most frightful hemorrhages he ever witnessed. By the introduction of the hand, and the application of cold, it was speedily arrested. More than a year afterwards, the same lady came to town to be confined, and Dr. G. did not see her till she was in labour. On entering the chamber, he was struck with the same state of the circulation that had preceded her former accouchement—" she was sitting in her easy chair, with a red face and a throbbing pulse." In a few minutes the pains increased and it was necessary to put her to bed. The child was soon expelled, but gradually. The uterus contracted in the usual degree, yet, in a few minutes afterwards, the blood burst out with prodigious impetuosity, and gave rise to a fearful scene. The introduction of the hand and the application of cold speedily arrested the hæmorrhage. For many days afterwards, she could not sit up without faintness. Our author wisely considered, that if she again became pregnant, it would be prudent to take such measures, before her accouchement, as might cause her to fall in labour with a cool skin and a quiet pulse. In twelve months afterwards, she informed our author, that she was five months gone with child. He advised her to avoid fermented liquors to take meat only thrice a week-a purgative of salts and senna twice a week-a scruple of nitre thrice a day. This plan was to be begun two months before confinement. Our author saw her four days before her accouchement, and was gratified to find her with a cool skin and quiet pulse. Yet the former inflammatory state recurred, the same as before, for forty-eight hours before labour. The child was gradually expelled-the uterus contracted— but the hæmorrhage came on in a few minutes. It was, however, trifling, compared with the former attacks, and was easily suppressed by wetted napkins to the belly. In process of time, she again became pregnant, and to the precautionary means above described, she was twice moderately blooded, a little before confinement. Her labour, this time, was unaccompanied by flushing or quickened circulation, and no uterine hæmorrhage ensued. Our experienced and intelligent author has met with other instances, similar in kind, though less striking in detail. He has seen a strong cordial, given unnecessarily towards the conclusion of a labour, excite inordinate action in the heart and arteries, the consequence of which was a flooding after the separation of the placenta, though the uterus was contracted in the ordinary degree. On the other hand, he has ventured to separate the placenta, while the uterus remained largely dilated; but the circulation being languid, no more blood was lost than after an ordinary labour. "How often a disturbance of circulation plays an important part in uterine hæmorrhage it is difficult for an individual to know; but I suspect sufficiently often to deserve the especial attention of practitioners. I advise them when they meet with patients subject to hæmorrhage after delivery, to notice the state of the circulation before labour, and, if disturbed, to employ means for tranquillizing it before labour comes on. I advise them during labour, to use cor dials cautiously, lest the placenta should separate during an excited state of circulation. I advise them after delivery, though the uterus may feel contracted, to be slow to leave their patient, if the circulation be greatly disturbed." 161. Dr. Gooch alludes to the important subject of a contracted uterus becoming relaxed, and thus giving rise to hæmorrhage. The states of contraction and relaxation may, and. do alternate, with corresponding cessations and recurrences of hæmorrhage. Thus, the first time he attended the lady, whose case has just been related, the bleeding returned again and again, although the abdomen had been covered with pounded ice-the uterus, at one time firm and distinct, becoming at another, so soft as no longer to be felt. "Finding the ice so inefficient I swept it off, and taking an ewer of cold water, I let its contents fall from a height of several feet upon the belly; the effect was instantaneous; the uterus, which the moment before had been so soft and indistinct as not to be felt within the abdomen, became small and hard, the bleeding stopped and the faintness ceased; a striking proof of the important principle, that cold applied with a shock, is a more powerful means of producing contraction of the uterus, than a greater degree of cold without the shock." 