ways run its course. By antiphlogistic diet, and a few simple means calculated to restore the secretions, and, if required, to cause revulsion from the inflamed part, a cold may often be checked in a few days, which if left to itself might run on for weeks, entailing on some subjects other and worse evils, The means which we have found most effectual are as follows :-At the first feeling of the cold, let a purgative be given, with two or three grains of ipecacuanha or James's powder. Let a hot pediluvium be used, the patient getting into a warm and well covered bed immediately after, and promoting any disposition to perspiration by a warm draught of thin gruel, barley water, or any other mild diluent. If perspiration comes on, and the purgative operates well, the cold is sometimes already cured; and it is only necessary to remain at home, and to abstain from animal food and wine next day to prevent a return.

If, however, perspiration do not follow, or if the cough has already come on, the disease generally proceeds, and we must then endeavour to mitigate its severity, and bring it quickly through its course. If the patient cannot, or thinks it not worth while to remain in bed for a day or two, he should clothe more warmly than usual; for the susceptibility of the body is such as to render a very slight exposure enough to keep up the disease, and abstinence from meat and all fermented liquors or spirits is at this period equally necessary. To loosen the cough and lead the bronchial inflammation to the stage of free secretion, small doses of ipecacuanha or tartarized antimony are often most effectual; and, although called a stimulant expectorant, squills, when combined with these, have always appeared to us to exert a beneficial effect: ten minims of the tincture with thirty of the vinum ipecacuanha, and six or eight of liquor potassæ, given three or four times a day, seldom fail to facilitate expectoration and relieve the cough. Whether the alkali act by facilitating the absorption of the medicine, or by any specific action on the vessels of the bronchial membrane, we cannot deter

mine; but its effect in increasing the action of expectorants we have proved in a variety of examples. Should nausea be produced, the dose of the medicines may be diminished; and if the cough is still troublesome at night, a little extract or tincture of hyosciamus may with advantage be added.

This treatment is generally sufficient to relieve the tightness across the chest, which yields as the cough becomes loose; but if the case is obstinate, it may be necessary to resort to a blister, or some of the means which we shall presently recommend for the more severe forms of the disease.

The inhalation of the vapour of warm water may be sometimes useful; but we have seen it in some instances increase the oppression; and, from its effect of determining blood to the part, we do not deem it so universally safe a measure in recent bronchitis as it has been represented to be.

With still more force would we object to the cure by spirits or wine, as recommended by Laennec; not that we doubt its occasional efficacy, but from the experience that where it does not cure, it greatly aggravates the inflam mation. Towards the termination, when the matter expectorated has become thick and loose, and all febrile symptoms are dissipated, animal food and wine may be indulged in with impunity, and even with advantage. At this period, too, if the disease shows a disposition to linger, much good may often be obtained by using some of the stimulant expectorants, as myrrh, copaiba, &c. and if necessary, the cough may be allayed by opium. This treat ment will be noticed under the head of chronic bronchitis.

There are very many remedies which are in common use for coughs, which it is impossible here to advert to. The safest are those which are simply demulcent; many are stimulant and narcotic, and often do mischief. Ipecacuanha lozenges is a remedy worthy to be named, as the convenience of its form recommends it when more formal medicines are objected to; and although it is apt to cloy the stomach before suffi cient quantity can be taken, it often

proves as serviceable as the less agreeable compounds of the medicine.

2. The danger attending severe acute bronchitis renders far more energetic measures necessary; and these, although generally of the same class as those usually directed against acute inflammations, must be exercised with more than usual discretion and caution.

As long as the phlogistic state continues, with high fever, hard pulse, and great feeling of straitness and oppression in the chest, there can be no doubt of the propriety of bleeding more or less freely, according to the intensity of the symptoms, and the strength of the patient; but it is not prudent, as in pleurisy or peripneumony, to bleed to syncope, or to push the measure with an expectation of very marked relief. From sixteen to twenty-four ounces may be taken at first in severe cases; and the repetition of general bloodletting must depend on the state of the pulse rather than on other symptoms. If it is weak, or if the patient is advanced in life, we must endeavour to subdue the symptoms by less violent means, such as local bleeding and medicines, rather than run the risk of destroying strength that is absolutely required for the act of expectoration.

