Dr. SWIFT read a long and very complete paper upon the morbid anatomy, causes, symptoms and treatment of Otitis and Otorrhoea.

REGULAR MEETING, October, 1846.

Dr. TRASK read a paper upon the pathology of Phlegmasia Dolens, accompanied by a large number of cases analyzed and presented in a tabular form. The tables Dr. T. considers as establishing the identity of this affection with phlebitis. (This paper has since appeared in the American Journal of Medical Sciences, January, 1847.)

Case of Anasarca.- Autopsy.

Dr. J. G. LADD reported the following case with post mortem : Nicholas May, aged fourteen years. General health during life had been good, with the exception, that at times he was subject to accumulations of serum in different parts of his body, never before amounting to anasarca. A few days before his decease, a slight tumidity and oedema behind the sterno-cleidomastoid was observed, with a puffiness of the face, but little notice was taken of this apparently unimportant symptom. On the evening of his death, after having retired to rest, his mother observed that "something ailed him," and made him get up and come down stairs, which he readily did without assistance. Shortly after, upon lying down on the bed prepared for him, dyspnoea came on, and in a few minutes he was dead.

Autopsy, twelve hours after death. Subject found lying on his back-much extravasation of blood into the most depending parts of the body. Great tumidity and oedema of the face, neck and whole surface of body. Brain; upon removing the scalp a considerable flow of blood and serum followed the incision. Strong adhesions of dura mater to the calvarium. Great thickening and opacity of the membrana Arachnoidea, and a serous deposite under it at the base of the brain, with great vascularity of the substance of the organ. Thorax. Large quantity of serous effusion into the thoracic cavity. Pleure and mediastinum full of liquid. Lungs. Right lung, one-fourth natural size, completely solidified from compression--no remains of vesicular structure. Left lung. Small portion of upper lobe retaining vesicular structure, but congested. Lower lobe completely solidified. Heart, small and flabby. Pericardium distended with serum. Liver, very much enlarged, extending downward as far as the umbilicus, over the left side to the spinal column. Substance of right lobe hard and extending up into the thoracic cavity, making compression upon the solidified lung. Gall bladder very much enlarged and distended. Intestines, contracted and hard. Serum between the serous and muscular coats of colon. Other organs natural. Bladder slightly distended.

ART. III.-Remarks on the Use of Galvanism in the Treatment of certain Nervous Diseases, By H. P. DEWEES, M. D., of New-York. (Concluded from page 307, Vol. VIII.)

MUCH discrimination is required as regards the proper period at which - a galvanic current should be used in paralysis, and in being able to appoint this, the causes and the stage of the disorder should be duly weighed. Unfortunately if the disease is announced by an apoplectic

seizure, the friends of the patient become anxious and alarmed, the medical attendant being thwarted or biassed in his judgment through these fears. This is strongly verified in those cases happening to strong plethoric men, free from cardiac difficulty, but where the nervous power has been unduly taxed. Here, in place of a mildly-stimulant expectant treatment (the loss of blood from the temples or arm being regulated by circumstances to be mentioned shortly) the patient is generally copiously bled and purged. Because he is plethoric and fat, he is bled profusely, or "until he comes to," thereby taking away the nutrition of the great nervous centres already below par. The man, to be sure, may recover his senses, but he comes to with what may be called a life of proportion, one or both sides being paralyzed; or, he may not be even so lucky, and death is speedily ushered in by a second or several quickly-recurring attacks. As in autopsy, the ventricles are frequently found filled with serum, the medical man says, "it is no wonder he died, he could not resist such pressure on the brain." But does he ask what was, in this case, the cause of this effusion, and whether it did not result from the loss of nervous power, whereby the tonicity of the vessels was impaired, the transudation taking place of necessity?

Now, in these cases, take them all together, it would be safer not to draw a drop of blood, than to take such a vast quantity. If, on auscul tation, the lungs are found laboring heavily, and the effects of so much imperfectly-arterialized blood are showing themselves by the retention of the highly-carbonized fluid within the brain, the circulation being labored and slow, then it may be necessary to relieve the vessels of a few ounces of blood, in order to start, as it were, the stagnating cur. rent, on the principle of opening a drain in the meadow to relieve the whole. At the same time, a moderate stimulant will be called for to renew the exhausted nervous power to support the circulation. Cold moderately applied by the iced water bladder, with dashing or sprinkling of cold water over the face and neck should not be neglected. When the patient returns to consciousness, he will in all probability be free from paralysis, or but slightly affected. The only excuse for large detractions of blood can be found in the knowledge that the exhaustion of nervous power has been great, and its capacity to be speedily renewed is destroyed; then the vessels have to be emptied, to proportion the circulating fluids to the diminished nervous supply.

