brain and the spinal canal, M. Magendie avers that, in all morbific affections of the brain, as acute and chronic hydrocephalus, in which there is an undue dilatation of one or more ventricles, these "entrées," or communications, become very much enlarged. The experiment of pressure on a spina bifida affecting the head proves the communication in the living body, The following experiment was made by M. Magendie :-he injected four ounces of ink, very gently, into the lower portion of the vertebral canal. This was sufficient to blacken, not only the whole surface of the brain, but the internal surfaces of all the ventricles. Whenever pressure was made on the spinal envelopes, a fresh quantity was pushed into the third ventricle.

In more than fifty bodies of people who had died without any cerebral affection, M. Magendie found from half an ounce to two ounces of fluid in the ventricles of the brain. Care should be taken, however, that the body be not placed in a position to favour the draining of the ventricular fluid into the spinal canal. This eminent physiologist is of opinion that, if the cephalo-rachidien liquor amount to more than two ounces, certain morbid phenomena will be the result, especially serous apoplexy. M. Magendie terminates his memoir with these words :-" is it not remarkable that those parts of the brain, called by the old anatomists, valvule, aqueduct, bridge, should have precisely the uses which their names import? It is thus that the valve of Vieussens, or valvula magna cerebelli, performs the office of a valve (soupage) and opposes the exit of fluid from the fourth ventricle. Never did a part better merit its name than the aqueduct of Sylvíus, since, according to the experiments which I have made, this canal transports the fluid, sometimes from the ventricles to the spine-sometimes from the spine to the head. Finally, that part which has been termed a pons, is, in fact, an arcade of medullary matter, placed over the current of fluid which traverses the aqueduct."-Revue Medicale, Janvier.

14. ACUTE RHEUMATISM,

For several years past, we have occasionally taken opportunities, as they presented themselves, to protest against the indiscriminate practice of bloodletting in acute rheumatism. Venesection is usually carried to a very great extent in this disease; and the state of the blood, the hardness of the pulse, the local inflammation, and other phenomena, appear to justify the depletory measures, in their fullest extent. Yet the course of the disease is seldom shortened by free depletion, even in strong constitutions; while, in weak habits, or where there is a tendency to any disease of an internal organ, we not unfrequently find some metastatic action set up, not, indeed, at the very time of the rheumátic attack, but at a longer or shorter period afterwards, which is of much more serious consequence than the original malady. For many years past we have been in the habit of making minute enquiries into the previous histories of those who have laboured under organic disease of the heart, especially dilatation of that organ, with or without thickening of the parietes. In by far the greater number of cases, rheumatism, of the acute or subacute kind, had preceded the cardiac affection; and the majority of these asserted that they had been freely bled for the rheumatic complaint. It is true that this species of evidence, as to cause and effect, is far from being demonstrative; but, unfortunately, it is such as we are too often obliged to put up with in medical enquiries.

In the Medical and Physical Journal, for February, Dr. A. T. Thomson has detailed four cases of rheumatisın, and made some observations on the disease, which we shall briefly notice. Dr. Ta conceives that modern expe

rience has "thrown doubts upon the inflammatory nature of rheumatism, and altered the treatment of the disease." He instances the striking resemblance between acute rheumatism and ague, as noticed by Hulse, Morton, and others. “The pain,” says he, “when the disease is left to run its course undisturbed, recurs periodically every night or every morning, once, at least, in 24 hours." The term "recur," however, is only applicable to certain forms of rheumátism; for, in the common acute rheumatism, of every day occurrence, we have remissions and exasperations of the pain, but rarely, if ever, intermissions. Where we have regular periodical recurrence of the pain, it is then intermittent rheumatic irritation, rather than inflammation. In common acute rheumatism, where we have all the attributes of inflammation, dolor, rubor, calor, tumor, we do not see how the "inflammatory nature" of the disease can be doubted. But it does not follow that every inflammation is to be cured by bleeding. Nobody doubts that, when the foot, in gout, is hot, painful, red, and swelled, there is inflammation; but experience has proved that this phlogosis cannot be removed, at least with safety, like that which follows a local injury in a healthy constitution, by bleeding, &c, The specific nature of an inflammation must always modify the treatment. This is the case with acute rheumatism. It is a specific inflammation; often taking on the form of periodical or intermittent irritation.

Dr. Thomson believes that the dread of metastasis, in this disease, has led to the discontinuance of bark; "but experience has demonstrated that this dread is unfounded, and where the employment of this remedy has been prefaced by the exhibition of calomel, tartar-emetic, and opium, with cathartics, he has had no reason whatever, in a practice of twenty-five years, to alter his opinion of its efficacy and safety."

Case 1. A young lady, after exposure to a current of moist air, felt a sudden pain at the inner angle of the left orbit, which was slightly swelled. It extended thence along the brow, and disappeared in the evening. Next day it returned, and disappeared as before; and this went on for eight days, when Dr. T. was called in. The accessions were characterized by febrile and inflammatory symptoms; but the remission every evening was complete, and the lady slept well. Dr. T. prescribed calomel and hyosciamus at night, with saline aperients in the morning, in which was a drachm of the vinum colchici. The next paroxysm was later, but equally severe. Dr. T. prescribed one grain of calomel, a grain and a half of opium, and a quarter of a grain of tartar emetic, every six hours, dolore urgente; and a mixture of oil of turpentine with the cinchona, every four hours, absente dolore. The paroxysms not only returned later, but became much milder, and soon ceased altogether.