Cupping is generally to be preferred to leeches, as its effect is more speedy and more within control; and it is of considerable advantage to apply it to the part in which auscultation has discovered the greatest obstruction to the passage of the air.

There is an objection which obtains so against blisters, as to exclude their use in many cases of the early stage of acute bronchitis; namely, that before they rise, they always produce an irritating effect on the whole system, which is very apt to aggravate for the time the inflammation for which they are applied. This effect, however, varies much in different individuals, and in those whose skin easily vesicates under a blister, it is obviated by the serous discharge that immediately succeeds.

In other instances, it is advisable to resort to other counter-irritants, and we give the preference to the tartar emetic. To make it available in an

acute disease, we have found it necessary to excite the skin previously to its application, by means of a brush or coarse flannel, by applying a warm hand wetted with ether or camphorated spirit, or by a short application of a mustard poultice. The tartar emetic should then be immediately rubbed in, either in the form of a warm saturated solution, or an ointment composed of one part tartar emetic to two of spermaceti ointment. With these precautions we have rarely failed to excite a full pustular inflammation in as short a time as that required for the rising of a blis ter, with far less irritation to the system, and with decided relief to the pectoral symptoms. We have reason to believe that a minute quantity of the tartar emetic is absorbed into the system, as we have sometimes observed nausea succeed its use; and this, instead of being injurious, as in the case of cantharides, is a part of the treatment which has been found most serviceable. This brings us to the subject of internal remedies.

At the onset of the disease, the earlier the better, a brisk purgative should be given. Where the inflammation is high, calomel, with a grain or two of ipecacuanha, combined with jalap, scammony, or any of the active cathartics, is to be preferred, and followed by repeated doses of a saline aperient, containing a small quantity of tartarized antimony. This medicine proves useful not only as an evacuant, but as a sedative and diaphoretic, and the nausea, which it sometimes produces, is generally beneficial by modifying the secretion of the bronchial lining, and facilitating expectoration. For the same reason, a full emetic has been generally recommended, and is often decidedly useful; but it is better adapted to children, and to cases in which the bronchial secretion is profuse, than to the more inflammatory forms of the disease.

For the relief of the dyspnoea and cough, those medicines are to be preferred which act on the vascular system. The sensation of dyspnoea is not to be looked on as one merely of discomfort, to be relieved by means which deaden sensibility, but as an indication of the

inroad made on a vital function, which, if not restrained, must terminate in its destruction. To aid, therefore, the antiphlogistic measures that we have already recommended, it is proper to administer such medicines as are likely to moderate the action of the vessels and relieve the congested lungs. Tartar emetic, digitalis, and colchicum best answer this indication, and we generally prefer the two former. The tincture of digitalis, in the dose of eight or ten minims, with thirty or forty of the liquor antimon. tartar., three or four times a day, is the form which we usually adopt. Of course it will be necessary to watch the effects of these medicines, and to diminish or discontinue the digitalis if the pulse become intermittent. It will be of considerable advantage to increase the dose of tartar emetic; and if the dyspnoea continue, and the mucous rhonchus in the chest is undiminished, to persist in its use even should it excite vomiting; for its beneficial effects in peripneumony, to which bronchitis, in its severe form, really approaches very nearly, are sufficient to prove its power to restrain effusion and promote absorption. Dr. Badham strongly recommends this medicine in doses frequently repeated, and-increased till the maximum which the stomach can bear without vomiting is attained.'

