acid, or the hydrate of the per-sulphate of iron. But these means are prophylactic, not curative. c. The curative indication directs itself to the elimination of the absorbed lead, and acts by inducing or favouring secretion. The cutaneous system may be thus usefully employed, but experience proves that the most prompt results are produced by the use of evacuants, and especially as employed at La Charité. D. A fourth indication should consist in counteracting the poisonous agency of lead by a medication possessing an opposite mode of action. According to the Italian doctrine, opium would be precisely this agent; but its employment as the basis of treatment in some patients has far from confirmed the good opinion entertained of it. E. The last indication relates to certain morbid conditions which the saturnine affection leaves behind, of which the most constant is a condition of anæmia requiring ferruginous medicines and a supporting regimen. Any plan of medication which does not comprehend the whole of these indications is imperfect. The two first are purely prophylactic, and expectation with them chiefly accomplishes the cure. The third without the others, and especially without the first, exposes to relapse. The fourth, used alone, has the same inconvenience, and the cures so obtained are only the effects of a spontaneous depuration. Finally, without the fifth the cure would not infrequently leave behind it a more or less serious morbid condition, and a debility which would singularly expose the workman to relapse upon the resumption of his labours.-Gazette Medicale, Nos. 38 and 44.

OBSERVATIONS ON SOME CASES OF SUDDEN OR VERY SPEEDY Deaths, PROBABLY DEPENDENT ON DISEASES OF THE HEART AND Large BLOOD-VESSELS. By H. C. LOMBARD, M.D. Geneva.

It is not a very long time since all cases of sudden death were regarded as apoplexies, and consequently referred to affection of the brain. At the present time, in consequence of more accurate researches, it is generally agreed, that the greater portion of them depend upon diseases of the heart or large blood-vessels. In fact, if we except some cases of hæmorrhage into the Pons Varolii or Medulla Oblongata, it is very rare for sudden death to occur from cerebral apoplexy, the patient almost always surviving the rupture of the cerebral substance, and the compression of the brain by the effused fluid, several hours. We must then receive with distrust several of the cases related under the title of "thundering apoplexy," when the death has been very sudden, and the lesion not verified by an autopsy.

It is quite otherwise with regard to death produced by a morbid condition of the heart and the large vessels. An old practitioner, Dr. Butini of Geneva, once said to me, in reference to a sudden death which took place in a case of heart disease "You must not be surprised at this sudden termination. More than a third part of such patients die in this manner, some in turning round in bed, and others, and this is the most frequent case, while getting up to go to stool; so that you must consider sudden death as an ordinary consequence of disease of the heart and hydrothorax." I have had frequent occasion to verify the exactitude of these words, which were addressed to me at the commencement of my medical career: and now, after seventeen years' practice, I wish to add the result of my experience to that of the distinguished physician I have named. In fact, both in my private and hospital practice, I have had frequent occasion to meet with sudden terminations of heart disease. I have seen patients die suddenly at every stage of these affections, sometimes when the organic changes were so little advanced as not to prevent them following their ordinary occupations; at others, when the extent of the changes, and the complication of dropsy had long

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confined them to bed, or at all events to the house; and, if it were desired to establish the proportion between the frequency of sudden deaths among those who seemed only to be slightly attacked and those who were so seriously, it would be in favour of the former I should declare-in other words—the less advanced the organic disease the more frequent are the sudden deaths.

Theory easily explains the sudden death of persons suffering from heart-disease. In fact, when the central organ of the circulation is in its normal condition, the temporary cessation of its functions is rarely of serious consequence; while, when its cavities or orifices are in a diseased condition, such suspension, for however short a period, may be attended with the worst consequences. A comparison will cause this to be better understood. Two waggons heavily laden seem to roll along with like facility as long as their movement meets with no obstacle. But suppose the horses stop a while, you perceive a great difference. The axle of one of the waggons presents an irregular surface from lack of oil. That of the other turns easily without noise or friction. The efforts of the horses are now tasked to put the wheels in motion, and while the waggon having the easy axle is drawn with the greatest facility, the other obstinately resists the most vigorous efforts of the horses. The two surfaces, which should slide easily over each other, are motionless, and the horses uselessly exhaust themselves. However trivial this comparison may seem, it may give some idea of what takes place in a diseased heart, which has yet up to a certain time performed its functions without much difficulty. A syncope then however happens to occur, and all the efforts of the cardiac nerves upon the muscular substance, either enfeebled or impeded by obstacles at the orifices, are powerless, and the syncope, which in a healthy heart would have promptly disappeared, becomes the cause of death in a diseased one.

