. But where it usually terminates in the rectum, it turned upward, extending al- most to where the duodenum crosses the spine, and then turning down it terminated in the rec- tum. All the colon, from the termination of the arch to the rectum, was contracted to the size of the small intestines, and in some parts even small- er. The coats were much thickened and indu- rated, and the longitudinal bands were unusually thick and firm. The whole colon and rectum were filled with hard scybala, although he was actively purged the week previous. The blad- der wTas very much contracted, and its coats much thickened and indurated. It was full of urine, at the bottom of which was a copious pu- rulent sediment. At the right side of its fundus the bladder terminated in a neck or process of considerable length, which we found to extend to the top of the sacrum on the right side ; the 22 MEDICAL CASES. cavity then passed to the left side, and extended along the vertebrae, lying between their bodies and transverse processes and the psoas muscle of the left side. It communicated with a cavity in the body of the middle lumbar vertebra, w7hich was found to be almost destroyed ; a portion of the body and the separated processes only being left. The adjoining vertebrae appeared to be somewhat diseased, and approaching the state of the first. All the ligamentous and cellular membrane around them, wras changed into a semi-cartilaginous, cheesy substance, interspers- ed with particles of bony matter. Thus it was clearly seen, that this was a case of caries of the lumbar vertebrae, producing an abscess which extended along the inside of the left psoas muscle to the sacrum, when it passed to the right side, and formed a communication with the bladder. It w7as an exceedingly obscure case, which was very little cleared up by the appearance of a copious purulent discharge in the urine ; as this rather, on the contrary, gave reason to suppose the symptoms were produced by a destruction of one of the kidneys, and thus still farther confused the diagnosis. MEDICAL CASES. 23 M O L L I T f E S O S S I U M . A very remarkable instance of this disease, probably the most so upon record, occurred in the city of Bremen, wdiere I saw the skeleton in August, 1820. I am induced to insert it from its near connexion with the last cases. The subject was confined to his bed for ten years previous to his death: several years before this event, his joints were rendered whol- ly useless by anchylosis, and he was quite inca- pable of motion. He had many ulcers, and they " became so painful a few weeks before death, that they could only be dressed once a week. They became in consequence full of vermin, which literally ate his flesh, and yet he prefer- red the pain of this to that of the dressing. The skeleton I saw in the Museum. The earthy part of the bones appeared to be totally absorbed, with the exception of the shaft of one os femo- ris, so that they were all translucent, and quite elastic. The chest was more deformed than I ever remember to have seen ; it being quite flat and its anteroposterior diameter in no part more than four inches, generally less. It was also a most wonderful specimen of anchylosis, every 24 MEDICAL CASES. joint in the body being firmly anchylosed. The vertebrae were all united to each other by bony union, and the head to them. The union seems to have preceded the softening of the bones. Diseases of the bones, as rickets, caries, &c. I found to be peculiarly common there, meeting large numbers of persons with deformed chest and back, and lame and diseased limbs. The above will certainly be Considered a very remarkable instance of the extent to which, in some constitutions, these morbid processes are carried. As such I thought it worthy of record. In cases of children predisposed to rickety affections, I have found very great advantage to be derived from a diet consisting almost wholly of fresh eggs. These are given either slightly cooked, or raw. In the latter case, I order two fresh eggs to be beaten up in a tumbler of cold or milk-warm water, with loaf sugar: of these the child is to take as many as he can be per- suaded to eat or drink, generally from four to eight daily. This diet, without medicine of any kind, I have found to give quite new life and tone to the system of a delicate child. The same article, viz : eggs in cold water, I have found to be a most refreshing thing for invalids of almost every description, but espe- cially for persons of an irritable stomach. I have myself, when out of health, taken as many as eight in the day, and found them to sit lighter on my stomach than any article of food what- ever. MEDICAL CASES. 25 In the chronic bowel complaints of teething children, the stomach is often so irritable, thai no fluid aliment can be retained. A child of my own of about ten months, which was in this con- dition during the month of August 1831, was kept nearly a month upon eggs alone, prepared as above directed. At the time of commencing their use, the stomach rejected every fluid nou- rishment. But she soon became very fond of the eggs, using a dozen every two days, and upon this diet, with plenty of fresh air, soon recovered. I do not hesitate to recommend it as the light- est article with which I am acquainted. It rare- ly disagrees with the stomach or bowels, and the coolness of the water is, during the hot wea- ther, peculiarly grateful to children; who, indeed, have generally a longing for cold drink, while laboring under summer complaints. By this means, we are enabled to gratify this natural desire, and, at the same time, to supply the sto- mach with a most nutritious diet, 4 26 MEDICAL CASES. REMARKS UPON SOME SYMPTOMS OCCASIONED BY AN EXHAUSTED NERRVOUS SYSTEM. There is a class of nervous symptoms and af- fections, that I know not how better to class, than under the above denomination. They are somewhat analogous to those which Dr. Hall has described in his work on the Mimoses, and yet are so different as to merit a separate no- tice. The chief and most troublesome of them I do not remember to have seen in any medical work. It is always described as a sensation of burning or flashes of heat over the front of the chest, chiefly along the sternum. When I first met with it, I was quite at a loss to understand its nature or cause ; but at a subsequent period, I became familiar with it in my own person. It generally shows itself in persons whose sys- tem has been exhausted by venereal excesses, or by working in an overheated atmosphere. It is also brought on by any thing which distresses or embarrasses the mind. In my own case, I ascribed it to writing too much in a hot room, MEDICAL CASES. 27 combined with great anxiety of mind. I am anx- ious to call the attention of physicians to it, be- cause I am convinced that medicine does no good, but rather hurt, in these cases, while a nutritious diet, and free exercise in the open air, are almost specific in its cure. In one instance, when it existed to a great degree, it was wholly removed for the time by dining upon very rich beef-soup, nearly in the state of rich gravy. This removed it entirely, within twenty-four hours. An entire cessation of the causes producing it is indispen- sable to its cure, and in an especial manner the avoiding all hurry, and all mental care and fa- tigue ; for bodily fatigue is one of the most direct remedies. After this heat upon the breast shows itself, if the same habits are continued, there is soon added to it a decided hoarseness, indicating a disposition to pulmonary affection. In fact, I could hardly define it in fewer words, than by say- ing, that it is an exhausted state of the nervous system, showing itself in a simple weakness or debility of the lungs and chest; and exercise in the cold air is almost immediately effectual in its removal, if it be adopted at once, and carri- ed to a sufficient extent. I first became acquaint- ed with these symptoms in the following case. Case 8. I was called in the fall of the year to see Miss P., aged about 20, a farmer's daughter, who lived at some distance from town. She was confined to her room, and so weak that she could sit up but half an hour at a time. Her friends were apprehensive that she was the subject of 28 MEDICAL CASES. consumptive complaints. But upon a careful investigation, I could find no reason to believe her lungs affected. The symptom she complain- ed most of, was a sensation of heat or burning over the front of the chest, or, as she termed it, " burning at her stomach," which was much in- creased by any attempt to occupy her mind or body, or by any the least mental disturbance. This, at the time, I did not in the least compre- hend, nor did I understand the true pathology of the case, until I afterwards became subject to the same symptoms. She was very feeble, trembled much upon attempting to move, and had no ap petite. The bowels were slow in their motions. and the tongue very much furred. Her pulse was rather frequent, and she had slight palpitations. but I could find no reason to suspect any organic affection of any part. I considered it a case ol chronic derangement of the stomach and bowels. During four or five months, I tried every modi- fication of alterative and tonic treatment, with- out the slightest benefit. I also consulted Dr. Jackson of Boston upon her case, who recom- mended almost precisely the course of treatment which I had been so long in vain pursuing. Her tongue continued furred, her appetite very indif- ferent, and her other symptoms nearly the same. At last I relinquished the case in despair, and her friends began to take her out to ride, and by degrees she recovered her health and strength, almost without medical aid ; but this was not until the case had been of nearly a year's con- MEDICAL CASES, 29 tinuance. It was impossible to ascertain the fact, but from the entire absence of all other causes, I had no doubt of the existence of some improper habits. Had I been as familiar with this symptom as I now am, I should have regarded it as a mark of an exhausted nervous energy, and should from the beginning have ordered her to take the air every day. It. wTas certainly one of the most embarrassing cases I ever met with, and I have since met with others equally unmanageable; but they all occurred previously to my acquir- ing a knowledge of the true cause of the symp- toms. It is very possible that others may be familiar with these symptoms and their cause, but I do not find any satisfactory description of them in the authors, where I thought it most likely that I should meet them. Hot rooms, mental anxiety, mental labor, especially writing, any haste or hurry, and all venereal excess, I have observed to be particu- larly apt to produce this state of things ; as in clerks in offices and stores too much heated, girls in factories, &c. The direct and effectual remedies are a rich nutritious diet, careful avoiding all the causes and constant and fatiguing exercise in the fresh air. In myself I have found the exercise of rowing early in the morning to furnish an entire remedy. From the circumstance of the hoarseness at- 30 MEDICAL CASES. tending it, I have no doubt that this state of the system may often prove the precursor of pulmo- nary consumption. And this danger can be guarded against only by the prompt abstinence from every thing which is found to exhaust or debilitate. It is in cases of this kind, that I have found the diet of fresh eggs, recommended at p. 24, to be especially serviceable. Rich beef or turtle soup, or rich stews of any kind of tender and nutritious meats, and especially rich choco late, I have found to be of the greatest service, as conveying a very strengthening nourishment in a small bulk. The efficacy of the latter arti- cle is in some degree explained by the fact, which I but lately learned from Messrs. Delmo- nico, chocolate manufacturers in this city, that the cocoa contains a butter or concrete oil, in quantity more than sufficient to make the best chocolate. So that the animal oils, soap, &c. which are added to the cheaper and more com- mon kinds of chocolate, are made use of only because the manufacturers do not choose to use a sufficient quantity of cocoa, but substitute flour and other substances, to render it a cheap- er article. Mr. D. exhibited to me a cake of this butter of cocoa in its pure state, nearly resem- bling hard white soap in its appearance. I can- not refuse myself the pleasure of recommending to all who love good chocolate, and to persons whose systems require a stimulating nourish- ment, the chocolate manufactured by Messrs. D. I have also found Welsh's No. 1, from Boston, to be nearly equal to it in quality. MEDICAL CASES. 31 And while I am recommending an article as wholesome to persons of the above description, I feel obliged to enter my protest against three ar- ticles in almost universal use, as in the highest degree injurious: viz. strong coffee, green tea, and tobacco. It must be remembered that these observations are addressed to persons of an ex- hausted or debilitated nervous system only: but it is well even for those in good health, to call to mind the homely proverb, " that the pitcher may go nine times to the well, and be broken at last." All proverbs are, moreover, the recorded results of popular experience. But to persons whose nerves are debilitated or ex- hausted by early excesses, by care, anxiety, or fatigue, the above articles are among the most deleterious that can be mentioned. Those in whom strong coffee at breakfast produces an irritable temper through the day, or coffee or green tea cause sleeplessness at night, may be assured that those articles are exerting a per- nicious influence upon their nervous system. They are exciting that which needs repose, and weakening the very part of the system which is already deficient in strength. The same may be said of those who find to- bacco, whether smoked or chewed, to produce palpitations, nausea, or dizziness—for all these are evidences of a direct attack upon the ner- vous system. To avoid the injurious effects of these so agreeable cordials, let the coffee be diluted with 32 MEDICAL CASES. an equal quantity of milk, let black tea be sub- stituted for green, and let tobacco be wholly abstained from, and they will soon find how much they are gainers by the change. Those who do not know that they have a sto- mach or nerves by any feeling they have ever experienced, may be allowed to judge for them- selves, but they must not be suffered to regu- late the diet of those, whose stomachs are good for nothing, and whose nerves are all unstrung. Let people who are in health, live as they list, but invalids must live as they may, or they will certainly live to see and feel their mistake. And those, who in spite of dyspepsia, disordered nerves, restless nights, and irritable tempers, still choose to indulge in hot strong coffee at breakfast, and in strong green tea or coffee at night, or in tobacco at any time, will be fortu- nate if they are permitted at last to see their error, and to learn wisdom, even at their own expense, MEDICAL CASES. 