163. After the second labour, and at the beginning of the hæmorrhage, Dr. G. found the placenta separated and lying in the vagina. He removed it-the hæmorrhage abated, but returned in a few minutes. He took several handkerchiefs soaked in vinegar, and passed them, one after the other, into the vagina, so as completely to plug it. This prevented all external hæmorrage, and some uterine pains came on. But presently the pains ceased, the uterus softened and enlarged, and she turned ghastly pale. It was now evident, that an external, had been merely converted into an internal, hæmorrhage. He withdrew the handkerchiefs, and applied his hands in the manner described in the following extract, with perfect success. My belief now is, that when hæmorrhage occurs after the removal of the placenta, the quickest way to stop it, is to introduce the left hand closed within the uterus, apply the right hand open to the outside of the abdomen, and then between the two to compress the part where the placenta was attached, and from which chiefly the blood is flowing. When the hand is introduced merely as a stimulant, there is an interval of time between its arrival within the uterus and the secure contraction of this organ, during which much blood is often lost. By directing the hand to the very vessels from which it issues, and compressing them as I have described, this quantity is saved. If I may judge by my feeling, the blood stops, in a great degree, even before the uterus contracts; the hand acts first as a tourniquet, then as a stimulant. It is true we cannot tell with certainty where the placenta was attached, and consequently where the pressure should be applied; but as it is generally attached to or near the fundus, if the pressure be directed there, it will generally be right. Vol. III. No. 11. 4 Q Besides, after the child is born, it is often several minutes before the placenta separates and descends; if, during this interval, we pass up the finger along the chord and observe at its entrance into the uterus, whether it turn towards the front, the back, the right or left side, or straight up to the fundus, we shall form a tolerably exact idea of the spot to which the placenta has been attached in this individual case." 165. Dr. Good does not consider it necessary during syncope, in such cases, to delay introducing the hand until the patient revives. On the contrary, he introduces the hand, and endeavours to stop the blood, and induce contraction, before giving cordials or stimulants internally. We have now given our readers a full and complete account of this valuable and truly practical paper. It is a great pity that Dr. Gooch does not write more-for very few can write better. 11. Irilis. Dr. Smith, of the Army Ophthalmic Depôt at Chatham, has made a valuable report of cases to our respected cotemporary of the North. Twelve instances of iritis are narrated, accompanied by the usual symptoms of increased vascularity of the iris and external tunics of the eye-ball, pain, intolerance of light, lachrymation, immobility, contraction, or irregularity of the pupil, dimness of vision, and sense of over-distention of the eye-ball. The cause was, in almost all the cases, attributed to the action of cold. Some of the men had had syphilis, and some not. The same might be said of mercury. These results, as far as they go, in Dr. Smith's opinion, “have little tendency to support the supposed noxious effects of syphilis or mercury on the eyes." ." Dr. Smith, from much experience, is inclined to view the syphilitic and mercurial actions as predisposing, not exciting causes of iritic inflammation, partly by their deranging the healthy functions of the system, and partly from their requiring confinement, whereby the body is rendered more susceptible to the action of cold, which appears to be the general exciting cause of idiopathic iritis. The treatment was regulated by the severity of the symptoms. When the pain was violent, or moderate but of long standing, venesection to syncope was ordered-but when the pain was pretty moderate, and the other symptoms did not run high, local bloodletting was considered sufficient. After the bleeding, a purgative, generally containing some tartrite of antimony, was exhibited. No benefit was derived from full vomiting. "As soon as the bowels were freely evacuated, the next object was to affect the mouth with mercury. This was done by giving calomel in conjunction with opium, during both the day and night, * Dr. Smith. Ed. Journal, No. 73. in doses of two grains of the former, and a quarter of a grain of the latter, every hour, or perhaps every two hours, till the gums felt tender, or an increased flow of saliva was manifested. About this period of the cure the patients generally stated that they experienced a very considerable abatement of the pain, and sense of fulness with which they had been hitherto annoyed. The vision immediately became more clear, and the irregularity of the pupil and effused lymph began to subside, and the iris to assume its natural colour. A continuation of the mercury for ten days or a fortnight, so as gently to keep the mouth affected, removed the disease in all except one.' Our author observes that iritis may be cured in the ordinary way, by antiphlogistics, but neither so safely nor so speedily as on the mercurial plan above described. Added to which, the chance of losing or impairing the visual orb is much more by the one