On examining the facts we find these cases may be divided into two quite distinct classes; that in which there is simple syncope and instant death, and that in which there is a considerable impediment in the circulation, and not leading to instant death, but producing such a disorder in the vital functions as leads to their cessation in the course of a few minutes. To fatal syncope are to be referred those cases of sudden death occurring when persons affected with disease of the heart are in the act of turning round in bed, or rising to go to stool. Besides death by syncope, however, diseases of the heart and large blood-vessels also frequently induce another description of death which I shall term death from suffocating spasm, in order to indicate its predominant charactertstic This, as that from syncope, may occur in persons apparently in the midst of excellent health, but who are really subjects of organic lesions.

Three cases are detailed in exemplification of the characters of this species of death. It is not so sudden as that from syncope, the patient dying in ten or twelve minutes. The attack occurs in the midst of apparent health. The respiration excessively laborious and noisy, the patient the while tossing his arms in convulsive struggle, and expressing by his countenance or some word, for consciousness continues, the extreme of anguish and terror. A white foam flows from the mouth for some hours after death. "What is the mechanism of death in these cases? Is it a paralysis of the cardiac or inspiratory nerves? Is it a spasm of the cardiac or thoracic muscles? Paralysis, it seems to us, if complete should induce instant death by a fatal syncope; while, if it came on gradually, it would cause a lingering asphyxia which would only induce death at the end of some hours, or at all events in a much longer period than a few minutes; and the pallor of the countenance of these patients contradicts the supposition of the existence of any such asphyxia. I am disposed to place more weight on the explanation by the existence of a spasmodic condition of the muscles of the heart and of inspiration, inasmuch as the symptoms are such as those resulting from the condition known as spasm: and the sudden nature of the death indicates the muscles implicated. These cases bear some resemblance to Angina Pectoris, but yet need not be conNo. 107 18

founded with it. Indeed, although death is usually sudden in angina, yet, out of the great number of cases I have perused, and especially those collected by Jurine and Forbes, I have not been able to find one in which it occurred during the first and only attack; while in no one of the three cases I have related had the patient previously suffered from angina. Angina usually occurs either while the patient is walking or asleep; but in two of these cases the patients were quietly seated in their rooms, and no one of them was asleep. Again, in angina there is not that abundant issue of foam from the mouth and nostrils seen in these cases. Lastly, two of the three patients were women; and yet of the 88 cases of angina analysed by Forbes in the Cyclopædia of Practical Medicine, 80 occurred in men and only 8 in women.

"What should be done if called to a case of suffocating spasm soon enough? In the absence of all exact notion of the cause of the affection, we must content ourselves with treating symptoms. I should cause the patient to be seated with his head supported, all ligatures formed by articles of dress being removed. I should apply sinapisms to the thighs, or better still, a cloth dipped in boiling water to the chest. I should administer some alcoholic or anti-spasmodic fluid, and if the patient could not swallow, a napkin might be dipped in æther, Eau de Cologne, or some such fluid, and held near his face. As long as the pulse continued low or the respiration embarrassed I should sprinkle the face with cold water. As a general rule I should, on account of the pallor of the countenance, abstain from bleeding."-Gazette Medicale, No. 47.

PUERPERAL CONVULSIONS- -MALPRAXIS.