33 PULMONARY ABSCESS, TERMINATING BY EXTERNAL OPENING. Case 9. When first called to see Miss K., the subject of this singular case, aged about six years, I found her in the following situation. She had hectic fever, perfectly developed, re- curring in daily paroxysms, the pulse wras almost too frequent to be counted, she was much ema- ciated, had constant cough, with copious puru- lent expectoration. Upon the left side of the chest were three or four fistulous openings, viz. one about two inches below the left axilla, upon the side, and two others in front, between the third and fifth ribs. They were covered with thick, horny scabs, half an inch or more in thickness, which were formed by the drying of the matter that was discharged from the si- nuses. These scabs were succeeded by new ones, which continually formed, as the old ones were removed or thrown off, and there was a constant discharge of thick matter from all the orifices. She had been several months in this state, and had been under the care of other practitioners, who had left her, or been dis- 34 MEDICAL CASES. missed, (it is forgotten which,) because the case w7as regarded as incurable. During the year pre- vious, she had had the whooping cough very severe- ly, and afterwards experienced a severe attack of inflammation of the lungs, terminating in a pro- fuse discharge of purulent matter by expectora- tion, and in the formation of these openings, from which pus had constantly been discharged- Some time after the last attack, she threw up, in coughing, a common white bean, which bore the mark of having been long soaked in matter; and which her friends regarded as hav- ing ben the cause of the disease, by lodging in the bronchia. Upon examination with the stethoscope, I found the right lung to be still sound, present- ing only a mucous rattle, which led me to hope that she might yet recover. The right side was sonorous upon percussion, but the left gave an obscure sound in every part, and was much contracted in size. Respiration could be heard in but a very small portion of the left lung, but a distinct pectoriloquy in various parts, corresponding to the external openings; while the remainder seemed to be perfectly solid. Here, then, had been a pulmonary ab- scess, of which nature was effecting a cure, by adhesions to the chest, and spontaneous open- ings. I ordered her a nourishing diet, and put her upon the use of pills, prepared according to the following prescription. MEDICAL CASES. 35 R. Pulv. Gum. Myrrh. 3ss. Sulph. Q,uin. 3j. Sulph. Ferr. gr. x. Muc. Gum. Arab. q. s. Ft. Mass. in pill. no. xx. dividenda. Of these she took two or three daily, and continued their use until she was quite re- stored. The paroxysms of hectic soon ceased, the expectoration, and the discharge from the ulcers, diminished; she began to recover her appetite and flesh, and in a few months was able to play about with activity. At the last time of my seeing her, the ulcers and scabs were much diminished, and the ex- pectoration only occasional; being found to increase with a cold, or any change in her general health. She continued under my eye for a year or two, grew stout and went to school, enjoying good health, although the whole pro- cess of removing the diseased lung was not yet completed. This was the only case of the kind I had ever seen, when I met with Mr. B., a stout farmer in Pennsylvania, who had been himself the subject of a similar cure ; and whose case was briefly stated to me by a medical friend, who. attended him. He was attacked with severe inflammation of the lungs, which terminated in pulmonary abscess of the right lung, attended by all the common symptoms of an approaching fatal re- sult. He continued for some weeks in this state, when the abscess pointed at the lower 36 MEDICAL CASES. part of the chest, upon the right side. It opened spontaneously, and great quantities of pus were discharged ; the orifice gradually closed, his strength was restored, and he remains, (perhaps now ten years,) a stout, healthy man. The right side of the chest is somewhat smaller in dimension than the left, but otherwise he is welL Why the orifice should so soon have closed in this case, and have remained open so long in the other, I am unable to say, unless that in this case the abscess opened at the most de- pending point, thus keeping free of matter. MEDICAL CASES. 37 ALTERATIVE TREATMENT IN CHRONIC PULMONARY COMPLAINTS. Case 10. In November, 1832,1 was called to see Mrs. S. J., an English emigrant, who pre- sented the following appearances. She was exceedingly emaciated, her skin was bedewred with a clammy, moist sweat, her pulse was constantly one hundred and twenty or upwards, she had, at times, a hec- tic flush upon the cheek, and a continual cough. During the day and night, she expectorated a quart of watery fluid, on the top of which floated sputa of thick, purulent matter, which remained suspended upon the more fluid part, with ragged ends and portions below. She had no appetite, and ate but little. She was wholly confined to her bed. I learned from her that she had been confined a few weeks previously, had lost her infant, and was not yet wholly recovered from the weak- ness naturally consequent upon child-bearing. Her voice was whispering and hollow7. She had an attack of pulmonary inflammation a week or two before her confinement, which had 33 MEDICAL CASES, resulted in her present state. For this she had been bled and blistered. Several of her con- nexions had died of consumption. Upon a slight examination with the stetho- scope, I could find no distinct pectoriloquy, but still I considered it a case of consumption, and nearly hopeless. As there was some pain in different parts of the chest, I applied small blisters, which had the effect of removing it. Rather with a view to comfort her, than from an expectation that it wTould be of much service, I ordered the follow- ing powder to be given every fourth hour, which was continued with more or less regularity for at least six weeks. R. Pulv. Nit. Potass. \ - ^ ■ Pulv. Dover. / aa gr n" Pulv. Scill. gr. j. Ft. Pulv. After taking a few doses, it was found to operate upon the stomach as an emetic, and as I did not desire this, I directed her to take but half a powder, and to repeat them rather more frequently. To check the profuse perspiration, I directed a few drops of elixir vitriol, in water, which soon had the desired effect. At the time of commencing this treatment, the expectoration amounted to four rather small half-pint tumblers, perhaps a wine quart, in the twenty-four hours, being most copious at night. After about four wTeeks, she was removed to the country, at which time she was able to sit up most of the day, the skin had become nearly MEDICAL CASES. 39 natural, the pulse much reduced in frequency, the expectoration less than a tumbler in the day and night. As I had no expectation of meeting her again, I took leave, impressing upon her mind the probability of a recurrence, of her symptoms, after a few weeks. But to my surprise I met her in town a month after wholly well, her cough was gone, her strength almost entirely restored. And subsequently I saw her in the street, returned from a long walk, and reporting herself quite well. She had taken several parcels of the powders with her to the country, which she had continu- ed to take daily, until the cough wholly left her. Her disease, I consider to have been a suppu- ration upon the pulmonary mucous membrane, attended by chronic inflammation of the sub- stance of the lungs. A similar mode of treatment I have frequently pursued in chronic inflammation of the pleura, and in hepatization of the lungs, without much regard to the character of the expectoration. True consumption I regard as wholly incur- able ; and any form of chronic irritation or in- flammation about the chest, I have found to yield to a persevering continuance of the above treatment. Its peculiarity I conceive to consist in the extreme smallness of the dose, the above prescription being the largest powder; the dose being often less than half that here given. 40 MEDICAL CASES. When there is any reason to fear injurious effect from the Dover's powder, I make use of two grains of ipecacuanha in its stead. I have often been quite at a loss to under- stand the modus operandi of this treatment, for it appears to produce an accumulating effect, if I may so term it, the stomach becoming daily more sensible to its operation, instead of becom- ing less so. This is rather the reverse of what we generally experience in alterative medicines long continued, as the cicuta, for instance, and others, of which the dose requires to be con- stantly increasing, as the system becomes gradu- ally less sensible of its operation. But in using this prescription in the treatment of chronic in- flammation, I have observed that a constantly diminishing dose produced an equal effect. It produces the combined effect of quieting the cough, lessening the expectoration, and di- minishing the frequency of the pulse, as in the above case. I believe the cough-pill of some practitioners consists of nearly similar ingredients, but other- wise I have been inclined to regard this simple alterative mode of treatment as rather peculiar. This may result, however, only from my igno- rance of the practice of other physicians. In similar cases of chronic suppuration of longer continuance, as of several years duration, I have found very happy effects from the dry vomits long continued, as in one case, to the extent of thirty emetics. In this instance the MEDICAL CASES. 41 disease had been of seven years duration, and there was distinct pectoriloquy in the medial and upper portion of the lung. The subject of the case, a stout fisherman, persevered in the use of the emetics, until he assured me that they be- came so odious, that upon seeing his wife go to the closet for the powder, free spontaneous vo- miting was produced. He was enabled within the year to return to his laborious occupation. The emetic used consisted of equal parts of sulphate of zinc and ipecacuanha, from eight to twenty grains of each. In another case, which had been of many years duration, and which was regarded as a case of consumption, but which I did not par- ticularly examine, from his residing at a great distance from my house, the same treatment was effectual in removing all his symptoms in a few weeks, without ever producing emesis. He took the same powder of about ten grains of sulphate of zinc, with ten of ipecac, which had only the effect of producing a few motions from the bowels, and a very slight nausea, without any vomiting, but entirely restored him to health; removing a cough which had reduced him exceedingly, and had troubled him for many years.—I saw this man myself but twice, once when I prescribed for him, and once after he was quite restored to health. 42 MEDICAL CASES. PROCIDENTIA UTERI. Case. 11. The subject of the following re- markable case was a woman about fifty yeai> of age, the mother of several children. She had been four or five years afflicted with the disease, and had consulted several practitioners, who had assured her that her case was incurable. Upon inspection, I found a large tumor de- pending from the place where the vagina should have been, and resting upon the thighs. It was of an oval form, hanging in the direction of its longest diameter, and was about thirteen inches in circumference. At the bottom was a trans- verse orifice. Upon examination, it proved to be the vagina, wholly everted, containing a uterus slightly enlarged, at the bottom ; the re- mainder constituting a large sac filled with in- testine, and quite soft. From long exposure to the air, the once internal but now external sur- face, had become quite dry and rough. As the orifice of the sac seemed to be quite large, I felt assured that the whole might be returned into the abdomen, although it would not, perhaps, be so easy to keep it there. _ Placing her upon her back, with the hips a MEDICAL CASES. -13 little elevated, I embraced the tumor with both hands, and by a little firm pressure, thrust the whole sac and contents into their natural situa- tion. A very large sponge was then introduced, Avhich was supported by a common bandage. She at first experienced some difficulty in ap- plying the bandage so as to keep the sponge in place, and the uterus descended a little ; but never so as to appear externally, and by in- creasing the size of the sponge, it was kept tolerably in place. I may here remark, that after many trials of pessaries of various kinds, I have been led to prefer the sponge, as the best and most conve- nient. The patient should be furnished with two or three, and they should be changed daily, those not in use being immersed in lime water, which keeps them perfectly free from unplea- sant odor. It has the advantage, that the patient can remove and apply it herself, without the least difficulty, thus saving her the pain of many examinations, &c, which cannot but be disa- greeable in the highest degree. They can be every where obtained, easily fitted, and as easily replaced; nor have I ever found them to fail in keeping the organ in place, if they were properly selected and applied. I have made fre- quent trial of pessaries of various other descrip- tions, and have found them very liable to become displaced. I have also found, that it required no common degree of skill to fit them ; while any 44 MEDICAL CASES. one can judge of the dimensions of a piece of sponge, requisite to fill a given cavity. For country practitioners, and for those whose practice and experience are but limited, I es- teem the sponge pessary by far the best. For I have known very respectable physicians to make the most bungling work, in their at- tempts to cure this very common complaint. In the country, especially, other pessaries are difficult to procure; and to prepare a substitute, demands a mechanical turn, and a degree of in- genuity, not ordinarily possessed. But a soft sponge is always at hand, and is easily fitted and introduced, and a little loop of tape upon one end is all the preparation it needs for suc- cessful application. The sponge should be boil- ed in water, to free it from all impurities, and especially from any remains of the acid in which it was originally prepared. I may be permitted to remark, that sufficient regard is not commonly had, in the education of students, and in the writing of medical works, to the unavoidable simplicity of country practice. The materia medica of the country phy- sician is, of necessity, almost confined to the con- tents of his pocket, and his surgical apparatus to his pocket case of instruments; it is, therefore, much more important to him, to be taught to simplify his practice, than to depend upon articles which it is hardly in his power to obtain. And, it is far better for his patients, that he should learn new ways of using old and simple remedies, than MEDICAL CASES. 45 be always looking after something wholly new and untried. In truth, the more simple the practice of any physician is, the better is it, both for his own reputation, and for the safety r»f those committed to his care. 46 MEDICAL CASES. INVERSION OF THE UTERUS. This accident generally occurs after the birth of a child, at or near the full period of utero- gestation; and it is perhaps generally due to some neglect or mal-practice on the part of the attendant. The following is an instance of its spontane- ous occurrence after a miscarriage in the third month only. Case 12. I was called to Mrs. K., who was a patient of Dr. Tho's. Boyd, and who had suffered an abortion, being, as she supposed, in the third month. As there was not much hemorrhage, I left her, apparently doing very well, and ex- pecting, as a matter of course, that Dr. B. would be called to her. This was, however, neglected, and the next day I was called in haste to see her again. They then informed me, that upon getting up to evacuate the bladder or bowels, she had felt something come down, and wTasmuch alarmed. Upon examination, I found a soft substance filling the os uteri, and extend- ing perhaps about an inch into the vagina. Now7 this might be either a coagulum of blood, or it might be the placenta retained, or an inversion of the uterus. Bv the touch MEDICAL CASES. 