rally be almost immediate. I feel much disposed to adopt this opinion; in favour of which, he possesses several beautiful cases in his Journal.

"The paralytic stage of Neuralgia being merely a temporary diminution of the vital force, the patient often feels himself more than half cured when the practitioner has finished the eschar. It is of great consequence to cure neuralgia of the sacral extremities during the first three months of the inflammatory stage; for when it has lasted more than a year, the patient is very obnoxious to relapse."

White swelling is another disease to the cure of which Dr. Hood has directed the nitrate of silver. He thinks it will hardly be denied that "white swelling of the kneejoint proceeds from defective lymphatic absorption-or, in other words, morbid contraction of the lymphatic tubes." He endeavours to place this in a clear light by the following experiment.

“When a lunar caustic eschar is applied to a white swelling of the knee-joint, the expansibility of the absorbents is renewed; but although there be generally no inflammation except at the edge of the slough, yet the extreme arteries of the joint are also a little expanded the first three or four days. But by the twelfth day of the eschar, the swelling has subsided sometimes a full inch by absorption alone; for lunar caustic causes scarcely any discharge of pus. The sudden abstraction of the effused fluid, in a diseased joint thus treated, cannot be supposed to result from the lymphatics alone; the veins, doubtless, contribute material assistance; but the principal of venal and lymphatic absorption is the same."

In an appendix, entitled "PRACTICAL OBSERVATIONS," Dr. Hood has again adverted to the external use of nitrate of silver in the cold stage of ague, which he considers to proceed from a diminution of the vital force.

"It was," says he, "from a deep impression of the truth of this conclusion that recommended Dr. Sillar to apply externally the nitrate of silver in a case of Quartan Ague, which had lasted upwards of

twelve months, and had resisted both bark and arsenic. The eschar was made an hour before the accession of the paroxysm; we returned to see the patient at the period when the cold stage usually ended, but it had not come on; our entrance roused him from a comfortable sleep. It would be superfluous to descant here on this synthetic proof of Cullen's theory; I leave it for the discussion of the contending theorists of the present day."

The last passage which we shall extract from Dr. Hood's work, and which, indeed, is the only other one which we could find on the subject of lunar caustic, will be found between pages 195 and 199, of the volume.

"HEMIPLEGIA. In these kingdoms, the treatment of acute hemiplegia cannot be improved. Bleeding and blistering often remove this disease in the course of six weeks or two months; but if, at the end of this period, the use of the paralytic side be not partially restored, a cure is generally considered hopeless. If, however, all the apoplectic symptoms be entirely removed, and there remain no appearance of plethora of the cerebral blood-vessels, even chronic hemiplegia may sometimes be greatly benefitted, by a succession of small lunar caustic eschars. It is impossible to say, à priori, in what case this treatment may be successful; but this information is very easily ascertained, by making an eschar over the course of the nerves of the paralytic arm, either in the axilla, or above the clavicle; and if either the sense or motion of the arm be improved, just expectation may be entertained of alleviating the disease.

"The nervous system of those individuals who possess the sanguine temperament, is most easily excited by the nitrate of silver; a circumstance which is to be borne in mind, when this substance is applied to the spine. But when hemiplegia is relieved by lunar caustic, the cure goes on as fast when the eschar is about half the size of a sixpence, as when it is much larger; the nervous system requires a constant, but mild stimulant. The applications may be made on the back of the neck, and renewed every twelve

or fourteen days. The longer a patient has been under the operation of the nitrate of silver, the more sensible he becomes to its influence; but if the treatment be pursued in a judicious manner, and only in proper cases, no untoward circumstances can arise from its use.

"NEURALGIA.-The eschars for the cure of neuralgia of the sacral extremities, may vary from the size of a shilling to that of half-a-crown. The caustic must be applied over the course of the affected nerve, and rubbed till the part assumes a red colour studded with grey spots. Rest and warmth are to be strictly enforced during the cure, and a considerable time after recovery."