Calomel and opium combined, and given in frequently repeated doses, as in other acute inflammations, are like wise sometimes highly beneficial; and we consider that their use is especially indicated, where, as is not unfrequently the case, the bronchitis is complicated with gastro-hepatic disease. The opium should be in smaller proportion than usual, and is, perhaps, most safely given in the form of Dover's powder.

focate him. We are disposed to think that this remedy is more than an ordinary stimulant, and acts in an especial manner on the bronchial membrane.

The attenuating or solvent power of alkalies may with advantage be resorted to in the latter stage of bronchitis, when the matter of expectoration is very consistent, and, lodging in the bronchi, occasions local absence of the sound of respiration, and, if copious, dyspnoea. The liquor potassæ, in doses of ten ininims, given with the vinum ipeeacuanhæ, is productive of obvious benefit.

From what we know of the effects of the lobelia inflata in suffocative catarrh of the chronic kind, we should judge it to be worthy of a trial in the collapsed stage of acute bronchitis.

Besides attempts to relieve the lungs of the load which prevents the penetration of air into them, another indication presents itself in this stage, which is to obviate the bad effects of black blood in the system; for this it is, unquestionably, that gives that peculiarly depressed and adynamic type which precedes the fatal termination. Here, unfortunately, our experience fails us; and we feel the necessity of appealing to further researches of experimental physiology."

The subject of Bronchocele, from the pen of Dr. A. Crawford, concludes the third part of the Cyclopædia of Medidicine. We shall notice the other parts in our next Number, while we strongly recommend this work as by far the best

indeed the only good work of the kind in the English language. It promises, in fact, to be a national concern.

LXXXI.

CASES OF ENTERO-VAGINAL HERNIA,* ENTERO-VAGINAL hernia has in a few cases been gradual in its formation, but in the majority it has suddenly followed some exertion, strain, or shock. The first case on record was related by

M. Garengeot, in the Memoirs of the French Academy of Surgery. As this is a rare yet important affection we shall give an abstract of some of the more interesting cases reported by Dr. Davis.

Case 1. The patient was the wife of a costermonger, of middle stature, who had borne five children, all large. About a month after her last confinement she made an effort to assist in lifting a load on the shoulders of a porter. At the instant of that effort she felt a derangement within the abdomen and an acute pain in the vagina, of which also she had a sense of great fulness. She consulted her midwife, who told her that she had a bearing down of her womb, and that she must place herself under the care of a surgeon. She however neglected this advice, and continued to busy herself with her ordinary affairs for some time subsequently. The descent into the vagina became so considerable that it manifested itself at the external orifice, beyond the level of which a tumour protruded about a finger's breadth. The patient felt from time to time pains of an internal spasmodic character, which seemed to take their origin from that part, as also pain of the stomach with sickness. Moreover, she was not able to void her urine except in the position of lying on her back. Informed of these particulars, M. Garengeot discovered on examination a whitish tumour, which not only occupied the vagina, but which projected beyond the labia pudendi in such a manner as to admit of the introduction of a finger between it and the vaginal parietes posteriorly. On passing his finger beyond the tumour in that direction, he could feel the orifice of the uterus occupying very nearly its natural situation whence he concluded that that organ was not implicated in the existing mischief. He also found that the pressure which this examination caused to be made on the tumour, which indeed was unavoidable, had the effect of reducing it to about one half of its previous size. Such a change in the size of the tumour excited at once

the suspicion that it consisted in a descent of intestine. With that impression on his mind he placed the patient in a lying position on her bed, and applied the taxis to the tumour with the utmost accuracy of attention. Whilst this operation was performing, he felt its contents as if receding through the superior and right lateral portion of the vagina and after the retrocession was effected, it was left soft, relaxed, thin, and imperfectly occupying the space which had been previously occupied by the visceral protrusion. In order to strengthen his conviction that the case was one of entero-vaginal hernia, of which however he had never heard before, nor known any author who had described it, he desired the patient to get up and walk, and also to cough strongly. These movements caused the tumour to present itself immediately again. That circumstance served to establish M. Garengeot's conviction that it was actually a hernia. effected its reduction a second time, and desired the patient to keep her bed until he should be able to supply himself with a suitable pessary. After some failure on this point, in the first instance, a well-adapted contrivance was at length applied, which had the effect of preventing any future descent so completely, that the patient never afterwards sustained any inconvenience from it.