47 alone no satisfactory information could be ob- tained. She complained of much pain, and it was long before I could ascertain among her at- tendants, whether any one had seen the foetus or the placenta. Amid this very painful uncer- tainty, I endeavored, as the uterus was low in the pelvis, to get a view of the substance, but found this was impossible. At last a female was found who had seen a small foetus, of an inch only in length, and the whole placenta. I then made another careful examination of the parts, and found the os uteri closely constricted about the substance which filled it, and made up my mind, that the uterus was partially inverted, — All attempts to replace it were found unavail- ing; a full opiate was given, and she was left to rest for the night; in which Dr. B., who came in just after, acquiesced, as the only proper mode of proceeding; and in the morning he re- stored the displaced portion to its place without difficulty. As I found the diagnosis of the case ex- tremely difficult, I thought it important to pre- serve an account of so singular an accident.— For it is evident, that any attempt to have extracted this apparently foreign substance, under the idea that it was a coagulum, which, to the touch, it perfectly resembled, might have been productive of the worst consequences to the patient, 43 MEDICAL CASES. CHRONIC INFLAMMATION OF THE UTERUS. There is perhaps no complaint among females which is so frequently overlooked as this. The symptom which most arrests the attention of the patient, viz., the watery discharge from the vagina, unfortunately but too often receives all the attention of the physician. Whereas it is in fact a mere accidental circumstance, of little consequence, either as an object of regard or medical attention. These cases are too often treated empirically as cases of Leucorhcea; and the physician, unwilling to take trouble or to distress his patient, who is usually both delicate and nervous, omits the only sure way of gaining knowledge of the state of the womb, a ma- nual examination. The first of the following cases offers a sad instance of neglect of this kind; and I doubt not that many females suf- fer from lingering disease, which might have been prevented or easily cured, if the attend- ant had possessed an entire knowledge of th e case. It should therefore be laid down as a rule, to treat no chronic complaint of the uterus or vagina without a satisfactory examination. Case 13. Mrs. C. the subject of this case was a young married woman, the mother of MEDICAL CASES. 49 one child. She had been married about five years, and was of a delicate constitution. She had been for a year under the care of her fami- ly physician, a very respectable practitioner, who had been treating her for leucorhoea, by the use of various local and constitutional reme- dies, as injections of white vitriol, green tea, &c, and with sulphate of quinia, sulphate of zinc, isinglass, &c, as general remedies. — During the greater part of the time she had been getting worse, and during the whole attendance he had never proposed an examination. At my first visit she presented the following appearance. She had been wholly confined to her bed for five or six weeks, was very much emaciated, pale, and bloodless; she had daily paroxysms of fever ; the pulse was very frequent, the skin of a dingy yellowish color, and the urine high-colored and scanty. She complain- ed of a constant and debilitating discharge from the vagina, of much pain at the lower part of the abdomen, and in the back; her stomach was very irritable, would bear but the lightest food, and she complained of much un- easiness in the epigastric region. Upon exa- mination per vaginam, to which she readily con- sented, I found the os uteri, and, in a less degree, the whole body of the organ, exquisitely painful. It was at once evident that the complaint was a chronic inflammation of the uterus, and that the stomach, the liver, and the general health, 7 50 MEDICAL CASES. were all deranged, from sympathy with the local disease. I put her at once upon a light, and chiefly fluid diet; the use of the blue pill at night, and a Rochelle powder the following morning; which treatment was continued, until the stomach and liver were restored to a more healthy action. The following plan w7as then resorted to for the purpose of removing the original source of the complaint. She was cupped daily upon the hypogastrium, until all pain on pressure was removed ; was ordered to sit in a warm hip bath every evening, as long as her strength would admit, and to use frequently, during the day, an injection of w7arm decoction of poppy heads. She was put upon the use of the extract of ci- cuta, (Con. Mac.) in doses of four grains, repeat- ed three times daily, and with directions to take as much as she could bear without nausea or dizziness. Every third day she took a sufficient quantity of Rochelle salts to operate three or four times. The cupping was continued for about two weeks, the bath for about six, and the remainder of the treatment until her strength was fully re- stored, and the uterus would bear pressure and pinching without pain. In about four months she was able wholly to discontinue her remedies; the menses returned, and she became pregnant. She was safely delivered, and continued to do well, although she remained slender. MEDICAL CASES. 51 Case 14. Mrs. D., a colored woman, had been affected with complaints of this description for five years; but, owing to her extreme diffi- dence, had never consulted a physician. She had been married about seven years, but had no children. At the time of my seeing her, she was very much in the situation of the last pa- tient, with the following remarkable differences. She had constant severe shooting and lanci- nating pains, which extended from the region of the uterus up the left groin and hip. The vagi- na and labia were excoriated by a constant acrid discharge, so that her neighbours falsely suspect- ed the origin of her complaints;—there w7as a most intense pruritus about the vagina, and so sore were all these parts, that the introducing a finger into the vagina caused her to grind her teeth with anguish. The whole womb and vagi- na were found to be exquisitely tender and pain- ful. There was here great reason to fear that the disease had passed on to a cancerous state. She wras, however, put upon the same treatment as the last patient, and not finding any relief to her pain from the cicuta, the extract of hyos- cyamus was substituted, of which, at the time of my leaving her, she had taken nearly one quarter of a pound. This was in the course of three months.—The symptoms gradually gave way, the tenderness and pain subsided, the menses returned, at first with much pain, but subsequently without, and in a few weeks more she was enabled to perform all her domestic 52 MEDICAL CASES, duties, carefully, however, avoiding the marital concubitus : — at the end of three months, when she discontinued the hyoscyamus, she was quite well, and has since gone to Virginia. In this case, the extreme acridity of the dis- charge, and the consequent burning and itch- ing, gave more inconvenience than any other symptom.— The free use of lapis calaminaris, in impalpable powder, was found to afford the most relief from this inconvenience. — This symptom, however, disappeared with its cause, and she was enabled to walk out and to take exercise, which she had long been unable to do. Case 15. The disease, in this case, was of longer continuance than in either of the others, and was of a much more obstinate character. The subject of it, a town pauper, was a woman of very bad habits, who had led a very dissolute life, and of whose folly this was probably the fruit. The case was complicated with great en- largement and prolapsus of the womb, and was rendered remarkable by the occurrence of fre- quent abscesses in the substance of the uterus, or some of its interior dependencies, with dis- charge of much foetid matter per vaginam.__ These abscesses she had been subject to for many years, and seemed quite familiar with them. The uterus was enlarged to about double its natural size, and was kept in place by a pessary, of her MEDICAL CASES 53 own construction. Her complaint was at last wholly overcome, by the long continued use of the cicuta. She was subsequently married, and became the mother of a healthy child. 54 MEDICAL CASES, CASES ILLUSTRATIVE OF THE NECESSITY OF ALCOHOLIC MEDICINES. I give the two following cases as illustrations of happy effects resulting from a bold and de- cided practice in extreme cases, and also as proofs of the indispensable necessity of using alcohol and its preparations, under certain cir- cumstances. Case of Tetanic Spas?n suddenly removed by Laudanum, &c. Case 16. On Monday evening, just at night, I was called to see the daughter of J. D., aged about eleven years, who was said to be dying. On inquiry I found that she had, in the fore- noon of the day previous, fallen about twenty feet from the girder of a barn, across which she and other children were walking. In falling, she struck directly upon her chin, the head being violently thnwvn back. By this, the muscles of the neck, and the abdominal muscles and dia- phragm, had been very much strained. She suffered excruciating pain, and was very faint during the whole day. A learned quack, who MEDICAL CASES. 55 was called in, prescribed calomel and jalap; and finding the next day that, notwithstanding his most judicious practice, spasms were coming on, he consumed the day in sending an express for Balsam of Life, which, he assured the friends, was infallible. Fortunately, they chose not to wait its arrival. Upon entering the room, I found her extended upon the bed, almost without pulse, the skin cold, the lower half of the body and the inferior extremities perfectly fixed and rigid with spasm, in which state they had been for several hours. She seemed nearly exhausted, and said that all the objects in the room began to look green. I had about half an ounce of laudanum in my pocket; and knowing there was not a moment to be lost, I mixed it with a glass of hot whis- key punch, very strong and hot, and in a few minutes got her, although with great difficulty, to swallow it all. In a very short time her pulse began to im- prove, her skin to become warm ; she said things returned to their natural color, and the rigid extremities became relaxed. In a word, in twenty minutes from the giving the medicine, she was out of danger, and I mounted my horse to return home. She recovered rapidly, suffering- only from a stiffness of the joints of the lower jawr, naturally consequent upon so severe a blow. Now I ask the most bigoted opposer of alco- hol, what, in such a case, could by any possibi lity have been done without it 1 56 MEDICAL CASES. Case of Tympanitis cured by Alcoholic Medicines. Case 17. I was called at bed time one eve- ning to see a child in the neighbourhood, in its third year, ill with severe complaint in the bow- els. I found it laboring under tympanitis of the most complete character. It had been trou- bled for some weeks with disordered bowels, and on this day the discharges had ceased, and the bowels began to swell. At the time of my seeing it, I found the abdomen enormously dis- tended, so that it was almost spherical; it was hard and tense as the head of a drum, and the skin was stretched, until it was almost of a po- lished smoothness. Its pulse w7as exceedingly frequent, and its countenance indicative of the greatest anxiety. Judging, from the degree to which it had been reduced, that there was very little danger of in- flammation, or of any medicine doing harm from its severity of operation, I ordered it at once the following prescription, of which a tea-spoonful was directed to be given every fifteen minutes. fy. Tinct. Aloes, Soc. ) — Tinct. Rhei. f aa iSS* Tinct. Cinn. Comp. gj.—Mx. At the same time I ordered a saturated tinc- ture of cloves and pimento to be prepared with hot brandy, and flannels wrung out of this to be MEDICAL CASES. 57 rolled firmly round the abdomen These were directed to be kept wet with the hot tincture, and drawn tighter as the wind should be dis- charged. This treatment was commenced at 11 P. M., and by 3 A. M., or in about four hours, the wind began to be discharged from the bow- els with great force, and the bowels to be freely opened. In a few days it was well, and had no return of the complaint, One such case is worth more than volumes of declamation about alcohol; and I trust the young practitioner may learn, from these two cases, the safety of a bold and decided practice in all simi- lar cases. For it is certain that the patient will soon sink under the disease, and it is only the very boldest treatment that can give any chance of success. If he waits to think how much he may do without incurring the risk of censure, or what treatment will be safe at all hazards, or in what he would be sustained by the opinion of others, he will, probably, but seldom enjoy the exquisite satisfaction that results from saving the life of another, under circumstances of im- minent danger MEDICAL CASES DELIRIUM TREMENS. This peculiar disease I believe to be, in its' first stage, wholly a disorder of the nervous sys- tem. Watchfulness is its most distressing symp- tom ; it may be almost said that it is the whole disease, for if sound sleep can be procured, the disease is at an end. With sleep, all the pecu- liar hallucinations, that so torment the patient, vanish. One of the following cases, however, presents a very remarkable exception to this rule. In this instance, a. full recollection of the disordered perceptions of the delirium, and a full belief of their reality, remained for several days after sound sleep had been procured, and after the patient had wholly recovered the use of his reason in all other respects; thus presenting a case nearly bordering upon common mono- mania. The other case is remarkable, in having oc- curred in a person who was not known ever to have been intoxicated, but who acknowledged that he used spirits freely. He was steady, in- dustrious, and respected, but used to take spirit and water very freely. I have had greater opportunities of observing MEDICAL CASES. 