communicated by Dr. Ormerod to Dr. Ogle as an objection to the practice of tracheotomy in epilepsy.

CASE. "Henry B-, t. 55, came under my care at the Brighton Dispensary, in January, 1852, with disease of the larynx. He was a tall man, of an extremely cachectic appearance, but he said that he had been quite healthy and well until two months before. Then came sore-throat, gradually increasing, with some hæmoptysis during the last three weeks. He spoke with great difficulty, but there was no notable obstruction in breathing or swallowing. There was nothing to be seen on examination of the fauces, but the attempt to examine them caused distressing retching. There was no dulness on percussion between the clavicles; auscultation elicited no reliable results.

"For a month he steadily improved under the use of blisters, spermaceti mixture, cod-liver oil, and tonics. Then his breathing became more difficult, and he had a severe settled pain in the throat, for which Mr. Fuller, the housesurgeon, applied a twenty-grain solution of nitrate of silver to the epiglottis, with decided relief. The dyspnoea, however, consequent on the operation was so severe that I did not dare to repeat the operation.

"He now became rapidly worse; his respiration grew more difficult, the breath having a horrible fetor. Still he was able to swallow without difficulty. Blistering failed to give him any more relief, and it was deemed necessary, on account of his urgent dyspnoea, to open the windpipe.

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Mr. Fuller accordingly made an opening through the crico-thyroid membrane with great and immediate relief, at 8 P. M., on March 1st. At 10 P. M., while I was with him, the tube being clear, but having shifted a little from the mesial line, he had a slight epileptic fit. He speedily recovered, and at midnight was lying asleep, breathing easily through the canula. At half-past 2 A. M. he had another epileptic attack, in which he died. I heard afterwards, that about a month before his death, he had a slight fit of an uncertain nature. "On post-mortem examination of the body, we found a ragged pouch containing a fetid putrilage, opening above on the right side of the rima glottidis, communicating below by sinuses with an ossified and partly necrosed cricoid cartilage. The chorda vocales were oedematous. The opening had been made clear from the seat of the disease."

ART. 39.-On the Treatment of Chorea. By M. TROUSSEAU.

(Gazette des Hôpitaux, No. 11, 1858.)

Although it is true that chorea left to itself may at last become cured, yet the intervention of medicine is of avail in preventing serious phenomena, moderating accidents, and abridging the duration of the disease. Among the means employed in its treatment cold baths are efficacious, acting probably in part as sedatives, and in part as tonics, as also, as when used in the form of sudden immersion, by the shock they induce. At all events they constitute an inoffensive means, which, in combination with other treatment, may do good service. M. Trousseau cannot understand why the sulphurous baths should meet with such favor at the Hôpital des Enfans. The gymnastic treatment has also been much followed there, but this can only be regarded as an accessory means, useful towards the decline of the disease. Moreover the means of putting it into force are not readily met with, and M. Trousseau has found a very useful substance in the employment of a metronome, the number of the oscillations of which can be regulated, each being indicated by a clicking sound. If one of these be placed before the patient, the sight and sound of the oscillations become of great utility in assisting him in regulating the movements of the whole or a part of the body. It is, however, only an adjuvatory means, and is more useful in the case of tic, the patient being directed to produce his tic voluntarily at the same time the click of the instrument is heard. He becomes fatigued by this voluntary effort, and the tic is speedily modified, though rarely cured. M. Trousseau has, since 1841, been in the habit of treating chorea methodically by the syrup of sulphate of strychnia, which is preferable to nux vomica itself. He dissolves five centigrammes of the sulphate in 100 grammes of simple syrup, i. e. about twenty-five teaspoon

