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stance, would then have made the amputation of the limb Iinevitable. ,

The effectual way in which the lotion of the chloride oflime was applied, gave it full opportunity of exercising itssurprising preservative influence, and the very speedy andsuccessful termination of the case cannot otherwise than ingreat part be attributed to it.

PRACTICAL OBSERVATIONS IN MEDICINE.BY GEORGE SMYTH, M.D.

LECTURER ON MATERIA MEDICA AND THERAPEUTICS AT THE CHAR-LOTTE-STREET SCHOOL OF MEDICINE, BLOOMSBURY.

PUERPERAL INFLAMMATION.

Uterine phlebitis and peritonitis, accompanied from the onset withdiarrhaea of a peculiar and obstinate character; the two former !

affections treated without venesection; the latter, after opium, ’

catechu, and chalk, had failed, arrested by acetate of lead; reco-very ; observations on the physiological and therapeutic virtuesof some of the remedies employed.

A LADY, of lax fibre and weakly stamina, but stout, and in theenjoyment of good health, was confined of her fourth child,after a somewhat tedious, though natural labour. The extrac-tion of the placenta was followed by flooding, rather obstinate,but not alarming in its nature; nevertheless, it reduced herto a state of great weakness and much physical debility,from which she slowly rallied. Her ultimate recovery proved,indeed, very protracted, nor did she, for a very long time, ifat all, regain the usual health and strength that she had for-merly enjoyed. On the contrary, she subsequently becamethin and delicate in appearance, easily fatigued by the slightestexercise, and, moreover, was much affiicted with erraticrheumatism and spasmodic affections.

This lady, although she had previously borne a child everyfifteen months, did not again accomplish the full period ofgestation for the term of three years and a half, during whichtime, however, she miscarried twice.The similarity, in the general features of these two cases, is

so striking, that one cannot avoid coming to the conclusion,that the cause which operated in bringing about the one musthave been of the same nature as that which produced theother. This I believe to have been the fact; and as in thelatter the uterine hsemorrhage was clearly the cause,-forthere was no other to which it could be attributed,-so, in theformer, there is every reason to presume that it was the blood-letting carried to excess; but upon this point I have alreadyexpressed my opinion.To regulate the treatment to suit the exigency of this case

(Mrs. H--) required much serious consideration, and was amatter of no small difficulty. In it there existed two distinctmorbid actions going on at the same time, which were con-sidered very different in their nature, and in the ordinarycourse of their occurrence in separate persons would require- opposite and distinct modes of cure: the one appeared of apassive, whilst the other was undoubtedly of an active, nature.However disposed, then, I might have felt to recommend vene-section for the peritonseal and uterine inflammation, takingthe view I did of the pathological nature of the intestinalaffection, I could not consistently sanction general depletionas a measure in any way applicable to it, or even to be tole-rated by it. The opinion entertained of the pathology of theintestinal affection was, that it was non-inflammatory; that itdepended, in some measure, upon a state of atony of the intes-tinal mucous membrane; that, in short, it was a kind of pas-sive flux, indicative of extreme and alarming debility, if notof absolutely sinking, and resulted from the severe shockwhich the whole nervous system had sustained. The subse-quent progress of the case corroborated this view of the mat-ter, and I think, in most respects, proved it to be correct.The question then arose,-How was the uterine and peri-

tonseal affection, the really inflammatory and active disease,to be combated ? It was plain that the system could notbear up against the debilitating effects of general depletion,for already its vis vitce appeared all but exhausted, and anyfurther diminution of it would, in all probability, prove sud-denly fatal. Nor is it the first time that bloodletting, inju-diciously exercised in the puerperal state,-a state under allconditions critical;—has been unexpectedly terminated by theawfully sudden dissolution of the patient, whilst still in thehands of the operator, the only warning, perhaps, of the me-lancholy event being a few hurried gasps and sighs. Indeed,even the operation of purgative medicine is gometimes suffi-

cient, at this period, to induce great and alarming weakness,an instance of which, as we have seen, occurred in the presentcase.