59 this disease than falls to the lot of most prac- titioners; for while I resided in the Alms House Hospital, in Philadelphia, there were thirty- eight cases treated, of which thirty-one were cured. The treatment generally pursued in that Institution was, the frequent repetition of emetics, as recommended by Dr. Jos. Klapp, then a physician to the house. The above suc- cess is certainly very remarkable, if the class of people occupying an Alms House Hospital is considered. Since I left the hospital, however, I have uniformly adopted the treatment de- tailed in the following cases, and with uniform success ; having lost but one patient of this dis- ease, and that was a man who was almost apo- plectic when I first saw him. The practice here detailed is that uniformly pursued in the Pennsylvania Hospital, and re- commended by Dr. B. H. Coates, in a paper on the subject in the North American Medical and Surgical Journal. I have always used the same dose, when called at the commencement of the attack, and have never found the slightest ill effect from so free a use of opium, having always found that the patient awoke rational from the first continued sleep. Case 18. A gentleman of rather free habits of living was attacked with insomnia and loss of appetite, after some excess in wine, com- bined with much mental anxiety. During the night previous to my seeing him, he had been go MEDICAL CASES. much disturbed by seeing persons perched upon the surrounding houses, who wrere singing ludi- crous songs, of which he had himself the mis- fortune to be the hero. It is worthy of remark, as connected with his subsquent belief of the fact, that they were in situations wholly inacces- sible to human feet. His room was filled with im- aginary persons, whom he also pursued through the house. Many other things, equally unfounded in truth, kept him busy through the day follow- ing. Any visible object, as he was near-sighted. was at once converted into some wonderful creature of the imagination. I was often mis- taken for another person myself. When called to him, at day-break, I found him trembling, wild, and incoherent, and busily pur suing a supposed black boy about the room, at the great risk of limbs, chairs, &c. His pulse was full and active, but not hard. I put him at once upon the use of ten grains of pow7dered opium, repeated every four hours, and which I administered myself. He continued wild and restless until night. The false perceptions di- minished in the course of the day, but still con- tinued partially the next day. With the excep tion of one subject, however, the hearing the sounds above described, he became quite ra- tional by eleven o'clock P. M., at which time he had taken fifty grains of opium. He slept part of the night well, and remained quiet in his room the next day, and for ten days after, with- out an attendant. As his perceptions were still MEDICAL CASES, 61 disordered, I continued the opium, until he had taken ninety grains in a little over thirty-six hours. Even this dose failed to produce sleep of more than a few hours continuance. The third day his perceptions were wholly correct, but he retained, at that time, and for several days after, a full belief of the reality of all the events of his delirium, which he recollected with the utmost mi- nuteness. During these days he also became hungry and ate well. This peculiar condition of the intellectual faculties I have never met with before, either in delirium from intempe- rance or from fever. He could give all the de- tails with the utmost distinctness and particu- larity ; and was so convinced of the entire real- ity of even the most grotesque of his inventions, that I avoided mentioning them after a few days, fearing it might have some tendency to terminate in mania, and that these recollections might conduce to its development. This state of things continued after he had so far recovered as to attend to business, and amuse himself with books. It may be doubted by some if this were a case of delirium tremens, but I think I never saw its symptoms more perfectly developed than during the first tw7elve hours of my attendance. From that time the effect of the opium began to ap- pear, and the disease to subside. He continued to attend to business from that time with undi- minished capacity. 62 MEDICAL CASES. Case 19. Mr. J. had been under my care for a week or ten days with an attack of pleurisy, for which he had been freely depleted, and from which he was convalescent, when symptoms of delirium tremens suddenly came on. Sleepless- ness and visions of cats were his constant trou- ble. He was a very stout and perfectly healthy man, but whose high color indicated the pre- sence of ardent spirits. As he wras never af- fected by it perceptibly, his family were quite indignant at the suggestion of the true nature of his new symptoms, and were about to dis- charge me upon the spot. They maintained that it was a metastasis of the fever to the head. After much persuasion, however, they consented to the administration of the opium, which was given as above. After the third dose he fell into a sound sleep, which continued thirty-six hours, and from which he awoke perfectly ra- tional, and became rapidly convalescent. The result, I believe, convinced the patient and his family, that a man might have delirium tremens who was not a drunkard ; thus affording another inducement to all, to hasten the abolition of the free or common use of ardent spirits. MEDICAL CASES. 63 WATERY COUGH. In persons of a phlegmatic temperament, and a soft, relaxed habit of body, I have met with several instances of very troublesome but not dangerous affection, to which I have given the above name. It is so peculiar, and so easily re- moved by appropriate treatment, that I have thought it worthy of record, although it is per- haps only a disease of personal idiosyncrasy. Case 20. Miss A., a young lady aged about twenty-four, very tall, and of a remarkably loose, soft texture of the solids, consulted me on account of a cough. She esteemed it to be a common cold only. She did not cough during the day; but, upon lying down at night, she found her lungs oppressed by a load of mucus, which kept up a continued irritation and dispo- sition to cough. The cough was attended by a copious expectoration of thin, watery mucus, of which she frequently raised a pint during the night. It was a perfectly colorless, homogene- ous fluid, rather ropy, and came up with the greatest freedom; but from her delicacy of ha- bit, and from its excessive quantity, it produced great debility. I regarded it as a merely mecha- nical draining of the fluids from weak lungs. 64 MEDICAL CASES. and determined to try the effect of strong astrin- gents. I therefore ordered her the compound pills of quinine, of which the formula will be found at page 35, which she took four times daily, together with five doses of the muriatic acid. The effect was immediate ; the expecto- ration was lessened by one half on the second day, and in a few days ceased entirely. Case 21. The subject of the case of chronic rheumatism, Case 3, was excessively annoyed by a similar cough, which always attacked him when lying down, and kept him from sleeping many nights. I put him upon the use of the same pills, and with such effect, that he assured me the cough disappeared from the first day of their use. I have since met a cough, apparently wholly similar, in a delicate infant of a few months old, whose lungs seemed to be inundated with the secretion from their mucous membrane. A simi- lar prescription, in a fluid form, and in propor- tionate doses, had the effect of putting a stop to it in a very short time. As there are many w7ho apprehend danger from the sudden check of any cough by the use of astringents, I have thought that these cases would point out an instance in which it is per- fectly safe to check the discharge as soon a.s possible, it being one of pure mucus only, and apparently proceeding from a merely relaxed state of fibre and constitution, a form of debility, MEDICAL CASES. 65 INFLUENZA. This disease has generally been termed an epidemic catarrh. But the influenza of Febru- ary and March 1826, as I saw7 it in Pennsylva- nia, might rather be called an epidemic Proteus; for it attacked every organ, from the top of the head to the diaphragm. In some cases, it ap- peared as a simple catarrh; but in others, it seized upon other parts than the mucous mem- brane. In one female it produced enormous and most distressing enlargement of both the parotid glands, from which she obtained no relief until they had suppurated, and the inflammation was carried off by a profuse purulent discharge from the ears. In a man of about forty, it seemed to affect the heart itself; producing a most intense pain in the centre of the chest, with a hard cough, and powerfully excited pulse, upon which bleed- ing and blisters seemed to have no effect. He died upon the fourth day, not having found the least relief from any of the means used. I have to regret, that, in consequence of a misunder- 9 66 MEDICAL CASES. standing, I did not see him until the third day of the disease. In a female, whom I saw afterwards in another section of the country, it produced a suppuration of some of the frontal or nasal cavi- ties, with a subsequent discharge of many por- tions of bone, and which caused an illness of seve- ral weeks. In others, it took the form of simple pleurisy; but by far the most interesting case, and which w7as one of the most appalling forms of disease I ever witnessed, was the case of the Rev. Mr. Barbary, a Methodist preacher. Case 22. In this case the inflammation seemed to fix upon the pleura, covering the lower part of the chest and the diaphragm. I had been attending him for several days, and the disease seemed to be abating under the use of free depletion, &c, when, upon visit- ing him at night, I found him presenting the following appearance. He complained of acute pain just above the epigastrium, and shooting through the breast. His countenance indicated the greatest distress and anxiety. His pulse was very frequent and hard. He had a convul- sive hiccough, which returned with every respi- ration, and at every return of which he groaned, or rather screamed with pain, so loudly that he could be heard many doors off. The diaphragm seemed itself to be the seat of inflammation, and its convulsive motion caused the most agonizing distress that I ever witnessed. MEDICAL CASES. 67 Thinking it impossible that he could live many hours without relief, I had my horse put up, and staid the night with him. Here was a double indication to be fulfilled, requiring almost contradictory means of cure. The highly acute inflammation was to be subdued, which could be effected only by the most active depletion; and, on the other hand, the spasm of the dia- phragm w7as to be relieved, which could only be brought about by the free use of the most pow- erful anti-spasmodics. I immediately opened a vein, and took as much blood as I thought the pulse would bear, and at the same time admin- istered a mixture of laudanum, ether, and oleum succini, in doses of a tea-spoonful, every few minutes. The violence of the pain continuing unabated, the vein was twice re-opened in the course of the night, and blood to the amount of not far from four pounds was taken, w7hile the mixture above mentioned was continued. I was, indeed, obliged to administer this with one hand, while I directed the flowing of the blood with the other. By this powerful combination of reme- dies, he obtained entire relief in about eight or ten hours, and I had the pleasure to see him, in a few weeks, restored to his labors. Had I bled him less, the inflammation must soon have terminated in gangrene; and had I been fearful of using a sufficient quantity of the anti-spasmodic, he must soon have sunk 68 MEDICAL CASES. under the mere violence of the pain, which was certainly the most acute I ever witnessed. Such cases are, fortunately, rare; but furnish, when they do occur, the most brilliant trophies of the medical art; and, in success, a most satisfactory reward. MEDICAL CASES, G9 ILEUS CURED BY CROTON OIL, Case 23. Mr. P., a laborer, aged about 50, of intemperate habits, was suddenly seized with vomiting and purging, after drinking very freely of small beer while much heated. I did not see him until the subsequent day. The discharges from the bowels had then stopped, he had great pain in the bowels, and constant vomiting. All the common means were resorted to for the purpose of quieting the stomach, both ex- ternal and internal, without the slightest relief. The bowels were obstinately closed, and medi- cine, in every form, was instantly rejected. He continued in this state for several days, and, up- on the third day, the fluid discharged by vomit- ing became decidedly stercoraceous, as tested both by the smell and taste. Finding all the usu- al means wholly to fail, I determined to make trial of the Croton oil. This was administered in doses of at first one, and afterwards of two drops, until he had taken ten drops. After a few hours the vomiting ceased, and small dis- charges took place from the bowels of bright yellow matter, like the stools of an infant, which 70 MEDICAL CASES. continued for a couple of days, becoming at last very copious. The pain then subsided, and a rapid convalescence succeeded. It was remark- able, that the operation of the oil caused very little griping or pain. Bleeding, blisters, sinapisms, injections, calo- mel, and opium, w7ere tried in every form with- out the least effect. I regret that I did not take particular notes of this very interesting case ; but, if I remember aright, the vomiting of fecal matter continued at least one day, I think, du- ring a portion of the second. It was about five days from the attack before he got entire relief. I embrace this opportunity to recommend an application, which I have always found in the highest degree serviceable and convenient, in all painful complaints of the bowels, when not at- tended by inflammation. It is the frequently re- peated application of dry hot salt, which is fold- ed up in a towel or napkin. This is always to be had, it is soon heated, and has this great ad- vantage over hot fomentations, that it does not leave the patient wet and cold after his pain is relieved. By keeping two napkins in use, the salt for the one may be heated while the other is applied, and thus a constant succession kept up. In all cases of colic, the heat gives relief, almost from the first application, and is by far preferable to any mode of applying heat, whe- ther dry or wet, that I have ever made use of. MEDICAL CASES. 