A woman 25 years of age, of strong constitution and sanguine temperament, was brought while in labour to the Hôtel Dieu, Paris, at nine o'clock in the evening. She was in a state of complete insensibility, agitated by convulsive movements, and gave vent to inordinate cries. At eleven o'clock the interne on duty was called, and found the head presenting, the uterus however having ceased to contract. He determined on turning; but instead of a leg, brought down an arm. After three hours ineffectual efforts to rectify this error he left the women to herself, the convulsions continuing as bad as ever, although bleeding had been twice practised. The child was dead. Seven o'clock next morning the woman being in a state of profound coma, the chief-de-clinique next tried turning, without success. A surgeon of the hospital was summoned, but declined attending, the case falling within the province of the accoucheur of the hospital. Before the latter could be summoned another three hours had elapsed. Turning was then effected; but before delivery was completed the woman had ceased to exist!

A case of puerperal convulsions also recently presented itself in M. Dubois' wards, in which the woman, after suffering an immense number of paroxysms, was delivered by means of the forceps of a living child. Within about thirty hours after delivery she had two other paroxysms; but then seemed in a fair way of doing well, when, after fifteen days of quietude, the convulsions again returned and carried her off, at the end of about the thirtieth paroxysm, the next day.—Gazette des Hôpitaux, No. 134.

[With respect to the first of these cases, we have only to observe that the delays and erroneous treatment of the patient reflect the greatest discredit upou the officers of the hospital in which it occurred; and that it is well for them they have no Coroner for Middlesex to visit their neglect with the castigation it deserves. second case is interesting on account of the remote period at which death took place.-(Rev.)

The

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ON THE ELEVATION OF PARTS IN THE TREATMENT OF SOME SURGICAL DISEASES. By M. MARC Dupuy.

The object of this paper is to state the great success which has attended the practice long followed by M. Gerdy in the treatment of various inflammatory affections of a surgical character. The influence of position both in the normal and anormal conditions of parts must be familiar to all, and M. Gerdy has but carried out farther than others and more methodically the application of a wellknown principle, that the circulation in a part is much aided or impeded according to whether it be performed in accordance with or against the laws of gravity. In inflammation of the fore-arm M. Gerdy orders the slings to be worn excessively short, so that the hand of the bad limb may lie upon the opposite shoulder, the elbow being supported in one of the folds of the sling. If the hand is affected the elbow must be laid upon a pad so as to avoid pressure, and the forearm sustained in a vertical position by means of cushions. The elevation is accomplished in another manner in M. Gerdy's wards with great success, when the patient possesses sufficient docility, viz. by fastening the uninflamed fingers to the rope by which the patient assists himself in turning in bed. The sound fingers must be previously carefully bandaged, however, so as to avoid all injurious pressure. If the patient feels fatigued, the rope, which as it were suspends the limb in the air, may be from time to time loosened, taking care however not to allow it to fall into a dependent posture. The means is of an easy application, also, in respect to the lower extremity. M. Gerdy raises the end of the bed by placing a chair under it, thus raising the foot upon the summit of an inclined plane. Once so placed, and care taken that no injurious pressure is exerted, the patient must not move from the position even to satisfy natural wants: for he may destroy in a few minutes all the benefits which have been obtained by whole days of repose. Although elevation cannot be so efficaciously applied to the head and trunk as to the extremities, it yet may be employed to a certain extent. Supposing the eye is inflamed, the patient will lie with his head high, and on the opposite side to the one affected. Why are inflammatory affections and discharges from the womb so tedious in recovery, but for the stagnation of the blood in the organ? Let a woman, who has been accustomed to keep herself in the vertical posture, go to bed and raise her hips by means of pillows, and she will soon find her case amended. The same principles apply to inflammatory affections of the face, breasts, &c.