In cases of sudden rupture of the vessels, when there has been no previous effort or exhaustion, the sanguineous effusion being more or less extensive, the seizure may undoubtedly be attributed to the severance of nervous connection and to pressure, the paralysis ensuing as a natural sequence. The causes may be various-viz., softening, ulcerative action, atheromatous alterations, mechanical interference from bony spiculæ or ossific plates, &c.

The early treatment becomes a matter of nice diagnostic discrimination; but one thing is certain, there is nothing to be gained by the immoderately "prompt treatment." The clot is forming, or has already formed, when the practitioner is called in, and no violent measures can force it away. The indication becomes to sustain life by relieving the other parts of the machinery, so that their performances shall be as duly maintained as possible. Hence the benefit so frequently obtained from those remedies regulating the pulmonary and hepatic circulation,

but which are often misconstrued as having a specific action on the brain, when in truth, the effect so produced was secondary. The lungs and liver being enabled to sustain their functions, the brain will not be so greatly oppressed with black blood, whilst its nutrition will be properly carried on.

In the early invasion of the attack, the great nervous centres receiv. ing such a shock, the functional activity of almost every vital organ is interfered with the lungs labor with impeded respiration, the heart contracts sluggishly upon the imperfectly aerated blood, whilst the liver tardily eliminates the bile. Here the highly-venous state of the blood and the elements of the biliary secretion circulating through the brain, serve to depress the nervous forces essential to reparation. Therefore in the treatment of all recent apoplexies and paralyses, much caution is required in proportioning the loss of blood, if necessary, to the state of the nervous power and its capability of being aroused.

There are some cases in which the nervous depreciation is so great, and where at the time no speedy renewal can be given, in which the copious detraction of blood is absolutely called for, thereby proportion. ing the amount of the circulating fluid to the nervous supply for its sustension. But these cases are comparatively rare, and happen, for the most part, in the completely broken down, or where the exhaustion from some known cause cannot be overcome, save by perfect and longcontinued rest. These cases may be likened to two horses, each drawing a load of wood; both fall, but the one is fresh and strong, and a few sticks taken off, and the whip applied, puts him on his feet again—whilst the other is fatigued by over-exertion, and the whole load has to be taken off, and the animal be allowed to regain his strength by rest and nourishment, the whip not being able to rouse him, or if applied, causes him to waste all his power in one ineffectual effort.

Those cases resulting after a too hearty meal, and especially where wine and great hilarity of conversation have been indulged in, are not always to be set down as caused by sudden rupture. The brain in these instances becomes much oppressed by unassimilable blood, and as the nervous power has already been over-taxed in the performance of digestion, and by mental excitement, besides the local pressure of an over-distended stomach upon the neighboring ganglia, affording a direct impediment to the functional performances, the vessels become loaded, and pressure results-effusion may or may not occur. If vomiting comes on, the offending meal is cast off, and the patient generally recovers without much disturbance in his power of locomotion. But if the effort of nature be inadequate to the task, and medical aid is not speedily rendered, the brain and medulla oblongata become more and more oppressed, sensation and impressibilty rapidly decline, and effusion, or rupture with laceration of cerebral fibre may now ensue, ushering in the second attack, as it is termed, and generally with fatal issue. If not fatal the clot forms the chief obstacle to return of comparative health, its absorption and isolation regulating the progress.

There is another form of apoplexy in which paralysis invades slowly but surely, and is apparently hopeless of remedy if the attack prove not fatal. It is announced by giddiness, with a sensation as of the aura epileptica, and an after consciousness of having, for a second or more, lost memory, the return to self being heralded by a deep sigh or half sob, sometimes accompanied by nausea, and always by pallor at the

onset, frequently followed by purple flushing of the face. These cases happen for the most part amongst persons of debilitated habit, and where there have been great emotional causation for a length of time, excesses in venery and the like. In such subjects, the entire organism is depraved, the blood is defibrinated and deprived of its red globules, whilst the nervous power is wasted by perpetual demand. The want of tonicity is witnessed in every tissue, and effusions varying in extent feak, as it were, into the ventricles, the symptoms announcing the quantity, though not always their situation. This form of disease is insidious, as frequently the attacks are slight, and at first scarcely perceptible to the subject himself; the poverty of the circulating fluid increases, the temper becomes more peevish, and the memory gradually fails, or suddenly a complete loss of connection in the idea or sentence takes place. In some paralytic contraction of the flexors of the fingers, arm or leg ensues, accompanied with pain, and many times attributed to a neuralgic or rheumatic affection, but in reality frequently marking softening or other organic changes of the brain. After a time the disorder becomes more grave, and the patient suddenly falls, or is found in his bed insensible, the face drawn to one side, or the muscles collapsed from double paralysis, the loss of power over the limbs being more or less complete. From this there is hardly a chance of partial restoration, although treatment may delay the final issue.