71 Case 24. The subject of the following very interesting case I did not attend, but was pre- sent at the examination of the body, at the re- quest of the late Dr. Prescott, of Newburyport, for whom I made the dissection. The subject, a lad about five years of age, died of inflammation of the bowels, of a few days' continuance, immediately produced, as we found, by the strangulation or stricture of a portion of the jejunum by a membranous band, the result of inflammation during a previous attack. He had a severe attack of inflammation the year previous, from which he recovered, and was well for more than a year ; nothing appear- ing, to indicate that the disease had left so dan- gerous a consequence. During the present at- tack, it had been found impossible to make any medicine pass through his bowels, there appear- ing to be evidently some obstacle unknown, which defeated the power of the most active cathartics. After lying several days in this state, the case terminated fatally, with the usual symptoms. Upon examination after death, the intestines presented, in every part, the proofs of the most acute inflammation, both in this and the previous attack. They were so firmly agglutinated to each other, that in the lower part of the abdo- men it was found impossible to separate them. This was, for the most part, the result of the first attack. The surface w7as also covered with a purulent and caseous secretion, the product of 72 MEDICAL CASES. the recent inflammation. But in the upper part of the abdomen, near the stomach, the intestines were more free from adhesions, which were con- fined to a few membranous bands and fibres. The small intestine, at its upper part, was enor- mously distended, of a deep red, and almost purple hue. The cause of this distension and inflammation was found at the end of the dis- tended portion, where, just below the left kid- ney, a fold of the jejunum was found to be firmly bound down and closely compressed, by a band of false membrane, which passed over it and ad- hered to the neighbouring parts, as represented in the sketch in plate I., fig. 1. This band was drawn still tighter by the distension of the intes- tine above, thus producing a perfect .strangula- tion. The resistance here offered to the contents of the bowels, had undoubtedly been the prime cause of the recent attack. Below7, the intes- tines w7ere for the most part firmly compacted together, but still had retained their peristaltic power, as was proved by the oldness of the ad- hesion, and the fact that he had experienced no difficulty from the state of his bowels before the last attack. How they could continue their functions in such a state, is truly matter of won- der, but it is not a new thing. I thought the singularity of the mode of stran- gulation made it worth noting, and made a sketch of it, as seen in the plate referred to. Should I again have a similar case, or one in any degree analogous, I shall feel much disposed MEDICAL CASES. 73 to try the following mode of treatment, recom- mended to my notice by Dr. Roberts, of Mobile. He informs me, that in all cases of obstinate vo- miting, and irritability of the stomach, he has experienced the happiest results from the use of a large suppository of solid opium. This is kept in the rectum until the symptoms are relieved, when it is withdrawn, and the stomach is left in a state of repose. I say solid opium, because he uses a piece of crude opium, which he forms into a suppository with a knife, and which is evidently far preferable to one made of pow- dered opium with gum, inasmuch as the opera- tion of the first can be checked at once by with- drawing it, while that of the other cannot but by an injection, as the gum dissolves in the fluids of the rectum. He was so kind as to detail to me the case of a lady who was seized with violent cholera morbus, with cramps and spasms, a few days only after her confinement in childbed. In this instance, a large suppository of opium wras al- most the only remedy resorted to, and had the effect of putting a stop to the train of distress- ing symptoms, and leaving her in a kind and natural sleep, after which she rapidly conva- lesced. It is one of the great advantages of medical communication, that we are led to see things in a new light, to acquire new modes of practice, or new and valuable applications of well known and familiar remedies. It is for want of this 10 74 MEDICAL CASES. that we become wedded to a particular routine, and can hardly be brought to do any thing but as we have done it before. Witness, for exam- ple, the English and French schools of medi- cine, and modes of practice, each of which might derive valuable information and correc- tion from the other. For instance, I have seen a French surgeon give five grains of rhubarb to check an inflammation that called for twenty grains of calomel and free doses of Epsom salts. His patient died. Medical men are, perhaps, more apt than all others to be bigoted in their attachment to particular modes of practice, from the circum- stance that our science is so much a matter of personal experience. Every man naturally pre- fers his own. What he knows himself he thinks he is sure of, his neighbour's knowledge he is loath to trust. This tendency is much counter- acted by the free interchange of personal opi- nion and experience. It was by the habit of gathering knowledge every where, that the late Dr. Rush became so remarkable for the accumu- lated stores he possessed.* He laid every one * The following interesting anecdote of Dr. Rush was commu- nicated to me by an English physician, a fellow student of his at Edinburgh. He said that Rush acquired a very commanding influ- ence among the class, and, in particular, in their debating clubs, by the very remarkable stock of facts which he had even at that early age accumulated. After others in debate had produced and defended their theories, he generally settled the contest by the producing some obstinate fact which had come under his notice, with remarks of this kind, « Your theory, sir, is very good, &c, but it so hap- pens, that facts have fallen under my observation which prove MEDICAL CASES. 75 under contribution. How different from the proud sciolist, who wishes always to teach, while he feels little desire to learn. I am aware that the particular mode of prac- tice above referred to is familiar to the pupils of the Broussaian school; but when did rival sectarians submit to be taught by each other 1 the contrary." This, of course, settled the point, as no one chose to make it a personal affair, by disputing the truth of his as- sertion. Thus, he soon acquired such an influence as to be elected the president of the club, although my informant stated, that his obser- vations seemed so beyond his years, that many believed his facts to be fabrications. Still no one dared say this, and Rush remained triumphant in every debate. SURGICAL CASES. AN UNDESCRIBED AFFECTION OF THE EYE. Case 25. The subject of this singular case was a lady of this city, who, at the time of its occurrence, was upon a visit to the eastern states. It was at Newburyport that she called upon me. Her account was, that she had left New York just a week before, at which time she had no complaint of the eyes of any kind. She took a severe cold on board the steamboat, causing rheumatic pains, and slightly affecting her eyes. The road from Providence to Boston was very dusty, and her eyes became much ir- ritated from that cause, and the blowing of a cold easterly wind. She remained in Boston two or three days, during which she suffered excessively from pain in the eyes, but took no advice, from fear of detention at that place. The pain in the eyes was excessive, but espe- cially so upon lying down at night, when it be- 78 SURGICAL CASES. came so excruciating, that she w7as compelled to pass much of the night sitting up, and crying from the severity of the pain. This she de- scribed to have been, as if pins or nails were thrust into the balls of the eyes. On Saturday, the eighth day from her leaving this city, she came under my care. Upon examination of the balls of the eye I was surprised to find how little they presented the appearance of inflammation upon their external surface. The pain must have been caused by mere fulness of the eye, as it yielded too easily to treatment to admit the supposition of an internal inflammation. But what constituted the peculiar feature of the case, and rendered it a subject of great in- terest was, that at the external edge of the cornea of each eye, just opposite the outer angle of the eye, there was a small crevice, as repre- sented in Plate I. fig. 2, which occupied precisely the line of junction of the cornea and sclerotica at that part. The appearance was precisely as if an incision had been made by some cutting instrument, penetrating half the thickness of the cornea, and separating the edge of the sclerotica from the cornea. The edge of the cornea at this point was slightly irregular. The separa- tion extended through a space of two lines in length, and was precisely equal in both eyes. From the edge of the sclerotica at this point, numerous small inflamed vessels extended to- wards the angle of the eye, and were confined to that part alone, as represented in the plate. SURGICAL CASES. 79 The edge of the sclerotica was slightly elevated just at the same point. The treatment was briefly as follows. As she had not slept for many nights, an opiate was given to procure rest; small blisters were ap- plied behind the ears, and a collyrium directed as follows: — ft. Sulph. Cupri. gr. xii. Spir. Camphor. 3j. Aq. Pluv. gviij. Mx. ft. Sol. pro collyr. This wash was found to suit the eyes remark- ably well, and was directed to be diluted with rain water, as long as it produced any smarting. She was kept for two weeks in a room perfect- ly dark, as the sensibility of the eyes to the light was excessive. The blisters behind the ears were repeated without giving much relief from the pain, and a large blister was then applied to the back of the neck and between the shoul- ders, which had the desired effect of relieving the pain and lessening the inflammation. She was at the same time actively purged, and kept upon very low diet. From the drawing of the last blister, the symptoms yielded and the ulcers healed. There remains now, (5 or 6 years after,) a slight irregularity of the cornea at that part, rendering it rather more elliptical than common, the cornea appearing to have encroach- ed a little upon the sclerotica, (See fig. 3.) In about three weeks, she was able to bear the light 80 SURGICAL CASES. and move about, but was unable for several months to make much use of her eyes; she has had no return of the disease. This peculiar affection of the cornea is not, I believe, described in the works upon the subject. It was certainly a separation produc- ed by the ulcerative process, and probably the consequence of inflammation. It wTas perfectly formed when I first examined the eye. It was wholly distinguished,' it appears to me, from common ulceration, first, by its peculiar situa- tion ; and secondly, by its being precisely similar, and similarly situated in both eyes. It is almost impossible that this could have occurred in mere common ulceration of the cornea. It seemed a precise separation of the outer layers of the cor- nea from the sclerotica, following precisely the line of their union. I regard it myself as an ulceration, produced by distension of some internal part of the eye from the previous inflammation; but whether this distension was in the substance of the cornea, in the anterior chamber of the eye, or in the whole ball of that organ, I confess myself una- ble to decide. Its entirely peculiar features I consider as distinguishing it from any common form of ul- ceration of the cornea, and regarding it as an affection of the eye not known to the schools, I propose to term it Ajiosclerotis, a name of which the etymology is very evident, and which seems quite expressive of its character. SURGICAL CASES. 81 OPERATION FOR STONE IN THE BLADDER. The following operation for stone is detailed rather as an instance of what may be effected by small and inadequate means, than as an ex- ample safely to be imitated in all respects. Per- haps, in the eyes of many, it will appear highly censurable. Case 26. Mr. D., of Plymouth, Luzerne county, Pennsylvania, consulted me in regard to his son, a boy of three years old, supposed to be affected with stone in the bladder. He ex- hibited all the common and very distressing symptoms of that complaint; and upon sound- ing him with a very small steel sound, the cal- culus was distinctly felt. Its formation was at- tributed, by the boy's mother, to a fall it had upon its back, when about nine months old, if I remem- ber right, which was followed by a discharge of blood with the urine. As he grew older, the common symptoms were gradually developed. The parents of the child were desirous of an operation ; but as they wrere not rich, they could not afford the expense of a journey to Philadel- phia, and therefore requested me to perform it 11 82 SURGICAL CASES. myself. As I had not a proper set of instru- ments for the purpose, I felt at first almost un- willing to attempt it. But at last I determined to make the attempt, being assured that, at so early an age, the danger and the difficulty w7ere much less than in an adult. I therefore prepared the following apparatus : I cut a groove upon the back of the sound first used, with a metacarpal saw. This formed an exceedingly smooth and true channel for the knife. I then prepared a common straight bis- toury, by securing the opened blade with firm silk wound about the joint, while a common polypus forceps was to remove the stone. Hav- ing given a large opiate, I performed the opera- tion with this simple apparatus, in the presence of several respectable physicians, &c. I made the first incision down to the sound with a com- mon scalpel; and after a little difficulty in fix- ing the end of the bistoury in the groove, I pro- ceeded with it to make the incision through the neck of the bladder. This was easily effected; and a finger being introduced, the incision was enlarged by the same instrument. But what was my dismay, when, upon introducing the for- ceps, no stone was to be felt! Feeling, how- ever, quite sure of the fact of its presence, from the previous evidence of the sound, I proceeded to examine the bladder in every part with my finger, when, in a few seconds, it was found sus- pended by an adhesion to the bladder, directly behind the pubis. I say suspended, because the SURGICAL CASES. 83 surface, by which it wTas found to adhere, w7as very small, covering not a fifth of the length of the stone, while the remainder of it was per- fectly free. It was easily dislodged, or torn off, by the finger, and in a few minutes extracted. The child w7as put in bed; slept nearly twenty- four hours under the influence of the opiate given before the operation; passed water through the penis the same night; and in two weeks was about. Seven years after I heard of him, and learned with great pleasure that he continued well. The calculus was found to be of the mulberry kind; was quite rough; and the adhesion, the place of which was indicated by a red spot upon its side, had been formed about the neck of the little papillary projections upon its sur- face. It was of a flat, oval form, about one and a quarter inches in length by five eighths of an inch in breadth, and about three eighths of an inch thick. The adhesion of a stone, in this manner, is denied by some writers; and this is, perhaps, the only certain instance upon record. Of the fact I was assured, in this case, from much exa- mination. 