The indications of cure, therefore, appeared to be, to abstainas much as possible from depletion of any sort, and to use suchremedies only as would exert their influence, either directlyand locally, on the diseased actions, or indirectly and gene-rally on them, through the system, without, at the same time,subjecting the latter, if possible, to any further diminution ofits strength. Although this was my conviction, and althoughI felt satisfied that the condition of the patient would notpermit her to lose even an ounce of blood from the generalmass with impunity, still I thought the topical application ofa few leeches to relieve local congestion might be beneficialand salutary. Accordingly I prescribed, as external reme-dies, leeches and warm fomentations to the abdomen, and coldapplications and leeches (conditionally) to the head; inter-nally, calomel and opium, the latter in large proportion, inhopes of staying the bowel complaint, together with a mixturecombining in itself demulcent and mildly diaphoretic proper-ties. An enema of warm water was ordered in the first in-stance, partly as a kind of internal fomentation.Next day there was little or no improvement found in any

of the symptoms; but, on the contrary, they all, with one ex-ception, presented, perhaps, a more unfavourable aspect—n&abatement in the diarrhoea; abdomen more distended andtympanitic; and the pulse increased in frequency, and morefeeble.The exception was the frontal headach, which had been

so distressing the day before, but which had almost entirelydisappeared under the use of the cold cloths, without the ap-plication even of the leeches. This I regarded in a favourablelight. I did not venture to order a repetition of the leechesto the abdomen, however necessary such a step might, fromthe amount of pain complained of, appear to be. The faint-islmess and weakness which followed their application theday before deterred me from pursuing that course further;and besides, their further use was likewise contra-indicatedby the increasing feebleness and smallness of the pulse.What now was the course to be pursued, from which the

greatest amount of benefit, or even hope of relief, might re-sult ? The only one which appeared to me to afford anyprospect of suceess,-indeed, I may say, the only one whichcould reasonably be adopted under the circumstances, atleast as regarded the inflammation,-was to bring the systemunder mercurial influence, in as mild and gentle a manner as,possible; whilst, at the same time, the strength was beingsupported by such means as consistently lay in our power, andthe topical applications continued steadily to the abdomen as.well.With this view, the quantity of opium in the pills was first

increased, and subsequently an astringent mixture prescribed,in order, that by staying more quickly, if possible, the intes-tinal flux, the calomel might consequently be prevented frompassing off too rapidly, before it had time to be absorbed andenter the system. The astringent remedies, however, failedto accomplish the purpose for which they were intended; andit is a point worthy of observation, that notwithstanding theydid so, and that the diarrhoea continued just the same, stillthe mineral must have remained a sufficient length of time inthe stomach and intestines to admit of being taken up by theabsorbents, as it manifested its specific action decidedlywithin the ordinary period, and much sooner than might havebeen expected under the peculiar circumstances of the case.Now, although the principal intention for which the calo-

mel had been given was fully answered by the almost com-plete resolution of the inflammatory action, nevertheless, I

, was not a little disappointed to find that the diarrhoea conti-: nued unabated, not only during the time the system was

being specifically acted on by the mercury, but also after itwas fairly under its influence. This was certainly a circum-stance which I did not anticipate, and was unprepared for,

’ because, in all previous cases of disease, however varied in, their nature, in which I had occasion to push mercury, so as. to produce its specific action, the bowels generally (indeed, I, may say, invariably, as I do not recollect an instance to the

contrary) became more or less obstructed before the object’ was attained, and not unfrequently completely blocked up.