"The cure of white-swelling should be commenced by the application of a dozen or two of leeches to the joint, unless the patient's general health be already too weak, to bear even local bleeding. Leeches are preferable to cupping, as they do less mechanical injury to the joint. Two days af ter the bleeding, a lunar caustic eschar, as large as half-a-crown, must be made at one side of the patella, and the whole joint must be enveloped in a poultice, and maintained perseveringly in a state of rest. When the eschar comes away, the poultice may be discontinued, and the sore dressed with cerate or dry lint, and allowed to heal without delay. When the sore is quite skinned over, a fresh eschar may be made on the other side of the patella, and treated in every respect like the first. It is not amiss to keep a measure of the joint, to see the progress of the cure. For constitutional treatment, I generally employ alterative doses of calomel and James's powder; but I am not certain that much good is derived from these medicinés. Small doses of rhubarb are sometimes beneficial. When sinuses exist, they must not be laid open, if the cure be attempted on the principle of absorption. The patient should not be allowed to walk about for some weeks after the swelling is gone, and cold must be carefully avoided. By this treatment, the patient suffers comparatively little, and the cure is almost certain, if the constitution be otherwise good,

and the disease recent. The actual cautery, blisters, and potass eschars, frequently defeat the purpose of the practitioner, from the violence of their operation. As whiteswelling occurs most commonly in scrofulous constitutions, it is consequently often combined with diseases of the other organs, such as tabes mesenterica, tubercles of the lungs, rickets, and hydrocephalus ; it is not, therefore, to be presumed, that by any local application, the scrofulous tendency of the animal economy can be eradicated.

แ Many facts which I already possess, as well as rigorous analogy, might induce me to recommend the external application of lunar caustic in some other obstinate diseases; but I am unwilling to promulgate any opinion, of the accuracy of which my own mind is not entirely satisfied; and I venture to assert, that it presents the physiological practitioner with curative means, for which the res medica offers no substitute. I should even here have enlarged more on its medical properties, were it not that my friend Dr. Sillar is now occupied on this subject, and will perhaps lay his observations before the public."

We hope we have now done Dr. Hood ample justice, as to his claims of priority in the external use of lunar caustic. How far his observations interfere with or anticipate those of Mr. Higginbottom, we shall not undertake to decide. The authors were evidently unacquainted with each other's writings and so far they tend to strengthen one another, without any necessity for a war as to priority. We shall be anxious to see the announced publication of Dr. Sillar, since we have reason to believe that the range of diseases to which the nitrate of silver may be applicable, is not yet defined. We hope, indeed, ere long, to be able to communicate to our professional brethren some very important cases where the internal use of the nitrate of silver was followed by the most beneficial effects-cases, too, in which the remedy has never before been tried.

XXXII.

CASE OF MASKED DOUBLE TERTIAN FEVER. By M. GUIBERT.

Mad. G, aged 20 years, and of a nervous temperament, had been subject, for five weeks, to copious perspirations, which came on about three o'clock each morning, lasting till seven or eight o'clock. The urine, all this time, was high-coloured, and deposited a sediment. In all In all other respects the lady appeared in good health. The night of the 2d December passed without the usual perspiration, and Mad. G rose in the morning, complaining of great weakness and tentency to faint. She was very pallid, her voice extremely feeble-in short, she appeared in a dying state, both to herself and those around her. Nevertheless the respiration and pulse were unaffected. She took some nourishment and a glass of wine, by which she was somewhat recruited-and in the evening she was almost well. She passed a good night, and the perspiration returned at the usual hour next morning, after which, she got up and breakfasted in her usual health. At 11 o'clock on that day (3d of December) she experienced a slight malaise, which rapidly increased, and in a short time was insupportable. The most violent pains were felt in all the limbs and in the abdomen. This latter appeared to the patient to be suddenly and greatly inflated-an icy coldness seized the body, and she was soon delirious. There was next a most violent pain over the whole surface of the head, with great heat and flushing of the face. The pulse was imperceptible at the wrist. but the carotids were felt beating. Having recovered from her delirium, the former state of despondency returned, and she declared that she was dying. She therefore assembled her parents and relations around her bed, in order to take leave of them. The pulse continued imperceptible at the wrist-the extremities were of icy coldnesss-there were cramps and convulsive twitchings in the legs and thighs the respiration was oppressedthe eyes rolled in their sockets-but the head continued remarkably hot, notwith