He

Case 2. In the former case the recent confinement might seem likely to predispose the patient to the occurrence of such a hernia, but in the following there was no such apparent cause in previous operation.

A young woman, of good health and tallish stature, married at the age of twenty-four. Soon afterwards, having to walk along the unboarded joists of an unfinished house, she fell between them, and was precipitated with her face downwards on a heap of boards on the floor below. The face and temple were contused and she fainted for some time. On recovering her recollection she felt intense pain of the parts within the pelvis, referred more particularly to the bladder, and aggravated by the

erect position. She thought that her bladder was ruptured, and could pass no urine when she attempted to do so. About two inches on the right side of the navel there was a lacerated wound, and contusion in the right flank. She was seen by Dr. Davis about three hours after the accident. She was in a state of great excitement, complained of great pain in the region of the bladder, with incapacity of passing her urine, any attempt at which was attended with great increase of the pain, tremendous bearing down, violent retchings, and painful gaspings for breath, which had more than once terminated in syncope. There had been a considerable discharge of pure blood from the vagina. On making an examination per vaginam, the region of the bladder was extremely tender to the touch, particularly in the space immediately anterior to the vaginal part of the uterus. No laceration was discovered, nor any sort of tumour or protrusion, but on making a second examination, during which the patient was seized with vomiting, an intumes cence of such magnitude as very nearly to fill the upper and middle part of the vagina, soft and elastic, was found to proceed from the very termination of the vagina superiorly, intermediately between that part and the anterior lip of the uterus. The vomiting continued during the examination, and the swelling was exceedingly tense and painful. Thinking that this tumour was the lacerated or displaced bladder, Dr. D. introduced the catheter without meeting any impediment, and drew off twenty ounces of bloody urine. This produced no relief, the vomiting indeed became more severe. The true nature of the case was suspected, the patient was again placed on her left side, with her breech raised and brought to the side of the bed, and by slow degrees the whole of the left hand was introduced into the vagina. Cautious and gradual pressure was made upon the tumour which was reduced in about a quarter of an hour, a gurgling noise accompanying the return. The mucous membrane of the vagina had not been ruptured, but formed an investing coat to the hernia, which had protruded at

the part already mentioned. Towards this Dr. D. "bundled up" every fibre of tissue which might possibly be the remains of a hernial protrusion, and having procured a piece of fine sponge he employed it as a pessary, and found it answer extremely well.

The patient was now in a state of exhaustion, with very frequent small incompressible pulse, some disposition to vomit, great tenderness of the hypogastrium, and still some hæmorrhage from the vagina. In consultation with Dr. Sims, our author abstracted twenty-eight ounces of blood which produced deliquium, followed by marked relief. Leeches to the hypogastrium, a pill of calomel and opium every two hours, and strict quiet followed. We need not pursue the details of the case, suffice it that no more active means were required though judicious treatment was still necessary. A passage through the bowels was procured on the next day, and no further abdominal symptoms ensued. It was necessary to use the catheter for a fortnight, and the urine remained bloody for several days. The sponge pessary was withdrawn daily, and a fresh one imbued with a strong solution of alum substituted for it for about three weeks. Then, when the injured part of the vagina was pretty free from pain, a very light, hollow, and perforated wooden pessary, of nearly cordiform shape was substituted for it. This was withdrawn and re-applied daily for the first week, and after that left permanently in the vagina, without the ribband, that the patient might not remove it herself. The pessary was discontinued after having been worn for four or five months, but sponge pessaries gradually reduced in size were continued for a few weeks longer. The patient was perfectly cured with the exception of a slight difficulty in micturition which has since remained, and she is now the living mother of several children.

Entero-vaginal hernia has been more frequently observed in the posterior than in the anterior chamber of the pelvis.