84 SURGICAL CASES. MECHANICAL TREATMENT IN A CASE OF PARAPLEGIA IN A CHILD. Case 27. I first saw the subject of the fol- lowing uncommon and interesting case by acci- dent. While at the office of his father, S. W. Marston, Esq., of Newburyport, a beautiful boy, of about six years, was brought to his door in a cart, whom I found, upon inspection, to have wholly lost the use of his lower extremi- ties. The disease was ascribed, by his friends, to the having eaten the leaves of some poisonous plant in the garden, when he first began to walk. The cause was not certainly known, but the result was, that his lower extremities began to dwindle and become weak, until he lost the use of them entirely. In this state he had remained, I think, about four years. He had suffered much from practice, regular and irregular, and had been several weeks with Sweet, the noted " bone doctor." All, however, was in vain ; and, at the time of my seeing him, all hopes of his recovery had been wholly given up. His chest was finely developed, and from his active habits of climbing with his hands, he had acquired great strength SURGICAL CASES. So of body. But from the buttock, the nutritive process seemed to cease: the lower extremities were scarcely so big as his arms, and cold and powerless, while his form above was Herculean, and his color of the most blooming description. There was also an incontinence of urine, which was in the highest degree troublesome. Find- ing that the glutaei were partially developed, it occurred to me that if his lower extremities could be rendered firm, as if of one piece, that he could at least make use of crutches, which would give him the inestimable power of volun- tary locomotion. At the time I saw him, he never went out but in a little cart, in which his brothers dragged him about the streets. As the treatment I proposed would be rather an amusement than a pain to the child, and as his mind seemed of a high order, thus rendering it still more desirable to set him upon his feet, his father kindly consented to my taking charge of him. I am happy in being able to say, that the result exceeded my most sanguine hopes. I found that when both bones of the left lower extremity were secured to a strip of wood of equal length with them, that he could hold up his body by leaning upon a chair or table. I therefore procured for him, through the skill of my friend, E. Bradbury, Esq., machinist, the ap- paratus delineated in the accompanying sketch, Plate II. fig. 3. It is so simple as to need no description beyond the explanation there given. When this w7as fastened to his limb, (for the 86 SURGICAL CASES. right leg was soon abandoned as useless,) he was placed in a standing stool upon rollers, and made to push himself about. After a few weeks I put him upon crutches, but it was long before he could become used to his new mode of existence as a triped. When the leg and the crutches stood like the three legs of a surveyor's theodo- lite, he did very well; but upon every attempt to bring them in a straight line, or to make them pass each other, he invariably fell down. This difficulty was, how7ever, overcome by several months of persevering effort, upon the part both of master and pupil; and he soon be- came quite active and independent, and still continues to move round on crutches in compa- rative comfort; and w7hen contrasted with a helpless cripple, is certainly happy in his pre- sent state. It is only necessary to say farther, that the joint at the knee was found in some respects in- convenient, and it was dispensed with, the two pieces being riveted in one. As he grows, no doubt some improved form of apparatus may be found still more convenient. SURGICAL CASES. 87 COMPOUND FRACTURE OF THE LEG, WITH EXFOLIATION. Case 28. I was first called to see this case in consultation with the late Dr. Covell, of Wilkes- barre, to decide upon the question of amputa- tion. It was a compound fracture of the low- er part of the tibia, which had been four weeks under the care of a quack. The limb was, at the time of our seeing it, in the following situa- tion. The fracture was a transverse one, with- in about two inches of the bottom of the tibia. Upon opening the dressings, about two inches of the upper portion of the tibia presented itself, black, and in a state of perfect necrosis ; — the surface of the lower portion lay in the bottom of the ulcer, out of sight, but with the probe was found to be rough and bare. These were sur- rounded by a large suppurating cavity, embrac- ing the whole surface of the tibia, which had been exposed. The exposed portions of the bone, therefore, constituted the centre of a very large and foul ulcer, from which sanious pus was freely discharged. The whole ulcer was exquisitely 83 SURGICAL CASES. painful. From it proceeded several long sinuses, one of which extended up towards the calf of the leg, while others, which had been produced by the pressure of splints, extended down to the foot, passing up on the instep, and under the hollow7 of the sole. The man was intemperate in his habits, about 45 years of age, and now exceedingly reduced by the irritation and con- stant suppuration of the wound. He had pro- fuse sweats and hectic fever. A worse case could hardly be conceived. The only favorable symp- tom was found in the circumstance that the fibula was not involved in the ulcer, but was united with tolerable firmness. As he had received no proper treatment, we determined to try, for a few weeks at least, the effect of a better practice. He was therefore put at once upon the use of the proper constitu- tional remedies, and in a few weeks was reliev- ed from the hectic and night sweats. It was found that the ulcer was so exceeding- ly irritable, that no attempt could be made to apply any form of extension or counter-exten- sion. The foot and leg were therefore laid ea- sily upon a pillow, and compresses kept upon the various sinuses upon the foot and leg, by means of the many tailed bandage. It was of course evident, under the circumstances of the case, that it must be left to the strength of the fibula alone for support and steadiness. If I remember aright, it was dressed twice a day for SURGICAL CASES. 89 several weeks, and as his general health improv- ed, the sinuses healed, so that extension could be made upon the foot; the suppuration became less, and the painful irritability of the ulcer was re- moved. In a month he was comparatively quite comfortable. In the course of a few months large portions of dead bone were thrown off, and the bottom of the ulcer wras filled up with soft granulations of a yellow color, consisting chiefly of coagulable lymph, into which a pin or probe could be thrust an inch, without producing the least pain ; with this substance the cavity, originally about two inches square, was almost wholly filled up. This gradually changed to a cartilage, and in less than a year, a firm union took place by means of this cartilage, which was by degrees converted into bone. The ulcer healed, after the last portions of bone were thrown off, leaving at last only a depression that would admit the end of a finger, and which w7as quite superficial. The limb gradually became firm enough to bear his weight, and he walked with crutches some time before the end of the year, and was at last ena- bled to work in the field. Two or three years after he died of a pulmonary complaint; but I regret that I was not at the time in the same neighbourhood, or a very interesting preparation might have been procured. 12 90 SURGICAL CASES. Case 29. The next case, although not so hopeless in its character, was bad. A young man of twenty was thrown from a colt, about the first of winter, when the ground was frozen. The fall produced a com- pound fracture of the right leg, at about the middle. The fracture was very oblique, and the sharp triangular end of the upper portion was forced two inches through the integuments. He was placed in bed, but as it was ten miles to my residence, I did not see him until six hours had elapsed from the time of the accident. I found it necessary to enlarge the wound w ith a bis- toury, before the bone could be returned. It was then carefully adjusted, and a permanent extension applied. The fibula readily united, but from the length of time that elapsed previ- ously to the setting the limb, it was perhaps in- evitable that inflammation should succeed. This soon came on, and suppuration followed. The portion of the bone which had been exposed, being denuded of its periostum, soon turned black and became dead. From the extreme obliquity of the fracture, and from the circumstances last mentioned, it was found impossible to keep the fractured por- tions in contact. With varied fortune, the case continued to require daily dressing, for many months. At last, in June, finding no appear- ance of separation of the dead bone, I made pre- parations for removing them by an operation. As, however, I was making a very minute ex- amination of the parts involved in the wround. I SURGICAL CASES. 91 felt with the probe a soft and semi-cartilaginous union, covering the space of two thirds of an inch, at about the middle of the fractured sur- face. With this fresh encouragement, I deter- mined to wait the result; I left the family to dress the ulcer, having previously removed the splints; and in a few7 months more, the dead portions were thrown off, the ulcer healed, and he gradually acquired strength in the limb, and at last was restored to his labor and health. In a similar case, it would perhaps have been better to have sawed off at once the whole por- tion exposed, thus preventing the hazard of ex- foliation, and reducing the ulcer to a simple ab- scess, if inflammation should follow. I found that I had ridden more than thirteen hundred miles in attendance upon this man, and this during as severe a winter as I ever knew. For this I received, after five or six years, about fifty dollars ! The first of the above cases afforded an op- portunity, which does not often occur, of minute inspection of the manner in which a loss of sub- stance is supplied, in a bony structure. The first granulations, after the dead bone was thrown off, were a mass of yellow coagulable lymph, precisely similar to that which forms the bond of union in large incised wounds. This, by degrees, became organized; and, by a gradual process, was converted, in the first place, into a substance nearly resembling common cartilage, and subsequently into solid bone. 92 SURGICAL CASES, It may not be uninteresting here to state a fact which I found years since in the memoirs of the French Academy of Surgery. It exhi- bits an instance of the manner in which the dis- coveries of great men are sometimes anticipated by kindred spirits. It is there stated, that on the 22d May 1770, Gerhard Eyting maintained, in a thesis at Strasburgh, the following opinion upon the subject of the regeneration of parts, and the formation of callus. " He conjectures, that in wounds with loss of substance, there is a regeneration of flesh ; that the granulations formed upon denuded bones, &c. are a new form- ation : to prove which he seeks his reasons in the mechanism of the nutrition of parts, and he concludes, that nature acts for the reneical of substance destroyed by a wound, by the same ope- ration ivhich produces the natural increase of parts. He says, the same is the case in the re- union of fractured bones, and he confirms it by w7hat occurs in cases of teeth transplanted from one mouth to another, which, he says, receive nourishment from the vessels of their roots, and that they are subject to caries, pain, &c. like other teeth." In proof of this last fact he quotes several very respectable French authorities. These views accord most strikingly with those subsequently developed by John Hunter, whose work on the blood, it must be remember- SURGICAL CASES, 93 ed, was not published until 1792, although he be- gan it in 1765. These views, as might be expect- ed, are laughed at by the editors of the memoirs, and they attempt to refute them. See Mem. Acad, de Chirurg. Tome V. p. 111. Edition Nouvelle. J4 SURGICAL CASES. BANDAGE FOR TRANSVERSE WOUNDS OF THE EXTREMITIES. Case 30. A waiter in a public house, in at- tempting to uncork a bottle of wine, crushed the bottle betw7een his thighs, where he was holding it, and as he was bearing very hard up- on the corkscrew, the upper half of the bottle was pressed directly against the inside of the right thigh. The result was, a deep incision penetrating nearly to the bone, near five inches long, and gaping to the extent of an inch and a half. It bled very freely, and as it was pre- cisely across the middle of the thigh, I was fear- ful that sutures of any kind would not hold. I immediately secured two strips of bandage of about a yard long by a few turns of a roller, the one above and the other below7 the wound, and just opposite the centre of it, as represented in the sketch, Plate II. figs. 1,2. When both ends of these strips were drawn towards each other, I found they nearly closed the wound. I therefore laid a compress of lint upon it, and tied the four loose ends in a firm knot directly over the wound. SURGICAL CASES. 95 This had the effect of stopping the hemorrhage and bringing the edges of the cut nearly in con- tact. The bandage kept its place so well as not to require to be re-applied, and the wound healed in a few days, leaving but a narrow cica- trix. I found this dressing so simple and so superi- or to any form of suture, that I feel desirous to recommend its use in all transverse wounds of the extremities. Not the slightest inconve- nience arose from the pressure of either portion of the bandage, as many would at first sight ap- prehend, nor did it slip. 96 SURGICAL CASES. HEMORRHOIDAL TUMORS. I have often known much time consumed, and much pain needlessly suffered, by patients la- boring under this very common disease, while the physician was trying in succession a variety of simple applications, none of which had power to give relief. The following compound oint- ment I have found exceedingly serviceable in painful tumors of this kind: ft. Extract. Stramon. 3ij. Acet. Plumb. 3ss. Pulv. Opii. 3ss. Aq. Rosar. q. s. ad fac. ung. moll. This may be diluted by the addition of rose water, and applied by a linen rag. It rarely fails to give relief. If the parts are inflamed, leeches should of course be previously applied. The combining with this the free use of a de- coction of senna and manna, I have found to be eminently serviceable. My attention was first called to the powers of this especial purga- tive in these cases by a nurse of some expe- rience, and I have found it to exceed my ex- pectations. SURGICAL CASES. 97 It should also be observed, that in order to the successful treatment of hemorrhoids, the free application of leeches to the anus should invariably precede the use of local applica- tions, where any degree of inflammation exists. And it will often be found, upon a careful ex- amination of the rectum, that it is in a state of high inflammation, when the external tumor is the only thing complained of. In an extremely severe case of this kind, I knew a physician to administer opium in pills, not recollecting that his patient might die of pain before solid opium could act. It should ever be borne in mind by the young practitioner, that in urgent cases, of whatever character, all medi- cines should be administered in that form which w ill most facilitate their immediate operation. Thus, in severe pain, laudanum, or the solutions of morphia, should always be made use of. In other cases, where larger doses of opium are required, as in delirium tremens, &c, the opium should be given in substance, because an equi- valent dose of the tincture might produce unfa- vorable and even fatal results, by too sudden an operation. It is probably from not attending to this important circumstance, that so many have objected to the mode of treating cases of delirium tremens exemplified in one or tw7o cases in this volume. In comparing the results of experience, it is altogether necessary that a similarity of circumstances be ensured, other- wise the result is frequently fallacious. 