It is curious, and, perhaps, fortunate, that the same disease will often be cured by a great variety of remedies. The above is a very common case in practice. In many instances, we stopped the disease by bark and arsenic, exhibited during a single interval. Such decidedly intermittent irritations or inflammations, as the above case, scarcely require any preparation for that specific, which almost inevitably stops their progress.

Case 2. This patient was also a young lady, who, after a slight shiver in the evening, was seized with such violent pain over the whole head, that Dr. T. was roused out of bed at midnight to attend her. There was no heat of skin -feet cold as marble-feels as if her head were screwed in a vice, and it is sore to the touch-pulse is small and low, &c. Magnesia, colchicum, æther, and camphor julep—pediluvia-castor oil in the morning. There was a remission only of the pain next day. The bark was given till the evening

exacerbation came on. It was violent as before. Next morning, a more marked remission. The bark continued, and an emetic to be taken on the accession of the evening paroxysm. Third day. There was but very little pain after the operation of the emetic. It returned, however, at midnight. The bark continued-a dose of blue-pill, antimony, and opium, at bed-time. The paroxysms now became later and milder, and soon disappeared.

We cannot think that Dr. Thomson means to designate the above as a case of "acute rheumatism," though it is so headed. There was no pyrexia throughout the complaint. The general state of the pulse was "small and sixty"—the skin cool, or even cold. This is not acute rheumatism, but a periodical rheumatic irritation.

The third case related by Dr. Thomson is of a similar nature to the two preceding. The fourth case is the only one which has any pretension to the designation of "acute rheumatism." The patient was a servant, who had been exposed to wet and cold, and was then seized with severe pain in the wrists and ancles. In two days it shifted to the loins, and was accompanied by some heat of skin and fever, with the usual perspirations. He had a daily rigor, succeded by febrile re-action. Calomel, followed by saline aperients, with colchicum, were given—calomel and opium at night-and oil of turpentine, with bark, through the day. By these remedies he was soon cured.

These cases are selected by Dr. Thomson from among many others, chiefly on account of the combinations in which the cinchona was administered. "The oil of turpentine, in particular, has always appeared to increase the efficacy of the bark." In some constitutions it affected the kidneys, but not often. We have no doubt that Dr. Thomson's plan is a very good one—and, as we said before, several other plans may be equally successful. In the common acute rheumatism we seldom bleed, unless the fever runs very high, and the patient is plethoric. Even then we bleed sparingly. Some calomel and anodyne at night, with saline aperients and colchicum through the day, generally bring the disease to a remittent or even intermittent form, when we give bark and arsenic to finish the cure,

15. PHLEBITIS-CONSECUTIVE CEDEMA, PHLEGMASIA DOLENS. We are of opinion that the paper of Dr. Davis on PHLEGMASIA DOLENS, published in the 12th volume of the Medico-Chirurgical Transactions, has given, and continues to give, an erroneous view of the pathology of the above-mentioned disease, both in this country and on the continent. The experience of medical practitioners has determined phlegmasia dolens to be a disease so rarely fatal, that it was very difficult to find on record a dissection of a case; but now, by identifying the said disease with inflammation of the pelvic or crural veins, we have satis superque of pathological investigations. It was only this night (27th Feb. 1827) that a paper was read, and a preparation sent round, in the Medico-Chirurgical Society, shewing a case of phlegmasia dolens in the male, with the crural vein inflamed and plugged up-adding one more proof that the cause of the disease is phlebitis. The more experienced and observant members of the society, however, refused to admit that the case was one of phlegmasia dolens at all-but one of phlebitis, a very different disease, whether we contemplate the symptoms or the termination. There is no doubt, indeed, from the cases published in this and other countries, that inflammation and obstruction of the iliac veins may take place, and produce the swelling of the limb, and the death of the patient. But if this were the pathology of phlegmasia dolens, we should have as few instances of recovery as we have

now of death, in that disease. Besides, in all the cases which have been brought forward for the support of this doctrine, the swelling was quite of a different nature from that of phlegmasia dolens. It was adematous, while the swelling in the genuine disease is elastic. Lastly, we may add that, in the case published by Dr. Denmark, of phlegmasia dolens, in a male, and which proved fatal at Haslar Hospital, the vein was not inflamed or plugged up. In the discussion which took place at the Medico-Chirurgical Society, a case of genuine phlegmasia dolens, in the puerperal state, was brought forward by Dr. Granville, in which the new pathology failed, as there was no phlebitis. Several members, and among others, Dr. Tweedie, physician to the fever-hospital, shewed that the disease which is now confounded with genuine phlegmatia dolens, is often seen to take place after puerperal peritonitis, and even common fever; but is quite different in character from the genuine disease.