fuls, so that each teaspoonful contains two milligrammes, i. e. one thirty-fifth of a grain of the sulphate. At first a teaspoonful is given daily between breakfast and dinner, and if no effects are produced in two or three days it is given in the morning fasting, and at bedtime. The dose is, after awhile, increased to two teaspoonfuls, to three, or even to four, continuing it until stiffness of the neck and jaw and slight convulsive movements of the limbs are produced. The choreic movements now rapidly diminish, and sometimes after fifteen or twenty days of treatment the disease seems cured. Prudence must be observed in gradually increasing the dose, but with this accidents are not to be feared. The convulsions that are produced must not alarm us, as they are never dangerous if not carried too far. When the syrup has been taken for some days, stiffness of the jaws, headache, disturbed vision, vertigo, and itching of the scalp come on. The observation of this last sign, which the patients compare to pricking with small needles, is the safety-valve in the use of the medicine, as it is one of the earliest signs of its operation. When the children are standing they are seized sometimes with sudden sharp cramps, which oblige them to catch hold of any object. They should then be laid down. It is impossible beforehand to state the dose of strychnia that may be required; for very different effects are produced even by the same dose in the same child. With this means others may be used, accordingly as the patient is plethoric, chlorotic, or hysterical.

ART. 40.-Results of Tracheotomy in Croup at the Children's Hospital, Paris, during 1856. By M. ANDRÉ.

(Bull. de Thérap., May 30, 1857; and American Quarterly Journal of Med. Science,

Jan., 1858.)

The following interesting table is taken from the thesis of M. André:

From this table it appears that many successful cases of tracheotomy have been observed, as nearly one-third of the patients recovered. The most notable success has been obtained with children from nine to nine years and a half old, and then with those children who were from five to six years old. The least satisfactory results were observed from fifteen months to two years, for here we have six operations and six deaths. All the children under two years are to be found in the columns of deaths; and all those who died, except two, were just a little more than two years old. M. André thinks that these facts may be explained by the greater amount of resistance with the older children, both as regards the disease and the operation. He also conceives that debilitating means, as leeches, blisters, &c., should be sparingly used, so as to husband the strength for tracheotomy.

ART. 41.-Cold Applications in Pneumonia and Pleuritis. By Dr. NIEMYER. (Prager Vierteljahrsch.; and Dublin Hospital Gazette, Jan. 1, 1857.)

Professor Niémyer, in his clinical communications, recommends cold to be

applied externally in the treatment of pneumonia and pleuritis. The results of extensive experience in the Hospital of Magdeburg have confirmed him in the belief that cold applications are not merely devoid of danger, but that they are as efficacious as in inflammations of external parts. The cold produces marked amelioration, and the patients, even children, urgently request that the application be renewed as soon as it has become warm.

Professor Niémyer does not attribute to cold applications the power of cutting short the above named diseases; but he believes that the exudation process ceases at an earlier period; that the fever is sooner brought to a close; and the patients are thus frequently enabled to return to their occupations seven or eight days before they could do so under other treatment. Neither metastasis nor catching cold has been noticed as a consequence. In late stages of pneumonia and pleuritis (acting on the fact established by the best pathologists, that there is diminution of the blood-corpuscles, especially in old persons), he administers ferruginous remedies with great advantage.

ART. 42.-Asthenic Pneumonia and its Treatment by Quinine. By Dr. CORRIGAN. (Dublin Hospital Gazette, Dec. 15, 1857.)

In a clinical lecture recently delivered, Dr. Corrigan says:—

"I cannot allow this lecture to terminate without bringing under your notice a form of pneumonia and of pleuripneumony that is now, I may say, epidemic among us-asthenic pneumonia. It attacks all ages. It proves fatal either directly in the first stage of congestion, in which it is, indeed, a very fatal disease, the patient dying while the lung is gorged and dark, from which, on a former occasion of noticing it, I called it blue pneumonia, or it passes from the first into the third stage, scarcely showing at all the second or hepatized stage. Instead of being seated, like ordinary pneumonia, in the lower lobe, it is more frequently found in the upper lobe. Its symptoms are as peculiar as its pathology.

"It is not accompanied with the peculiar calor mordax of skin which is so characteristic of inflammatory or sthenic pneumonia, but, on the contrary, the skin is of its natural temperature, or cooler than natural, and the face rather

sallow than otherwise.

"Pain is variable, and appears to depend altogether on the degree of inflammation of pleura; most generally, however, it is not much complained of, the patient describing shortness of breath as his prominent symptom.