standing the application of ices. In this state, Dr. Ratheau was called into consultation and conceived that the disease was phrenitis. Leechess were therefore applied to the head, and sinapisms to the legs. The cephalalgia diminished-the extremities became warm-sweat broke out-and, in the course of the next morning (4th December) there was a great remission, almost amounting to an intermission. At three o'clock, p. m. there was a return of cold in the extremities, and pain and heat in the head, &c. The pa tient demanded leeches to the temples and sinapisms to the extremities. But the symptoms continued till nine o'clock in the evening, when a remission again took place, preceded by a copious sweat, and deposition in the urine. The physicians now began to suspect that they had to deal with an intermittent fever under a somewhat masked form. They therefore administered the cinchona in injection. Next day, (6th December) there was another accession, after which, the sulphate of quinine was exhibited, and the disease was stopped.-Journal Hebdomadaire.

When such cases as the above are narrated in print, it appears astonishing to the reader that medical men should be so blind as to overlook the intermittent character of these complaints. But daily observation presents us with examples where these characters are far less masked than in the above case, and yet where the practitioner goes on leeching, bleeding, and purging, whenever symptoms of excitement appear. The misery occasioned by such oversights is much greater than people imagine. None but those who have suffered an attack of the "FOUL FIEND," can appreciate the wretched sensations by which it is accompanied-especially when aggravated by unnecessary depletion, employed under the mistaken idea that the disease is of an inflammatory nature. We would therefore caution practitioners against blind routinism, and beg them to remember that now, as in the days of Sydenham, diseases differ in different seasons, and consequently require a modification of treatment according to the nature of each "CONSTITUTION OF THE ATMOSPHERE.

XXXIII.

STRICTURES OF THE URETHRA.*

We have been often much surprised, that, in a disease of such frequent occurrence, and in one so dreadful in its effects as stricture, no improvements of any moment should have suggested themselves in its treatment besides that of the application of caustic.

At a time when the knife of the surgeon operates with confidence in situations and on organs for years deemed inaccessible, we were prepared to expect that a mechanical obstruction in a canal so easily examined as the urethra, should partake of the benefits of the advanced state of surgical science. We therefore took up Mr. Stafford's book with pleasing anticipations, and it is but justice to him to say, that we have not been disappointed.

The author first enters upon the consideration of strictures in general, and the only point we think it necessary to notice in this part of his work is the very proper importance he ascribes to the inflammatory foundation and tendency of almost every form of stricture.

Mr. S. then proceeds to the treatment of permanent stricture, and it is to his description of an instrument invented by him for dividing it that we would call the attention of our readers.

"The instrument for operating on permeable strictures (which for the sake of distinction I have called the double lancetted stilette) consists of a round silver graduated sheath, open at both ends, of the size of No. 10 catheter, with rather a less curve, and of a stilette which is also hollow, and open at both ends. This stilette is furnished, at one end of it, with two oblong lancets, and at the other, with a handle, resembling a button. When

the instrument is complete, the stilette fits into the sheath, so that by pushing the handle the lancets will project from the extremity of the tube, and by drawing it back they will retire into it again. When used, (the mode of doing which will be presently explained,) the instrument is passed over a wire down to the stricture, and the lancets are thrust forward on each side of it, by which the contraction is made as large as the natural size of the urethra. The armed stilette intended to divide impermeable strictures, exactly resembles the one just described, excepting that instead of the stilette being hollow it is solid, and in the place of two there is only one lancet.

Before using the instruments, the exact distance of the stricture from the extremity of the urethra should be ascertained. In the armed catheter, which is intended to divide strictures over the wire, which serves as a guide, the wire must be introduced through the stricture first. The mode of accomplishing this is by passing the smallest possible sized catheter made to contain the wire into the bladder. The wire which is double the length of the catheter, and blunted at one end, so that it may not injure the bladder, is then pushed forward, and the catheter gradually withdrawn, by which the former is left in the canal of the urethra. The armed catheter is then passed over the wire, until its point rests against the stricture, (which is known by means of the graduation,) and being held securely in such position, the handle of the stilette is pressed gently and gradually.