In respect to the case which was read by Dr. Forbes, the swelling of the leg and thigh took place in the last stage of consumption, and the limb was œdematous in every part. The iliac and inguinal veins were inflamed, and obstructed by a concrete and fibrinous plug. The young man died of the pulmonary disease.

We shall now proceed to some cases brought forward by M. Bally, of Paris, for the support of the new doctrine, of which he is a stanch advocate.

Case 1. This was the case of Caroline Dunn, detailed by Dr. Davis, and of which we took ample notice in the first volume of this series, page 378-90.

In

Case 2. This case is recorded by M. Melier. The patient was a female 30 years of age, who, having come to the full term of her second pregnancy, was taken in labour. The child lay crosswise, and the accoucheur proceeded to turn; but while in this operation, the patient screamed violently, and he was forced to desist. A second and a third attempt was also unsuccessful. The woman, however, becoming more weak, and more placable, the child was ultimately turned, and the delivery effected. For the first 36 hours after her accouchment, nothing particular occurred; but at this period, she complained of acute pain in the right iliac region, accompanied by general malaise, and rigors. On the third day, she had fever-the abdomen was tender and tense, especially on the right side. The milk subsided this day from the breasts, and the symptoms indicated approaching peritonitis. Venesection-leeches to the abdomen-fomentations. spite of these means, the peritonitis made rapid progress. At this time (28th July, 1826,) Dr. Melier was called in, and learnt the preceding history. The pain was now very acute in the belly, particularly in the right side, where the slightest pressure, the succussion of a cough, or any movement of the body, occasioned insupportable torture. Obscure fluctuation was detected in the right ileo-lumbar region. The fever was considerable— the lochia suppressed-pulse small and frequent. The patient was bled copiously by the application of 40 leeches. Warm bath-fomentationslavements. 29th, The symptoms were still more severe to-day, and 30 more leeches were applied. Dry cupping was frequently practised on the breasts this day, by which means considerable swelling and some lacteal secretion were induced. There appeared to be some mitigation of the abdominal inflammation. 30th, Rather better. 31st, An exasperation of the symptoms-more leeches-blisters, &c. 1st August, sensibly better to-day. The pain in the right side of the abdomen is not so severe; but a fluctuation

there is still perceptible. From this time there was a gradual amendment, the pain diminishing, and the tumefaction of the abdomen subsiding. Hopes were entertained of her recovery, and Dr. Melier discontinued his visits. The accoucheur continued in attendance; although the fever did not entirely cease, it was very much reduced. There came on, in a few days, a slight discharge from the vagina, of a sanguinolent character, and very fetid; but it was considered to be the remains of the lochia. In a few days more, the discharge suddenly became abundant, and of a purulent appearance. This continued day and night, and was at any time, increased by pressure on the abdomen. The matter was, at first, inodorous, but became afterwards greenish and fetid-the fever assumed the hectic form-debility made great progress. The pain in the ileo-lumbar region was now renewed, and presently the lower extremity became infiltrated, first about the foot, then the leg, and ultimately the thigh. On the 16th August, Dr. Melier again came in attendance, and found the patient in a desperate condition, the right leg and thigh swelled and painful. She died on the 17th of the same month.

Dissection. The peritoneum presented universal traces of inflammation, more intense in the right than in the left side. In the right iliac fossa there was a vast abscess, with numerous surrounding adhesions of the intestines. This abscess communicated with the vagina. The uterus was healthy. The external iliac vein, and three or four inches of the crural vein were completely obliterated by a clot of blood and fibrin, resembling a polypous concretion. The parietes of these veins were thickened, and the internal membrane red. There was some pus in the veins. All the other vessels of that side were unaffected.

Here then is one of the cases which are now assimilated with phlegmasia dolens, and from which the pathology of the disease is attempted to be established. We should consider it an insult to the practical reader, if we were to stop a moment to shew how dissimilar are the two diseases. Who is it that will not, at once, perceive that the iliac vein, in the above case, partook of the destructive inflammation going on within the abdomen of that side, and thereby became obstructed. That the swelling of the limb was, in a great measure, occasioned by this obstruction to the return of blood, we allow; but all swellings are not of the same nature, nor do they all arise from the same cause; and again we aver that this disease was not phlegmasia dolens.

Case 3. Observed by M. Guiette, surgeon to St. Peter's Hospital, Brussels. The patient was an unmarried female servant, aged 22 years, and who had never been pregnant. She was admitted into the hospital, in the year 1824; for the treatment of a considerable swelling of the lower left extremity-" resembling the oedema which is often seen in puerperal women. "* În all other respects, the patient's health was good—all the functions natural and regular. The most accurate examination could not discover any cause for this swelling. No treatment was adopted. In the course of a few days, however, the swelling of the limb became much increased, the pain more intense, and the tension excessive. To these were added constitutional symptoms of irritation, and disorder of the digestive organs. Her nights were now passed in dreadful sufferings. The surgeon in chief

This is the general expression; but whenever the swelling comes to be particularized by the abettors of the new doctrine, no resemblance whatever is found between the two diseases.-Ed.