No matter from what cause it may be dated, the effect is the sameviz., the serous or sanguineous transudation to greater or less amount, or rupture of some small vessel or vessels, attended in many instances, with softening of recent or later date. The exhibition of remedies must be made with the view of retarding it. Bleeding from the arm is certain and sudden death-but if the vessels of the face are full and distended, though at the onset it was exceedingly pale, a little blood can be taken by cups or leeches with temporary relief. But the heart's condition requires attention, and its power must be rallied by local stimulants, as Granville's lot. fort. or strong aq. ammonia over the cardiac region and down the upper spine; for the state of spasm often exists in it as described above. The feet and legs must be stimulated by hot water and cayenne, either by bath at the side of the bed or by moist frictions; but care must be had in not suddenly lifting the patient upright, a fresh and fatal attack of convulsion being known to follow the imprudence. Internal stimulus, as brandy, &c., must be carefully administered, paying regard to the period at which reacti n shall be established, lest the excitation exceed the capability of the vessels to bear, and the nerves to sustain. If the respiration be imperfect, cold water should be sprinkled on the face and neck in the order of the natural time required for the act; as a safe rule, 18 to 24 times a minute. Small doses of Dover's powder and quinine can be given to support the strength, the congestive influence of the opium being carefully avoided. When the first effects of the attack have passed, nourishment and not medication must form the essence of the treatment. In these cases, happening as they generally do in strumous or "whitetissued" individuals, calomel is rarely well borne; it is only necessary to remember this, to proportion its use, for it should be remembered, that though it may cure the disease, it does so often by killing the patient. Hydriodate of potash serves a better purpose, if the absorption of the fluid is the intention; and as there always exists more or

less irritability, it should be conjoined with a tonic; the infusion of the wild cherry bark is the best, in my opinion. Minute doses of veratrine, as gr. or conjoined with aloes, rhei and taraxacum, form an excellent stimulant laxative. If necessary, pulv. sanguinariæ, gr. ss to gr. 1, may be given in conjunction. Tonics and tonic stimulant bathing are also beneficial. The surface can now be sponged with a light current of electricity.

The error among many, in considering apoplexy as entirely a disease of the vascular system, has served to perpetuate the most irrational treatments. As relief in some instances has been afforded by prompt bleeding in the commencement of the attack, where the pulmonary and cerebral congestion was great, it has warranted in but too many, those profuse detractions, that ultimately reproduced the very state they dreaded. If the diseases and functions of the nervous system were better understood and attended to, and a strict study of the period of the disease entered into, these murderous repetitions would not be so frequent, or if absolutely required, would be in smaller quantities than is practised by what is called "the bold practitioner."

No one of a sudden makes such a quantity of blood that its circulation endangers life, but his nervous system may become so disordered, either primarily or secondarily, that an almost mechanical impediment starts up to the performance of the circulation; and then the blood being delayed on its ascent or descent to the heart, may become a source of reactive danger, only to be subdued by lessening its quantity in order to proportion it to the nervous capability; whilst, at the same time, a stimulant-as brandy, ammonia, &c., will be required, to restore tonicity to the congested and over-distended vessels.

This arrest of the circulation in itself, would not be so dangerous to the individual parts, were it not that the brain becoming oppressed by highly-carbonized blood, and the respiration thereby being more and more impeded, organic changes rapidly develop themselves with the increasing functional embarrassment. And thus it is, that action and reaction move, as it were, in a morbid circle.

According to the original seat of disease and its implicating extent, do the phenomena of sensibility and impressibility take place. A want of distinction between these terms is a most common error, although from the labors of Hall and others, the contrary might be expected. A man may be perfectly conscious of the prick of a pin, yet be unable to evidence it by movement, voluntary and excito-motion being alike lost; whilst, on the other hand, he may be perfectly insensible to the pain, involuntary motion resulting, the spinal marrow retaining its impressibility through the incident excitor nerves, or, by direct nervous extension from below the point touched. Were this better understood, much needless cruelty might be spared the patient, and less empirical treatment would be resorted to. There is a very common, and at times, an unintentionally-cruel mode of testing a patient's consciousness-viz., by placing candles near his eyes, his not shutting the lids or following the light, being construed into an evidence of total unconsciousness. Now the being able to see and to shut one's lids, are very different. If the disease involves the base of the brain or medulla oblongata, the reflex action of closing the eye, does not reply to the optic nerves acting as excitors through the stimulus of light, voluntary power being at the same time lost. Yet how many, when recovered, will tell you that