13 OBSTETRICAL CASES. EMBRYULCIA The two cases following wTere scarcely less interesting than embarrassing. They w7ere both different, in many respects, from those which arc generally supposed to require the lessening the head of the child; and yet, upon a review of them, I am unable to see that the course pur- sued was not perfectly justifiable. Case 31. Mrs. B. had been subject, previous- ly to her marriage, to convulsions, partaking strongly of the character of epilepsy. When married, and about to be confined, she, in com- mon with her friends, entertained many appre- hensions of an unfavorable result, from her lia- bility to these attacks. She was young, and otherwise healthy, and of rather a plethoric ha- bit. Contrary to our expectations, the convul- sions did not appear; but her labor was lingering. She was bled freely, and all the common means 100 OBSTETRICAL CASES. were used to accelerate the progress of the case. As the labor still seemed to advance but slowly, and I was fearful that so long a continuance of pain might exhaust her, after having waited many hours, I determined to make use of the ergot. The parts were tolerably wTell dilated, and, from past experience, I apprehended a speedy termination of the labor from its effects. I accordingly administered it in the usual quan- tity, and it had the desired effect of increasing the energy of the pains. The child also ad- vanced gradually, though very slowly. But by degrees the pains subsided, her strength seemed nearly exhausted, and, indeed, during the tw7o last hours of her labor, life seemed to be sus- tained only by the free use of brandy and other stimulants. The pulse became a mere thread, she grew delirious, and was evidently near her end. The friends had long before urged me to resort to instruments, but at the time when the forceps could have been applied, there was every reason to expect a speedy delivery, from the in- fluence of the ergot. At this time the head had descended so lowT as to press firmly upon the perinseum, which was quite distended, so that it was utterly impossible to pass the thinnest in- strument between the head and the labia. In this critical situation she remained for at least half an hour. There were evidently but a few minutes between her and death, and she was constantly singing hymns in her delirium. Cir- cumstances more embarrassing can hardly be OBSTETRICAL CASES. 101 imagined ; and this in the woods, far from me- dical help or counsel. I saw that there was but one possible course to pursue; a scalpel wTas plunged into the head, it was emptied, and the child soon extracted. With the greatest diffi- culty, and after much exertion in the use of fric- tions, stimulants, &c, she was restored to sense and life. She soon recovered, and was about two years after safely delivered of another child. Case 32. I w7as called to see Mrs. S., of Abingdon, Luzerne county, Pennsylvania, re- siding about twenty-eight miles from me, under the following circumstances : — She was the wife of a respectable farmer, the mother of a large family, and had been growing every year more fat and full in habit. She was under the care of Dr. Bedford, a very respecta- ble practitioner of that place, and had been four days in labor. He had bled her freely, used sti- mulating injections, and all the means usually resorted to in protracted cases; but the head had barely entered the superior strait, where, however, it was firmly fixed. The pains had been constant and severe. Upon examination, I found the vagina nearly closed by fat and effusion into the cellular membrane and labia. This wTas so much the case, that it was with the greatest difficulty an examination could be made at all. Upon mature consideration of the case, it was decided by Dr. B. and myself that there w7as no 102 OBSTETRICAL CASES. possibility of delivery by natural means. There was also good reason for believing the child dead, as it had not been felt to move for a day previous. It was therefore decided to extract it by opening the head, and removing it in such portions as could be procured. With great dif- ficulty the left hand w7as introduced, cramped into the smallest space in which it was possible for it to remain without crushing the palmar arch, and so painfully pressed, that I was re- peatedly compelled to withdraw it for relief Through the hollow of this the perforator was passed, and an opening made. The brain was then broken up, and the crotchet introduced. With this the brain was drawn out, and by very slow degrees the bones of the cranium were ex- tracted in very small fragments. From the ex- treme smallness of the space, I was forced to use the crotchet in such directions, that, if it slipped, it should bring up upon the ends of my own fingers, and in this way I received some slight wounds. After about two hours of severe exertion, which Mrs. S. bore remarkably well, I succeeded in fixing the crotchet upon the base of the scull, and extracting the head. This was only accomplished with the greatest diffi- culty. A stout fillet was then passed over the neck of the child, and it w7as soon delivered. It was found to have been dead some hours. In both these cases, I have every reason to believe, the life of the mother would have been sacrificed by a more timid or cautious practice. OBSTETRICAL CASES. 103 Still the use of such means must ever be re- garded with a natural horror, and should never be thought of when other means are within reach. The next case will be found to be of a cha- racter still more deeply interesting; and al- though not occurring in my own practice, I am induced to add it, from its near relation to the preceding, as well as from its presenting some features which are, happily, of very rare occur- rence. II'IJ OBSTETRICAL CASES, CONVULSIONS WITH INSTRUMENTAL LABOR. Case 33. This very interesting case I give by permission of my friend, Dr. Thomas Boyd, whose patient she was. It was, on many ac- counts, a case of deep interest; and the manner of its termination will, I think, be found pecu- liar in the highest degree. Mrs.----, aged about twenty-two, was mar- ried in January 1832; and previously to her marriage, had been perfectly healthy. She was, however, rather inclined to obesity, and was of a soft, lax habit of body. In the month of May, 1832, she miscarried, in consequence of a severe and protracted diarrhoea, and perhaps also of a sudden fright, which occurred a few weeks be- fore. She was much reduced by this event, so that she was, for four weeks, confined to her bed. In July she again became pregnant, and twice was in great danger of miscarrying, but was freely depleted, and at last went to her full period. For several weeks previous to her confinement, her lower extremities were much swollen, and, at the time of that event, the OBSTETRICAL CASES. 105 swelling of the whole lower extremities was really enormous; especially when the youth of the subject is considered. The swelling even extended to the lower part of the parietes of the abdomen, so as to prevent her almost from sitting or moving; and to it, in a great measure, all her subsequent difficulties may, perhaps, be referred. Her first pains came on upon the morning of Tuesday, April 9th, and continued at inter- vals, until Saturday, w7hen they became more severe ; and on Saturday morning, some portion of the waters were discharged, and on Saturday night, Dr. Boyd was in attendance upon her. On Sunday, while Dr. Boyd was absent, being sent for in the morning to another urgent case, convulsions occurred. Dr. Bliss was called in his absence, who bled her. After some time the convulsions subsided, and the labor continued to advance slowly. Most unfortunately, however, the convulsions returned repeatedly during the day and night, until the case assumed a very alarming charac- ter. She was bled by Dr. Boyd repeatedly du- ring the day, with only temporary relief. The head, however, continued to advance. At midnight, the case being of so difficult a character, and Dr. Boyd being much fatigued, Dr. Bliss was called in consultation ; and, as I resided in the same house, I w7as called upon to assist. From this time until she was delivered, at 14 106 OBSTETRICAL CASES. about 6 A. M., the convulsions were incessant, and of the most distressing violence. As the head was fairly engaged in the lower strait, it was determined to attempt the delivery by the forceps, at once. It was found, however, after many trials, that every attempt to pass the blade of the instrument between the uterus and the head, brought on a return of the convulsions. This seemed to be wholly owing to the great irritability of the uterus; for the first pressure of the forceps produced an immediate accession of the convulsion. The difficulty was also very much increased by the (edematous swelling, which extended to the labia and internal parts. As there seemed no hope that she could survive unless speedy relief were obtained, it wras resolved to resort to embryulcia, it being in the highest degree likely that the child was already dead. The head was opened by Dr. Bliss, and the brain evacuated. After several ineffectual attempts to fix the crotchet upon some portion of the cranium, both the other gentlemen being exhausted with fatigue, they requested me to attempt the delivery. After a few endeavors to fix the instrument upon some internal part of the cranium, I withdrew it, and passing it carefully up on the outside, I fixed it upon what proved afterwards to be the upper edge of the orbit. Here the hook held so firmly, that I was enabled to apply my whole strength; and by a motion from side to side, the head was soon brought down; and a napkin being pass- OBSTETRICAL CASES. 107 ed round the neck, the delivery was completed. The after-birth came away without hemorrhage, but the patient was so wholly exhausted, that it required brisk stimulation for several hours to produce any thing like an established cir- culation. From this time, Monday forenoon, she appear- ed to be quite comfortable. The swelling of the limbs began to subside, the secretions were all fully established, and there was every ap- pearance of a speedy recovery. But on Friday, symptoms of great oppression at the chest mani- fested themselves, the patient requiring to be partly raised in bed in order to breathe. The most active diuretics were now resorted to, as squill, digitalis, calomel, &c, but with no relief. The oppression continued to increase; on Friday the urine, although copious, gave out the peculiar ammoniacal odor indicative of decomposition, and at about 2 A. M., on Saturday morning, she died. She appeared to die from mere oppression of the lungs, and expired without the slightest uneasiness. A few hours before her death she was bled again, it being thought that it might possibly favour the absorption of serum. This most unlooked for termination of the case I can only explain by the supposition, that the water constituting the monstrous swelling of the lower extremities was carried to the body, and finally to the lungs, by mechanical infiltration We know the rapidity with which anasarcous swellings disappear upon a change of posture, 108 OBSTETRICAL CASES and this wholly unconnected with the action of medicine. And it is highly probable, that in this case, the wrater spread itself through the cellu- lar membrane of the body faster than the kid- neys could remove it, until at last it reached the substance of the lungs themselves. If I should meet another instance of so exten- sive anasarca of the limbs during pregnancy, I should not hesitate to attempt its removal, or at least to lessen its quantity, by free scarifications, which could not be dangerous in themselves, and might remove all fear of a subsequent fatal result. MISCELLANEOUS OBSERVATIONS. SCIRRHOUS TUMOR OF THE ABDOMEN. Case 34. Mrs. P., a laboring woman, aged about fifty, consulted me on account of a large swelling, which nearly filled the abdomen. I found a solid tumor, extending from the ribs nearly to the pubis, rather inclining to the left side, and as large as the uterus in the seventh month of pregnancy. As it extended quite to the lower part of the belly, I was inclined to think it a scirrhus of the left ovarium. She in- formed me it had been several years in exist- ence ; but as it gave her very little trouble, she kept at her work, and thought nothing of it. At last, however, it became so large as to be very burthensome, and was very painful. From the time I saw her it continued to increase, hec- tic fever was developed, and after lingering a few months, she died much emaciated. Upon examination after death, a tumor presented it- 110 MISCELLANEOUS OBSERVATIONS. self, filling the whole abdomen^ and involving the mesentery, the small intestines, the abdomi- nal vessels, c^cc, in one mass of disease. It ad: hered firmly to the spine, and was evidently a scirrhous tumor, ulcerated and suppurating in various parts of its substance. The duodenum passed directly through it where it was attached to the spine; and all the organs in the vicinity were so involved in it, that it was with difficulty they could be traced at all. It extended from the stomach to near the pubis, and was, in all probability, a tumor originating in the glands about the mesentery. We could not but wonder that a person so affected should have been able to keep at work, or indeed to live at all; and yet she w7as many months in a tolerable state of health MISCELLANEOUS OBSERVATIONS, 111 CASE OF ATTEMPTED SUICIDE BY LAUDANUM. The following remarkable instance of escape from the effects of a large dose of laudanum, I think worthy of being recorded. Case 35. A gentleman very well known to me, and whose physician I was at the time, re- solved to put an end to his life by the use of laudanum. For this purpose, at about 7 P. M., in Decem- ber, 182-, he drank off the contents of a four- ounce phial, which, as it was about two thirds full, could not have contained less than from two and a half to two and three quarter ounces of laudanum. He walked nearly a mile after taking it, in a highly excited state of mind;' and feeling a little giddiness and slight disposi- tion to nausea, he went to bed at about 8 P. M., but, fortunately for him, not to sleep. A most intense itching soon developed itself at the tip of the nose, which wholly prevented him from sleeping. In this state, constantly tossing and rubbing his nose upon the pillow7, he remained until 7 o'clock, A. M., just twelve hours from taking the laudanum. His wife, suspecting the 112 MISCELLANEOUS OBSERVATIONS. cause, passed the night anxiously watching the result. At seven he became sick, and vomited freely, throwing up the whole contents of the stomach, consisting of a portion of his supper in a half digested state, and the laudanum, which smelt exceedingly strong of opium. He suffered much from a distressing nausea, and a partial paralysis of the bladder was produced, so that no water was passed until the end of twenty- four hours from taking the poison, and then only after a long continued effort. In the eve- ning he took a cup of tea, and in a day or two was well. This is, perhaps, one of the most remarkable instances on record; and if we take into view the fact that the nervous system of the indi- vidual is in the highest degree susceptible, so that a cigar will lay him upon his bed, and a two-grain pill of opium has been known to make him nearly if not quite as sick as did this tre- mendous dose; I say, when we take into view this fact, it requires no very extraordinary de- gree of credulity or faith to believe, that life in this case could only have been preserved by an extraordinary interposition of some overruling Power. As I myself doubted the strength of the lau- danum, I went privately to the apothecary, who assured me that it was standard laudanum of a good quality. The contents of the stomach ejected might amount to a pint, as I saw them afterwards. MISCELLANEOUS OBSERVATIONS. 