treatment than by the other. We have often been surprized that the treatment of iritis alone, which no one will deny to be an acute inflammation, did not alter the language of physicians and physiologists respecting the stimulant powers of mercury. It is considered a stimulus, a general or universal stimulus, and little else. Now wine or brandy is also a general stimulus; but would either of them cure iritis? The term (as a single one) most applicable to mercury is that of a universal secernant; and we have long thought that the increase of absorption consequent on the operation of mercury, results from the previous evacuation or depletion, which is well known, as in the instance of blood-letting, to set the absorbents actively at work in all parts of the system. 12. Pectoral Disease-Hypochondrias-Suicide. M. P. a celebrated gun-smith of Paris, 42 years of age, had enjoyed good health till the age of 23, when he experienced a pulmonic attack which left a chronic cough and expectoration of long standing. At this time he was attended by a friendly physician, who used to enter into long dissertations on the complaint and economy of the chest, &c. which greatly raised the patient's opinion of the doctor's skill. The latter promised a complete cure in six years; but at the end of three years put an end to his own existence without fulfilling his promise to the patient. The treatment during this first epoch consisted in general and local bleeding, and a caustic issue in the right leg to carry off the superabundance of humours which flowed to the lungs, and was discharged by coughing. In great despair at the death of his favourite physician, he determined to manage his health himself, but formed a project of acquiring a large fortune, in * Retrecissement du coté droit de la Poitrine-Hypochondrie et Suicide. M. Beulac, M. D. Journal Complémentaire, No. 50. the mean while, by perfecting all branches of his business. Before his wishes were quite accomplished he became so seriously ill, by intense application and great irregularity, that his wife insisted on his having medical assistance. At this epoch he exhibited symp, toms of hydrothorax, as irregular chills, difficulty of breathing, sense of weight in the right side of the chest, and bulging out of the ribs of that side, to which was added, slow hectic fever. The celebrated Bayle now attended him. One night he suddenly discharged a large quantity of sero-purulent, matter by coughing, after which the enlargement of the side became reduced, and, finally, that side of the thorax contracted. Cough and purulent expectoration continued. Being now in a state of demi-convalescence, M. P. went into the country, by the advice of his physicians, where he began to meditate profoundly on the "miseries of human life," and, for the first time, evinced an aversion to some of his nearest relations, especially his wife. The chimerical fear which he entertained of assassination induced him to always keep loaded pistols about his bed-and from this time may be dated his intellectual aberration.* In this state he continued, sometimes better and sometimes worse, for some years, viz. up to 1819. The treatment, during this epoch, consisted in expectorant ptisans, "cinchona to check the hectic fever" --and a cautery to the right thigh. In 1819 there were some consultations between Drs. Martin, Cayol, Recamier, Louis-Villermay, M. Roux, and M. Laennec.+ The right side of the thorax was found to be flattened and contracted-the shoulder depressedthe muscles wasted-the vertebral column slightly bent. When the stethoscope was applied, the breathing could be very faintly heard on this side, but very distinctly on the other. Pectoriloquism was evident between the clavicle and the edge of the trapezius muscle on this side, and intonation of the voice in the armpit. Two cauteries were applied to the vertebral column, and the sores kept open. During this period the patient manifestly began to suspect the fidelity of his wife-to look upon his affairs as in a very deranged condition; and, in short, to exhibit the most unequivocal phenomena of mental alienation. In this condition he chose a lodging in the Rue d'Enfer an ominous name for his abode and determined not to go out of doors on any occasion. In a consultation of the forementioned physicians, it was determined to suppress the cauteries, and in their stead to keep open a blister. This measure, our author thinks, was the cause of the fatal catastrophe which followed-in which opinion we decidedly disagree with him. The patient had long entertained a notion that a person, in whom We do not quite agree with M. Beullac on this point. We think his mind was wavering before this period, and from the moment that he placed pistols in his bed-chamber to guard against assassination, his insanity was no longer a matter of doubt. + This appears to be the case alluded to in the second volume of Laennec's work, page 371. Rev. |