The efficacy of elevation is not confined to inflammatory affections, but extends to hæmorrhages, ulcers, &c. By attention to it, uterine hæmorrhages may be materially mitigated. So too in M. Gerdy's wards in this way have varicose ulcers of the legs been frequently radically cured without any other treatment whatever. In partial dropsy of the cellular tissue the means is efficacious, and thus adema of the limbs disappears which persisted if mere horizontal, or an insufficiently raised position only was resorted to. Even when dependent on disease of the heart, oedema of the feet may be thus dissipated in a few hours. Hydrocele and articular dropsy have frequently been reproduced by the patient being allowed to go about with the parts in a dependent position. The benefit of position in varix and varicocele is indubitable, and M. Gerdy feels certain that these troublesome affections might be cured as well as relieved, could it be long enough maintained. Hamorrhoids, which are indeed little else but varices of the veins of the rectum, may be advantageously treated by raising the pelvis while the patient is in bed, the hori zontal position not sufficing for disgorging the vessels and relieving the distressing pains. Such persons should not sit on cushions with apertures in them, which do not support the margin of the anus. It follows from what is here said, that in some diseases the elevated posture alone suffices for their cure, and that in many others it is a powerful auxiliary. The paper is illustrated by several cases.Archives Generales, T. xii. p. 295–313.

OBSERVATIONS ON THE USE AND ABUSE OF MERCURIAL PREPARATIONS, ESPECIALLY IN INFLAMMATORY AFFECTIONS. By Dr. SICHEL.

Administered gradually and for a sufficiently long period, mercury induces the phenomena of scorbutus, that is of an affection of a diametrically opposite character to inflammation, being attended with a diminution of the plasticity of the blood. So important a medicine, given in non-purgative doses, is it, that we should as soon think of practising without the aid of the lancet as without it. It is an error to regard it as stimulant on account of the slight temporary irritation it causes. Nevertheless, in treating phlegmasiæ, we should avoid those of its preparations which most partake of this character.

The antiplastic agency of mercury is also exerted upon other diseases, which, without being strictly inflammatory ones, depend upon a too great plasticity of the fluids and a too energetic reproduction. This is the case with syphilis, upon which, in our opinion, mercury exerts no specific effects, but acts only by impoverishing the blood. As, however, this disease is chronic, and often inveterate, and insinuates itself into the different systems in a manner in which inflammation does not, we should employ the most active preparations of the metal which are not so well adapted for the treatment of mere inflammation. Independently, too, of their antiplastic action, they exert a beneficial effect by stimulating the absorbent system. In chronic diseases, active mercurials should be administered for a long period in small doses, while for acute diseases medicines are required of which the dose may be sufficiently increased to ensure the prompt production of the required effects. These more active preparations (such as the deutochloride, the iodides, the red oxide, &c.) are also indicated in other non-syphilitic chronic diseases, dependent upon a slow phlegmasia or an excess of reproduction. Nothing can be more useful than their employment in certain tumours of the soft or hard parts, and some impetiginous or scrofulous affections which seem to verge on cancer. In this last case mercury, combined with iodine, is, of all means, the most efficacious, when the disease has not yet passed the stage in which we sometimes see it arrested and even disappear during the atrophy of the organ affected. In the eye at least, we have several times seen, under the influence of these two medicines, encephaloid terminate in atrophy of the globe, without relapse or loss of general health.

If in treating inflammation and chronic disease we give mercury in doses which excite the gastro-intestinal membrane we lose some of its most important effects, owing to its not remaining long enough within the economy to exert any direct action upon the blood.

A substance so energetic must necessarily be a dangerous one when administered by an inexpert hand. We may advert to the principal cautions which should be observed. 1. The diet must be in no-wise stimulant and as little nourishing as possible. If this is not attended to, the plasticity of the blood becomes augmented. 2. All notable change of atmospherical temperature should be avoided. Unless this rule is observed, numerous disappointments will occur, and premature salivation is especially likely to be induced. 3. It is a general law that the special physiological action, or the toxical effect, of a medicinal substance only manifests itself after its action upon the pathological condition has become exhausted. The operation of this law is well seen in the employment of narcotics in those affections of the venous system which afford distinct indications for their use, as neuralgiæ and tetanus. This last, we know, demands large doses of opium, but the point of saturation must be carefully watched; so that the drug may be laid aside when the precursors of narcotism begin to replace the tetanic symptoms, unless we wish to see, as I have often seen in the hospitals, the patients cured of the tetanus to die of the poisoning by opium. The physiological action of mercury is exerted upou the salivary glands, and with the earliest