"One of the most remarkable features connected with it is, the absence, for several days, of any expectoration, and even when this does appear, its being very small in amount compared with the extent of local disease, as revealed by percussion and auscultation.

"Bronchial respiration; and very fine crepitating rattle, are the auscultatory signs developed in the disease.

"I have again, as two years ago, to recommend strongly its main treatment by quinine. The general dose which you see administered for an adult is five grains every third hour; and under its exhibition the pulse becomes slow and steady, the respiration free, and rapidly so. If the patient be young, with evidence of capillary congestion generally over the system, the exhibition is preceded by local depletion; but this is rather the exception. The patient, in this treacherous disease, often does not seek admission into hospital, nor advice in private practice, until too late, deceived by the absence of pain, of fever, and of expectoration, and feeling merely debility and shortness of breathing. In the instance which has furnished us an opportunity of examining the disease, the man died within six hours of admission into hospital.

"The whole upper lobe of left lung, you observe, is grayish or pale-colored, quite destitute of air or elasticity, solid like liver to the feel, but at the same time soft and brittle under the finger, with scarcely any evidence of pleuritic inflammation, while the lower lobe remains healthy."

ART. 43.-On the Arrest of Pulmonary Tuberculosis. By Dr. FLINT.

(American Journal of Medical Science, Jan., 1858.)

In this paper Dr. Flint furnishes the details of 24 examples of arrest of phthisis that have occurred in his own practice, and then makes some interesting observations upon the circumstances which seem to favor such arrest. The number might have been much increased had he not excluded such cases as were too recent, or the subsequent histories of which had not been sufficiently followed up, and those in which the disease was not arrested but simply slow in its progress. The evidence of arrest was decided from the fact of wellmarked symptoms progressively abating in intensity, the patient increasing in weight and strength. "Until within late years, instances of supposed recovery from phthisis were unreliable in consequence of the want of certainty in the means of determining the presence of the disease. This uncertainty has been removed by the discovery and improvement of the physical exploration of the chest. Physical signs in conjunction with symptoms, render the diagnosis of pulmonary tuberculosis positive in the great majority of cases. I shall include in this collection only cases in which the diagnosis rests on the conjoined evidence of signs and symptoms. With some exceptions, the results of exploration of the chest, together with the previous history and existing condition of the patient, were noted prior to the arrest of the disease. In a few instances, however, the cases came under observation subsequently to the arrest, and the diagnosis was made retrospectively; that is, the physical signs and previous history were deemed sufficient to render it positive that the patient had been affected with tuberculosis." In the narration of the author's cases a marked distinction is made between "arrest" and "recovery." Arrest, it is obvious, may take place without recovery, when the tuberculous affection ceases to be progressive, but the processes of restoration never being complete, recovery can only be said to have occurred when, in connection with restoration. of the general health, the local symptoms have entirely disappeared. Of the 24 cases, in 13 arrest of the disease was followed by complete recovery, while in 11 arrest was alone demonstrated.

"In several of the cases the arrest of the disease was evidently due to an intrinsic tendency to that result; in other words, the disease ceased to be progressive, in consequence of its self-limitation. This is fairly to be inferred in those instances in which no appreciable external influences, in the form either of medication, diet, or regimen, were brought to bear in the course of the disease. Eight of the cases may be embraced in this category." The fact of such intrinsic tendency Dr. Flint believes is not sufficiently appreciated, having been, indeed, only of late recognized; and adds, that while it is probable that the arrest of tuberculosis, supposed to be brought about by the measures resorted to, is really in more or less of the cases actually due to the self-limitation of the disease; so is it supposed that this intrinsic tendency has been sometimes thwarted by injurious therapeutical or other means-especially when it was the custom to resort to the antiphlogistic course of treatment. In the cases here detailed no resort was had to antiphlogistic debilitating measures, such as depletion, mercurials, emetics, low diet, confinement, &c.; and it may be fairly asked whether an abstinence from such measures did not contribute to the favorable result.

