"pneumonia "is selected as affording the best examples for illustration. Aside from the force of professional custom, as determining a precedent, there are, in my opinion, other and more important reasons why the study of this disease essentially bears upon questions connected with climatic influences upon acute disorders.

The

Three propositions may be stated which cover the whole ground. first of these holds that in warm climates certain morbific agents, by their greater abundance or activity, increase the liability to pneumonia. While it is generally admitted that exposure to low thermometric readings is the most prolific cause of pneumonia in cold latitudes, it must be remembered that falls of temperature, relatively as sudden and considerable, likewise occur in this latitude. Pneumonia is, consequently, with us, a disease mostly prevalent during the cooler half of the year. Prof. Chaille's compilation of mortality statistics of New Orleans, shows that in the five years ending with 1870, there occurred 1028 deaths from pneumonia during the half years ending with April, against 617 during the half years ending with October.

But in addition to variations of temperature, there is diffused over every square mile bordering the lower third of the Mississippi, an agent more mischievous against human health and life than all others combined. This is malarial poison. Does it increase liability to attacks of pneumonia? I add my opinion most emphatically to that of the learned Greisinger, that it does. This opinion rests both upon observation and analogy. The proofs furnished by observation I will not undertake to

lay before your readers, as they are too voluminous for mere desultory letters. The proofs afforded by analogy, may be found in that close resemblance in blood changes, between the malarial cachexia and the cachexia of Bright's disease. All of us admit that Bright's disease increases the frequency of attacks of pneumonia in common with inflammations of other surfaces.

The second of these propositions holds that the morbific agents, alluded to in the first proposition, exert a very unfavorable effect upon the mortality of pneumonia occurring during their presence in the system. Whatever discussions may be considered proper before accepting or rejecting the first proposition, the truth of the second cannot be questioned. The degree to which one of these agents is capable of influencing the death. rate of pneumonia, will be shown as we progress.

The third proposition is, that longcontinued exposure to the heat of warm climates, by diminishing constitutional vigor, renders pneumonia a more fatal disease in warm climates than in those which are colder and more bracing. All physicians know that the functional lesions of pneumonia entail upon the human economy, an amount and variety of derangement of chemistry which scarcely any other disease can inflict. It thus becomes a most extraordinary test of the constitutional vigor of its subjects.

However our short-comings may be attempted to be explained, it is certainly true that we invariably fail in obtaining such gratifying results in the treatment of pneumonia, as those which Bennett boasts of in Edin

burgh, or of the surgeon in the British army while stationed at Montreal.

Prof. Chaille shows that the proportion of deaths to cases treated in Charity Hospital, during ten years, was two in five. These figures relate to the whole hospital, and cannot, therefore, be chargeable to any individual imperfections of treatment. Again, taking my own hospital service for seven half years, beginning October 1st and ending April 1st, and the proportion of deaths reduced to Prof. Chaille's rule of estimate, was a little under one and three-fifths for each five cases. We had, however, no selection of cases, and those brought in when moribund are included in the count.

The most common and serious complication was malaria. This is recognized to be so universally present, that I never begin the treatment of a case of pneumonia without administering free and repeated doses of quinine, immediately succeeding the action of a mercurial or saline purge, if such medication was demanded. I gave from a scruple to half a drachm in doses of five to ten grains every third hour. If pain was a prominent symptom, or even if it were not present, and there was no contra-indication, I combined five grains of Dover's powder, or its equivalent in some other form, with each dose of the quinine. The contra-indication to opium in pneumonia in this climate, is the bronchorrhoea and pulmonary edema often present. Blisters I very seldom resorted to. More often I used, for urgent pain, a hot turpentine stupe. In every case I kept the chest continually enveloped with a sheet of oiled muslin, under which was neatly applied a

band of flannel preferably wrung from warm water before its application. For excessive fever I used digitalis, veratrum viride, or aconite. Patients were encouraged to drink largely of lemonade, generally made of a diluted infusion of flax-seed instead of water. If I desired a gentle effect upon the bowels, a teaspoonful of bitartrate of potash was used to each tumbler of the lemonade. The patient's nutrition was made a point of special attention, and all adynamic symptoms were met by concentrated diet and alcoholic stimulants. Carbonate of ammonia was much prescribed. I was never able to satisfy myself that either the carbonate or the acetated solution possess the virtues ascribed by Dr. Chambers. two cases death was hastened, if not principally produced, by heart-clot, which was diagnosed, in one instance, twenty hours before death. Large doses of carbonate of ammonia were

In

given, for at that date Richardson's doctrines were neither recanted nor disputed. No apparent benefit resulted.

I have never been able, practically, to verify the statements made by some writers in regard to the occurrence of intermittent acute inflammations. While, without violence to known pathological laws, we admit that the revulsion of a malarial paroxysm is quite sure to aggravate any co-existing inflammation, no case has occurred to me in which I was able to perceive that the progress of the inflammation was limited to the malarial paroxysm.

I have always observed the strictest watchfulness in order to prevent the recurrence of malarial paroxysms during the progress of pneumonia, or

during convalescence from it. Any increase of the discrepancy between morning and evening temperature would furnish an indication for quinine. Even if this did not exhibit such indications of waxing malarial influence, I generally considered it a good rule to give from ten to fifteen grains of quinine every third day.

In looking over my private practice for three years, I find that I have treated ten cases of pneumonia, one of which resulted fatally. Three of

this number were of the negro race, and the fatal case belonged to this group. The negro's constitution succumbs to attacks of acute disease more readily than the white man's, and this is especially true in regard to pneumonia. But as this letter has already reached greater length than designed, I will leave the discussion of this point to a future number. Respectfully,

MEDICUS MERIDIONALIS, Prytania St., New Orleans, July 20th, 1874.