Hence, therefore, it was expected that a similar occurrencel would take place in the present case, and thus would both

maladies be arrested simultaneously.But independent of mercurialism and the retarded action

- of the bowels,-which, as I say, I have usually found to precede, or accompany its first development, induced, no doubt, prin-- eipally, if not entirely, by the opium or other astringent

265

usually combined with mercury or its salts, when administeredfor that purpose,-there were other actions by which it waspossible for the calomel to have exercised a salutary influenceover the intestinal affection, so as to have checked it. Havewe not, for instance, sometimes recourse to this drug alone inmany lingering and obstinate cases of diarrhoea and dysentery,the latter more especially? And do we not find that thesediseases generally yield to it, when exhibited in moderatedoses, and repeated at proper intervals, so as not only to en-sure, but steadily to maintain for some time, a medicinal actionon the bowels? Effected in this way, the process of cure isaltogether a local matter, and completely independent of theconstitutional action of the remedy. It depends, in fact, uponits irritant or purgative properties, and is accomplished, per-haps, solely by the calomel setting up in the intestinal canal,and likewise, no doubt, in the hepatic viscera also, a newkind of irritation, or new set of actions, by which the struc-tural or functional derangement, (whichever it may be,) anddiseased tendency previously existing in these organs and tis-sues, and keeping up the diarrhoea or dysentery, is counter-acted, and ultimately displaced. This, then, is the modusmedendi under such circumstances.

Again: the calomel might have produced a beneficial in-fluence by reason of the sedative action which it is now wellknown to possess. I allude more particularly to the remark.able sedative effects which follow its administration, especiallyin large doses,* in dysentery and some other forms of entericinflammation. In these, instead of augmenting the irritationof the intestinal mucous membrane, and thereby aggravatingthe whole of the symptoms,-a result, in short, that might beexpected, considering its irritating nature under other con-ditions,-it appears to have a totally opposite tendency; thesecretion, though before profuse, is quickly diminished, thepain abated, and the spasm-a usual concomitant of such com-plaints-allayed, apparently from some peculiar sedative in-fluence exerted :n certain cases, almost instantaneously, eitherlocally on the affected parts, or generally on the system.

It is, however, to our medical brethren practising in Indiathat this therapeutic action of calomel is most familiar andbest known, as their experience in the treatment of acuteenteric and biliary affections is much more extensive thanours. But, nevertheless, the success which has attended itsadministration in cholera and dysentery, even in this country,as shown by the published statements of many practitioners,leaves not the slightest doubt of its great efficacy in suchdiseases, and of its absolutely possessing the power of control-ling and arresting their progress by some such property.And again: combined with the sedative, calomel, especially

in small doses, possesses well-marked febrifuge and antiphlo-gistic properties. This is, indeed, a fact generally known and Iwell exemplified by its power of arresting acute inflammationseither of internal or external organs, and of shortening theduration even of continued fevers. It appears to me, then,that in dysentery and other acute inflammatory diseases of theintestinal canal attended with fluxes, in which it is found sospecially serviceable, much-if not, perhaps, in many instances,the whole-of the curative effects should be attributed, and aredistinctly due, to these properties alone. That, however, I amnot at present prepared to affirm, although I think it must be ac-knowledged, that they, at all events, perform a most importantoffice towards accomplishing the removal of diseases of thisnature. Through their influence, the local, inflammatory, andgeneral febrile action is no doubt subdued; and as the intes-tinal irritation and morbid secretion, either wholly or in part,depend upon and are kept up by the former, it consequentlyfollows, that so soon as this begins to abate, and at length dis-appears, they become diminished, and perhaps finally cease.Thus, both the remote and proximate causes being removed,the abnormal discharges can no longer persist, andlaecessarilygive place to a return of the normal and healthy functions.

Here, then, were several distinct properties and modes ofoperation by which it was possible for the calomel to haveexercised a beneficial and controlling influence over the in-testinal flux, so as to have checked it if it had been of aninflammatory and active character; and its having failed todo so appears to me, in a great measure, to confirm the viewUrst taken of the pathological nature of the affection.