The occurrence of hæmoptysis resulted in no less than 18 of the 24 cases. In 10 of the 18 it occurred more than once, and, in some, several times. The proportion exceeds that in which hemorrhage may be expected to occur in phthisis, according to the researches of Louis (57 of 87 cases), proving that the symptom is not an unfavorable one as regards arrest; the fact according with the conclusion arrived at by Walshe, that the occurrence of hemorrhage does not hasten the progress of the disease, but appears to produce an opposite effect. It also agrees with the inference from observations in individual cases in which hemorrhage seems to take place in lieu of a fresh tuberculous exudation.

Comparing the 14 cases in which measures of treatment were adopted, it is

found that in nearly all a change was made in the habits of life, such change consisting in relinquishing, partially or entirely, sedentary pursuits, and giving proportionately more time to exercise in the open air. In 5 of the cases this change in habits constituted the sole treatment, while all the 8 patients in whom the disease was arrested without any measures of management, were persons of active habits of life. We are, therefore, warranted in regarding out-door occupation as conducive to this result. "The exercise in the open air was not generally of the kind which often goes by that title, consisting in simple airings by gentle walks or drives; but it consisted in rough occupation, often involving considerable, and sometimes great exposure to vicissitudes of weather." Change of climate occurred only in two cases prior to evidence of arrest. "On this subject I have been led to conclusions to which others have also arrived, viz., that climate, in itself, exerts no special agency in determining an arrest, but that it may favor this result indirectly by affording better opportunity for exercise in the open air, and furnishing objects of interest to the mind which will secure that object. It has seemed to me far less important to fix upon a situation supposed to be the most favorable in its climatic aspects to the tuberculous patient, than to select a residence where the inducements to active habits of exercise are greatest. To place a patient in a group of invalids, in a particular spot, where he is expected to derive some specific remedial influence from the atmosphere, is rarely useful. The ennui incident to such a position, for a man of active habits of mind and body, is intolerable, and the moral effect of his associations is injurious. Patients will do wisely in avoiding the favorite places of resort for those affected with the disease, and in choosing points where the incitements to and the resources. for physical exertion abound. Generally the objects of a change of climate are better secured by frequent change of place than by remaining stationary. Travelling in foreign countries, even when, so far as the climate is concerned, the change is for the worse rather than the better, may be in a high degree useful, because the exercise which it invites is not endured as a task, but accepted as a means of mental gratification."

With respect to diet, the object was not to lower the powers of the system, but, on the contrary, to support and develop them by nutritious food. The patients were encouraged to live generously, indulging and cultivating an appetite for any and all the varied wholesome articles of food, with a full proportion of meat. In consequence of carbonaceous alimentary principles appearing to be useful in the management of phthisis, and the alleged fact of the comparative freedom from the disease enjoyed by persons working in sugar-houses, Dr. Flint advises the free use of sugar. "It is a significant fact, apparent on referring to the cases I have reported, that appetite and digestion were, in general, not greatly impaired. It accords with the views just expressed to regard an unimpaired appetite and digestion as highly favorable for an arrest of the disease. Observation undoubtedly shows us instances in which the tuberculosis is progressive, notwithstanding the ingestion and apparent assimilation of nutritious food; but it probably can show few examples of arrest of the disease when, either from disinclination or injudicious management, the diet is insufficient for the full support of the body, or fails to be appropriated to that end. No part of the management of tuberculosis seems to me of greater importance than that relating to the diet; in fact, whatever efficiency belongs to active habits of exercise, it is reasonable to suppose, is in great measure exerted by means of the increased activity of the processes of assimilation thereby induced." Diffusible stimuli, as wine, beer, and spirits, entered more or less into the management of a considerable number of these cases. They were given in moderate quantities, subsidiary to alimentation, i. e., contributing to render the digestive processes more active and complete. "I have of late advised their use much more freely than formerly, and I think I cannot be mistaken in attributing to them much value. I have observed that patients affected with tuberculosis are often able to take spirits in large quantity without experiencing stimulant or intoxicating effects. The disease appears to be one of those in which these effects are with difficulty produced."

Beyond mere palliatives, little use was made of medicinal agents, properly so