113 But who would venture to take half the dose upon the security afforded by a pint of soup, or any other common article of food 1 Certainly we should be very loath to try the experiment. For myself, I am not ashamed to confess, that if Divine Providence, under any circumstances, interposes to arrest the hand of death, I fully believe it to have been the case here. Nor, when we consider the extreme sensi- bility of the individual to narcotic articles, which I have often seen myself, do I see how it is pos- sible to escape this conclusion. And why, I may ask, why should we wish to avoid a belief so full of consolation and delight"? Case 36. The subject of the following me- lancholy case was less fortunate. G. Brandon, a man of intemperate habits, arose one night in the dark, to make an application to his favorite companion, the bottle of whiskey, By mistake he took a bottle containing a strong solution of pearlash, prepared for culinary purposes. The fauces having been rendered insensible to nice distinctions by often repeated burnings, he did not detect the mistake until he had swallowed a considerable quantity of the liquid. He vo- mited freely, and probably threw up most of it; but it produced an acute inflammation of the mucous membrane of the oesophagus, which ter- minated in a confirmed stricture at the lower end of the passage. It became impervious. I saw him once only, at about hxc weeks after the in 114 MISCELLANEOUS OBSERVATIONS. accident. He was literally starving to death. He had been unable to swallow7 any fluid or so- lid since a few days after the accident. I thought there w7as a bare possibility that the use of the bougie might relieve him ; but as the difficulty seemed to be seated just at the entrance into the stomach, the chance seemed but small. As he lived thirty miles from me, I could not see him again. He lingered about seven weeks from the time of the fatal mistake, and died at last of starvation; a most distressing spectacle, in the greatest distress, his eyes sunken into the sockets, and his whole appearance dreadfully expressive of the pains of hunger. What a solemn warning does this sad case afford to the intemperate ! It is my hope that it may meet the eye of some unfortunate victim of this most destructive of our propensities, in season to arrest his hand, and to recal him to his reflection ere it is too late. MISCELLANEOUS OBSERVATIONS. 115 OBSTINATE DERANGEMENT OF THE DIGESTIVE ORGANS, CURED BY SWEET ORANGES. The following is curious as an instance of the manner in which obstinate complaints are some- times cured by the most simple of means, when regular prescriptions have wholly failed. Case 37. A girl of about fourteen wras put under my care, for symptoms strongly resem- bling the derangement of the system, commonly termed chlorosis. She had never menstruated, which was regarded by her parents as the cause of the complaints. She had no appetite for food of a wholesome character, which was almost uniformly rejected by the stomach ; the bowels were very constipated ; her mind and nervous system were highly excited and irritable, so that mental derangement was feared. Her general strength was good, although it was not easy to say what kept it so, for in several months she had not eaten a regular meal. Her tongue w7as coated and her breath offensive, and her stomach in the highest degree irritable. 116 MISCELLANEOUS OBSERVATIONS. I put her upon a course of mild purgative medi- cine, combined with slight tonics, which were continued for several w7eeks with no effect. She w7as so restless that she was obliged to leave her school, and so obstinate that it was exceed- ingly difficult to make her take her medicines. At last I left her to nature, in despair of effect- ing any thing by medicine ; and fearing much that her mind would become seriously impaired. Several months after, I met her father, who told me, with a hearty laugh, that he had cured her. He stated to me that he found she had a great desire for oranges; that he gave her one daily for several weeks, which soon had the ef- fect of removing every symptom, and restoring her to perfect health. They had the effect of opening the bowels, creating an appetite, and gradually of removing all her unpleasant symp- toms. So salutary a result from so agreeable a remedy, I thought worthy of record, although it is by no means slightly mortifying to medical pride, to be so " come over" by a sweet orange, administered by the unlearned hands of a brick- maker. MISCELLANEOUS OBSERVATIONS. 117 SPECIFIC ACTTON OF CALOMEL IN DISEASES OF THE BOWELS. The peculiar operation of calomel in equal- izing the action of the bowels, by a mode of operation apparently distinct from its purgative properties, is strikingly illustrated by the follow- ing fact. Case 38. I was called during the prevalence of cholera in this city, to see master T., a child of six years. He had been troubled through the day with diarrhoea, and at the time I saw him, about 8 P. M., his bowels were opened every ten or fifteen minutes, with copious milky evacua- tions, and a considerable degree of tenesmus. I administered twenty-five grains of calomel, and directed him to be kept as still as possible. From the time of taking the calomel until the next day, the purging ceased wdiolly, and the bowels were not again opened until he took a full dose of decoction of senna and manna, by which they were freely moved. The discharges were then dark, and subsequently bilious, and his convalescence rapid. He slept well during 118 MISCELLANEOUS OBSERVATIONS. the night, and the calomel seemed to act as an opiate, quieting the whole irritation. The mode of treating puerperal inflammation in the Philadelphia Alms House, w7as somewhat analogous. After a free bleeding, twenty or thirty grains of calomel were given at one dose, and were followed by free doses of Epsom salts, say an ounce and a half during the twenty-four hours, with an almost immediate relief of the symptoms. The effect in relieving the pain, which was often acute, was particularly remark- able. In all these cases it seems to have the power of equalizing the circulation in a very re- markable manner. And this, I apprehend, de- pends much upon the largeness of the dose. MISCELLANEOUS OBSERVATIONS. 119 REMARKABLE OPERATION OF A FULL DOSE OF OIL OF TURPENTINE IN A CASE OF REMITTENT FEVER. Case 39. Miss C. T., a child of seven years, had been ill for about five weeks, in November and December, 1832, with a slow remitting fe- ver, with which several other members of the same family were also affected. There was, during the early part of the case, (and in a less degree during the whole of it,) a disposition to affection of the head, which was in part reliev- ed by appropriate treatment. Still the disease showed no disposition to form a crisis. There w7ere constant symptoms of some abdominal irritation, dry tongue, picking of the nose, &c.; the pulse was very frequent and the child much reduced. She, in common with four or five brothers and sisters, had been formerly very subject to worms. It was therefore resolved, in the ab- sence of anv clue to any other cause of the pro- 120 MISCELLANEOUS OBSERVATIONS. tracted character of the case, to ascertain if. worms were present in the bowels. An ounce of oil of turpentine was therefore administered, which gave very little uneasiness, and operated in a very short time. It produced a large num- ber of copious, bright, yellow stools, during all the next day; the skin, which had been previous- ly very dry, became covered with a most pro- fuse perspiration, which also continued nearly a whole day, and had a strong odor of turpen- tine. In a word, it produced a perfect crisis of the disease, leaving the skin cool and moist, and the tongue soft. During the next day she seem- ed to sink from exhaustion, and the countenance evinced a slight disposition towards decomposi- tion of the features. Carbonate of ammonia was given for a few hours in pretty free doses, and the child became almost immediately convalescent. I am perfectly aware that this mode of prac- tice will meet the unqualified disapprobation of the admirers of Broussais, and perhaps of many others ; and it must be admitted that it is not to be often imitated. Still, under precisely simi- lar circumstances, I should repeat the experi- ment. And I cannot but regard it as a very singular instance of the power of some articles to produce a total change in the whole system. The following account I had from a very re- spectable ship master of Boston, whose own case it was. He had yellow fever in Batavia. MISCELLANEOUS OBSERVATIONS. 121 He was given up by the physician in attend- ance, and heard him say as he took leave that he must die. -He was still able to sit up, and resolved to have at least one moment of comfort first. He called to his steward to bring him two pint bottles of English porter, that he happened to have on board, poured the contents of both into a large bowi, which he proceeded to fill with broken biscuit, and to eat greedily. He then laid down to sleep, fully expecting that his course was run ; — he fell asleep ; the pow- erful stimulus produced a complete crisis of the fever, and his physician, who merely looked in to ascertain the hour of his death, found him out of danger, and heartily enjoying the joke. The respectability of my informant, leaves no doubt upon my own mind as to the truth of his story. lb 122 MISCELLANEOUS OBSERVATIONS. CASE OF LETHARGY. The following case occurred in the house of my father, while I was a medical student. Case 40. Mrs. D., a servant, aged about forty-five, short and habitually sleepy, fell down one day in a fit of stupor. There were no symp- toms of apoplexy or paralysis, but the coma was entire. The pupils were immoveable; but she moved if pinched, or pricked; and would try to speak, if called to in a loud tone. The pulse was slow and full. A physician residing near was called in ; who bled her, applied external irritants, and gave her spirits of hartshorn, in strong decoction of serpentaria. After several hours, finding she did not revive, and it being near bed time, he pronounced that she must die, and returned home. The ladies of the family proceeded to make proper preparations for that event. I found, however, that her pulse was yet good, and that she still moved if pinched ; I therefore resolved not to give the case up, and took charge of her; it being, I believe, my first at- tempt. I collected the alarmed and scattered females, set them to rubbing the thighs and MISCELLANEOUS OBSERVATIONS. 123 arms with oil of turpentine and other stimu- lants, while I proceeded to redouble the doses of ammonia, which were really enormous, and to apply a moxa upon her forehead. This she soon knocked off, began to moan, and at last to speak, complaining of the frictions; and by the next morning had recovered her senses, and was soon convalescent. She is, I believe, yet living, at least seventeen years after the attack. I mention this case as an interesting instance of a form of cerebral affection of rather rare occurrence, and as an encouragement to stu- dents and young physicians, alw7ays to act from a sense of duty alone, and to persevere until the last moment. It is worthy of remark, that she has always continued to be of a sleepy habit, constantly dropping asleep when she is quiet; but other- wise well and sound in mind. The attack lasted, as nearly as I remember, about twelve hours. 124 MISCELLANEOUS OBSERVATIONS. BLACK VOMIT, FROM SYMPATHY OF THE STOMACH WITH AN EXTERNAL INFLAMMATION. The following is a very striking instance of the manner and degree in which the stomach sometimes sympathizes with disease in other parts. Case 41. A boy aged about three years and a half was seized with a very acute inflamma- tion about the hip joint, probably caused by a fall upon the part. The part was inflamed to the highest degree; the hip and thigh much en- larged, and very tense; very active means were used to subdue the inflammation, which were wholly ineffectual. The limb became wThite in place of red, and within less than two days the child died. The pain was excruciating, and, for several hours before death, he threw up a sub- stance precisely similar in its appearance to the black vomit of yellow fever, which I had several opportunities of seeing in Philadelphia, in 1819. No examination w as made after death : but it is highly probable that gangrene had taken place in the interior of the inflamed limb, and MISCELLANEOUS OBSERVATIONS- 12a that the stomach was in a state of high inflam- mation. I have heard since of other instances, some- what similar, of sympathetic vomiting of black matter; of which, however, the particulars are not recollected. The above case occurred, if I remember right, during the hottest part of the summer. 126 MISCELLANEOUS OBSERVATIONS. REMARKS UPON BLISTERS. There are one or two circumstances con- nected with the application of blisters, from which I have derived much comfort myself, and by which, I believe, I have saved my patients much pain. In the first place, I believe it is not generally known, that it is not necessary to keep a blister applied until its full effect is produced. If it is kept on until the skin is decidedly irritated, and Very minute vesicles begin to appear, the appli- cation of a bread poultice instead of the plaster will draw a full blister. This is of great im- portance in the case of small children, who often suffer excessively from the application of a blister, and whom I have seen to fall into a quiet sleep, after the poultice was applied, and although the process of vesication was still ac- tively going on. The same remark may be made of blisters in persons of very nervous tempera- ment, in fevers, &c. Their distress is often very great under the action of blisters, and the disease is rather increased than lessened by them. In all such cases, the application of a soft poultice gives great comfort, and at the same time com- pletes the vesication. The poultice may be very conveniently folded in a silk handkerchief MISCELLANEOUS OBSERVATIONS. 127 The other remark I would make is, that a folded silk handkerchief makes a most excellent dressing for blisters, totally excluding the air, promoting the discharge, and absorbing all the serum as it flows from the blistered surface. I lay a silk handkerchief, folded to about six or eight thicknesses of silk, directly upon the blistered skin, and have found it by far the sim- plest, best, and most convenient dressing I have ever used. It may be changed daily, and will be found to give the most perfect ease; so that it can hardly be known by the feeling if there be a blister or not, EXPLANATION OF THE PLATES. PLATE I. Fig. 1 represents a portion of the small in- testine, strictured by membranous bands. A part of the intestine is of the natural size; and the part above the strictured portion enormously distended. Fig. 2, a peculiar affection of the cornea, described in Case 25. Fig. 3 is a part of the outline of the cornea, intended to show the degree to which the cor- nea is enlarged at the place of the cicatrix. Fig. 4 is a horizontal section of the front part of the eye, showing the depth of the fissure represented in Fig. 2. 'Ate 1. M* " ' 1 /^m^ .