The efficacy of the acetate of lead is well illustrated in thiscase; and its superiority over chalk, catechu, and opium, inchecking the diarrhoea, is likewise so very manifest, that Icannot avoid directing attention to the circumstance. It hasbeen observed, that although the chalk, catechu, and opium,

* The sedative action of calomel is seldom very manifest, unless whenadministered in halt.scruple, scruple, and half. drachm doses, the intestinalmucous membrane being at the time in an inflammatory state.

were employed freely, without intermission, for a length oftime, still no very obvious benefit resulted from their use-atleast, no decided mitigation of the complaint took place. Butso prompt was the saturnine salt in its action, that on thesecond day of its administration, the amendment was not onlyperceptible, but very considerable indeed.Now as this salt possesses sedative as well as astringent

properties, and in that respect differs, with one or two excep-tions, from other astringent substances, it might therefore,perhaps, be considered a proper subject for inquiry as towhich of these the amendment was principally to be attri-buted, or if attributable equally to both. Its powerful as-tringent properties, both on dead and living animal tissue, itis true, are now so well ascertained, that the importance of itsaction, as such, cannot for a moment be called in question.Nevertheless, it would appear to me, that the curative effectsin the present case were mostly indebted to its operation as asedative, because I conceive that it was by it the intestinalperistaltic action-a symptom to which I have already had oc-casion to allude, as forming a prominent and very remarkablefeature of the affection-was arrested.

, Judging from analogy, there appears to be little doubt ofthis. It has been found, that a solution of acetate of lead iscapable of almost immediately stopping the vermicular move-ment of the intestines, if brought in contact with their coats;and it is well known that it possesses also the power of allay-ing the pain of inflammation when directly applied to an in-flamed surface. Indeed, the quietude and immediate relieffrom suffering, which I have occasionally observed to followits application in some painful affections, especially of themammae, occurring in women about the middle period of life,have often astonished me. Even the lancinating and burningpain of carcinoma is sometimes greatly mitigated by thesteady application of the diluted solution of diacetate of leadof the Pharmacopoeia : These effects, then, it must be ad-mitted, are evidently the result of a sedative action exerteddirectly on the nerves of the parts to which the remedy isapplied. But all the preparations of lead appear to have apeculiar affinity for, and to act in some measure specially on,the nervous system, whether they be applied externally ortaken internally. Of this we have a somewhat conclusiveillustration, in the giddiness, coma, apoplexy, and that pecu-liar paralytic affection of the voluntary muscles (lead palsy)to which those who have been for some time exposed to theinfluence of lead are liable. It is the opinion, even of a greatauthority,t that colica pictonum is a nervous disease, (a neu-rosis,) the spinal marrow and the abdominal plexuses of thegreat sympathetic appearing to be the peculiar seat of lesion;the constipation seeming to depend either on the abolition of £the contractile motion of the intestines, or on the suspensionof the secretion of the intestinal mucus.

It is undoubtedly, then, this sedative, united with the as-tringent property of the acetate of lead, which renders it sovery serviceable both as an external and internal remedy inthe treatment of many special diseases. But in none, perhaps,are its beneficial effects as an internal agent more manifestthan in the chronic form of diarrhoea and dysentery, for thecure of which it is decidedly far superior to any other remedythat has yet been recommended. In them it appears to quietthe intestinal action and allay the pain by blunting the insen-

: sibility of the mucous membrane, whilst, at the same time, byconstringing the extreme vessels, it checks excessive secretion

. and thus stops the discharges., Sackville-street, Piccadilly.

ON DENTO-NEURALGIC AFFECTIONS.BY A. C. CASTLE, M.D., New York.

THE Editor of THE LANCET having, on two occasions, doneme the honour of inserting communications from me in hisvaluable journal, I again take the liberty of addressing a fewremarks to its readers, hoping that they will prove equallyacceptable.The subject of the present paper is that distressing affec-

tion, dento-neuralgia. Anatomical and pathological sciencehas been long and zealously engaged in the investigation ofthe causes of the affection denominated "neuralgia," but, un-happily for the sufferer, and unfortunately for the professionitself, this, like many of the other ills which flesh is heir to,* The officinal preparation is decidedly much too weak. For painful affec-

tions of the breasts, it should be made at least double or treble the strengthof that ordered by the colleges; and it is likewise of great advantage tapply it a little warm. If these precautions be attended to, it will be foumuch more effectual as a sedative.

t Aiadral.