As soon as any impression is made, the lancets should be allowed to retire into their sheaths, and the blunt point of the instrument urged forward. If it do not pass on the lancets may be again used as before. After the stricture is divided, the armed catheter should be withdrawn, and its place supplied by one of elastic gum of the same size.

* A series of observations on strictures of the urethra, with an account of a new method of treatment, successfully adopted in cases of the most obstinate and aggravated form of that disease. Illustrated by Cases and a Plate. 2d. Edition, by R. A. STAFFORD, M.R.C.S. &c. &c.

* This handle has hitherto been formed like a button; but I have thought it would be of advantage to have it made like two rings large enough to admit the finger and thumb, similar to the handle of a pair of

scissors.

This should remain for a day or two, to prevent the re-union of the divided parts, and to preclude the possibility of extravasation of urine; and on its removal, a bougie should be passed twice in the week, or as often as may be judged necessary, for some time; and the same treatment adopted as for stricture in general. The armed stilette intended to divide impermeable strictures, must be used precisely in the same manner as the other, of course excepting the wire which cannot be introduced; and the same direction for the after treatment are necessary for both,"

had been repeated proofs, it would hardly be credited. The inflammation which has occurred has never been very great; and when it has taken place, I am much inclined to attribute it to the irritation excited by the catheter having been left in the bladder. I am the more confirmed in this opinion from the fact, that in the only case in which I omitted its introduction no sensible inflammation followed.

The objections to the use of these instruments, and more particularly of the single lancetted stilette, besides its novelty and boldness, is the apparent risk and uncertainty of its results. This, however, Mr. Stafford, in the preface to his second edition, answers most conclusively, and we cannot do better than quote his own words.

"With regard to the safety of the operation, a subject on which I am aware there exists much prejudice and doubt, even among some of the most eminent and liberal surgeons, I can only say, that I have operated more than twenty times, without the slightest dangerous symptom occurring at the time or afterwards;-that I have divided strictures in the urethra in almost every part of its course, at distances of one, three, four, five, and six inches from the orifice, at the point immediately behind the bulb, and throughout the whole membranous portion;-that some of these strictures have been half an inch, others an inch, and, in one case, two inches in length; that I operated at one time on four strictures in the same urethra, varying from one-fourth of an inch to above an inch in extent; and that in no instance was there a symptom to occasion the slightest alarm. The small

quantities of blood lost from the operation was surprising, only in one case amounting to a table-spoonful, and usually not exceeding a few drops, or a tea-spoonful. This fact is so extraordinary, that unless there VOL. XI, No. 21.

The

"The superiority of the division by the lancetted stilettes over the only plan of treatment which can be brought in competition with it--that by the caustic--is evident from the following circumstances. The pain is much less. This was admitted by every patient who had experienced both plans of treatment. In truth, it is so little, as, by their own confession, to be not worth mentioning. As a proof of this, all my patients stood during the operation, which did not usually occupy a longer time than a period varying from one to two minutes. bleeding is not so great as what often attends the passage of a common bougie, consequently very much less than that after the application of caustic, in which the loss of half a pint or a pint of blood is no uncommon occurrence. The formation of a false passage, which in the most experienced hands will inevitably sometimes occur, from the use of caustic bougies, has never resulted in any case where I have employed the instruments. The last, and perhaps principal proof of superiority, however, of this plan of treatment is, the shortness of time occupied, and the rapidity of the cure. length of time necessary for the common method, of course varies indefinitely:-three months may be stated a short period, and it often extends to one or two years, with a great chance of the recurrence of the disease in a more aggravated form. On the contrary, the longest time which it has been found necessary to pass a bougie after dividing the stricture with the lancetted stilette, has never exceeded six weeks; and in those cases it was passed merely to satisfy myself and the patient of the non-existence of the disease. Usually a large sized bougie has been introduced immediately after the operation; and the cases have not required attendance more than three weeks or a month."

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