S

O many forms of uterine speculum

are now to be found in the stores, one may well hesitate to add to the number-already legion. But this variety demonstrates both the progress of gynecology and the probable fact that a perfect speculum has not yet been made.

The one I now offer the profession is very well represented by the accompanying wood-cut.

As will be seen, it is more like Nott's latest than any other instrument. It differs from Nott's in having the lower blade longer and of better shape to receive the neck of the uterus, and in having handles for

elevating and holding the upper blades.

The measurements of the instrument are as follows: Lower blade, 4 inches; extending beyond upper blades 5-8 of an inch; length of instrument, including handles, 7 inches. The upper blades are made shorter than the lower to correspond with the anatomy of the parts, as the posterior vaginal wall is longer than the anterior.

Some object to Nott's, and doubtless will to this instrument, that it is too short. But no physician has any difficulty in reaching the os uteri, except in rare cases, with the index finger, the available length of which rarely exceeds three and one-half inches, and the lower blade of my instrument is four and one-half inches in length and the upper blades nearly four inches. If the os is not exposed when the instrument is ex

panded, the difficulty is not in the length of the instrument but in its position, or because it is not sufficiently expanded to raise the anterior wall of the vagina.

The

To introduce the instrument: patient reclines on the back upon the gynæcological chair, with the hip near the edge of the chair. Having ascertained the position of the os uteri, grasp the speculum with the right hand with the fore-finger resting upon and projecting beyond the lower blade, and hold the handles vertical. Then carefully introduce. the fore-finger into the external organs and follow it with the instrument. When the instrument has passed beyond the external organs, it should be rotated so the handles shall lay horizontally; then, pushing the lower blade along the posterior wall of the vagina, it will pass under the posterior labium of the os. Then, compressing and bearing downwards and backwards upon the handles, the anterior vaginal wall will be raised and the os exposed, when the handles can be fastened by the thumb-screw. The instrument is self-retaining when sufficiently expanded.

If the os is not at first exposed, the instrument, partially expanded, may be withdrawn a little so as to allow the lower blade to pass under the os; or the os may be raised by the forefinger inserted through the expanded instrument, by raising the anterior wall of the vagina, there being ample room for the fore-finger to pass between the expanded upper blades. Or the os may be raised into the field of the instrument by a Simpson's sound, or like instrument, used as a lever. When the os is exposed, the uterus may be held in the field by a

tenaculum, which can be fastened to a hook on the right upper blade.

My tenaculum is the same as Nott's, except that it has a handle like an applicator. When the tenaculum is fastened into the anterior labium of the os from below upward, it rarely is felt at all by the patient, and the little hæmorrhage which may occur will be of no disadvantage. The advantages claimed for this speculum

are:

1. Its length is such as to expose the uterus in situ by bringing it nearer the external organs, rather than pressing it deeper into the pelvis as do the longer instruments.

2. Thus giving a better light, which is often of great importance, especially when the physician is obliged to visit the patient at her home.

3. The instrument is so short, and the upper blades expand in such a manner as to readily allow of the rectifying of any malpositions of the uterus through the expanded instrument, which is impossible in all the long instruments.

4. A large portion of the vaginal walls are exposed for examination and treatment, if needed, and by rotating the instrument the whole may be exposed.

5. While the blades are short, they are capable of expanding the vaginal walls more than any of the short instruments, and, indeed, more than most of the long ones.

6. The urethra and meatus are not pressed by the instrument, but lie between the upper blades, where they may be readily examined and treated if necessary.

I am under obligations to Mr. E. H. Sargent for the mechanical beauty and perfection of the instrument, and

S

CENE I, 1:45 P. M.-Large,

shabby amphitheatre; seats broad, wooden stairs, uncomfortable enough to have been chosen for Patience's smiling place; students scrambling for the best places; air full of tobacco smoke and expletives.

Scene II., 2 P. M.-Sudden silence and respectful rising on the part of the students. Looking down in the cock-pit, we see in the midst of his attendant "practical physicians," a gray-haired, well-preserved, soldierly old man. It is Herr Prof. von Langenbeck, elegant in dress and address, and of manners most courtlyexcept when sorely tried; e. g., he bows to the students and selects from the list one who is expected to make a diagnosis and prescribe the treatment necessary for a little baby that has just been laid upon the operating table. Herr B. has, unluckily, not made a specialty of spina bifida. utterly fails in diagnosis, and, when, hard pressed for treatment, he suggests that a section be taken out of the spinal column, the baron's righteous indignation knows no bounds. Baby has a carbolized dressing applied,

He

and poor B. flies incontinently to the upper back seats.

Case No. II is brought in upon a stretcher, and proves to be a young woman with a hideous protrusion of the left cheek. Examination reveals a tumor-probably malignant-in the antrum; hence excision of the upper jaw is determined upon. A la Nussbaum, Langenbeck then proceeds to perform tracheotomy, making fast to the tracheal tube about three feet of rubber tubing. This communicates with a chloroform inhaler, which is placed outside the crowd about the table, thus giving the one administering the anesthesia plenty of elbowroom. The patient's mouth is now plugged; Langenbeck makes a curved incision downward from the inner angle of the eye to the tip of the ear, and removes the superior maxilla at his leisure. The hæmorrhage, of course, is great, until checked by means of hot irons, under which the tissues siss and hiss like St. Lawrence on his gridiron, but the operation was wunderschon. What is left of the patient's face is sewed together, a flap is brought down from her forehead to