it horizontally. This single circumstance, had I had no assurances from the patient's own mouth, would have satisfied me as to the change produced by the operation. I visited him three or four times only, when he walked as well as ever he did in his life. There was no medicine exhibited on this occasion.

On the 22d July, this gentleman awoke in the morning with violent pain in the balls of both great toes, particularly at the flexures of the joints. Could not ascribe it to any cause, except that he had taken a walk the preceding evening rather longer than usual, but from which he experienced no fatigue or inconvenience at the time; and he went to bed, as usual, in perfect good health.

When I visited him at eleven o'clock forenoon, the parts were swelled, red, tense, and shining. The inflammation and pain were confined almost exclusively to the balls of the great toes, except that in the left, which was by much the worst, the pain reached upwards about half way along the metatarsal bone. The patient experienced continual excruciating pain, even when at perfect rest; his countenance indicated considerable distress, and he complained of sickness, general uneasiness, and oppression; pulse eighty-two.

When I entered my patient's room, he told me, that if I intended to apply friction to the parts affected, he was afraid he could not suffer it; for he had attempted that himself, but might as well have applied living fire.' I told him I knew friction was quite inapplicable to his case as it then stood, but that I would, notwithstanding, employ mechanical means for moderating the paroxysm; and I hoped with complete success. I therefore grasped the ball of the toe in my hand, applying pressure gradually, to a very considerable degree. Slight pressure gave pain; heavy pressure none. In this manner I compressed the parts, sometimes with one hand; at other times betwixt both hands, for about ten minutes,-now and then interposing gentle percussion; and then applied a thin flannel bandage. Ordered a brisk purgative of senna and sulphate of magnesia.

I visited my patient again, about eight in the evening, when he informed me he had had considerably less pain, or rather none at all, from the moment I left him; but a good deal of cold shivering through the day; pulse 100; medicine operated well; swelling and redness of the parts considerably abated, and motion of the affected joints practicable. Applied compression and percussion, which the patient bore much better than in the morning.

July 23.-Slept the whole night without interruption; pulse

eighty; pain, swelling, and redness of the parts almost entirely gone; can suffer them to be handled with the utmost freedom, and walks very well. Applied compression and percussion this morning, in the evening, and again next morning, when my patient went abroad in the prosecution of his business.

That this affection was as well marked a paroxysm of gout as can well be imagined, will, I believe, be denied by none: And I may venture to assert, that the eau medicinale itself cannot boast of giving more speedy and complete relief than did percussion and compression in the present instance.

To those who have implicitly adopted the pathology, that, in a certain plethoric and vigorous state of the system, and at a certain age, the extremities are liable to loss of tone;-that this atony is communicated, in some measure, to the whole system, but especially to the stomach ;--that, to restore the tone of the parts, inflammation is excited in the extremities by the efforts of nature; and that, by a certain degree and duration of this inflammatory affection, is the tone of the extremities and of the whole system restored;-to those, I say, who have regulated their practice entirely by this pathology, the mode of cure adopted in the preceding cases must appear dangerous and absurd.

In justification of the practice, however, it will to many be sufficient to say, that no such consequences followed the immediate check given to the inflammatory affection of the great toes, as is generally apprehended from any thing like repulsion of inflammation from the extremities, in gout. So far was this from being the case, that the dyspeptic symptoms in the one, and the sickness and general oppression in the other case, were removed in proportion as the pain and swelling of the extremities gave way. It may be said, that this might be owing to the purgatives employed; and I am very ready to allow them their proper share in the cures under consideration. I am even ready to admit, that purgatives are necessary or useful in every case of gout; but this, on principles very different from what are maintained by some pathologists of the present day. I do not believe, that the good effects of purgatives and emetics in rheumatism and gout, are to be attributed solely, or even chiefly, to their removing morbid secretions from the stomach and bowels; but to the excitation they occasion in the whole system, and particularly in the absorbents. Any person that has witnessed the effects of a drastic purgative in anasarca, will be at no loss to explain the modus operandi of such medicines, in any disease whose proximate cause is atony, either general or topical. Many of the more acrid cathartics are heating, and powerfully stimulant; and to its stimulant powers

alone, I am convinced, does the eau medicinale owe its success in the cure of gout. Many are in the habit of tin; this medicine in small quantity as a preventive, and with success, when apprehensive of a paroxysm. Now, in such ca-cs is success cannot be attributed to its evacuant powers; for it is not taken in quantity sufficient to produce any sensible evacuation. It therefore follows, that it produces its beneficial effects by increasing the action of the whole system-thereby preventing the atony and consequent inflammation of any particular part.

Dr Sydenham thinks, that in proportion as the inflammation and pain are violent, the paroxysms are shorter, and the interval betwixt them longer. Dr Cullen also, though much inclined to attempt alleviation of symptoms when pain is pressingly acute, ultimately decides, that the common practice of committing the person to patience and flannel alone, is established upon the best foundation."

If, however, some of the leading circumstances connected with a regular paroxysm of gout are duly considered; the danger of retrocession, from attempts to moderate or remove inflammation and pain from the extremities by topical applications, will not appear a priori even to be so great as the two high authorities just quoted would have us to believe.

In Mr O's case, then, it appears to me, that the inflammation and pain in the extremities were the cause, not the consequence of the disturbance in the system; for when I first saw him, which was within five hours after the sensible commencement of the paroxysm, the inflammation of the great toes was high, and the pain excruciating, whereas the pulse beat eightytwo only in a minute. There was, therefore, no proportion betwixt the cause and effect, on the supposition of the affection in the extremities being symptomatic only. Again, arterial action increased to a hundred strokes of the pulse in a minute during the day, notwithstanding the inflammation and pain in the toes were greatly moderated. Now, the affection of the joints ought to have kept pace with the increased arterial action, had this not been the consequence but the cause of that. Should it be asked why, if the derangement of the system was symptomatic, fever increased after inflammation and pain subsided? I answer, that as inflammation and pain in any part cannot excite sympathetic action in the system otherwise than gradually; so, when this sympathy is produced, it cannot subside immediately on the abstraction of the cause. The heart and arteries having, from sympathy, acquired a disposition to increased action, this disposition may and does continue its influence, after the original cause has ceased to operate. A

stream continues to run, and the ocean to roll, long after the fountain is dried up, and the winds cease to blow.

As to the sickness and general oppression of which this patient complained, they were, without doubt, occasioned by the excessive pain in the extremities. This was proved by their going off in proportion as pain abated; a circumstance, this, of no uncommon occurrence. Local pain occasions sickness, oppression, vomiting, fainting, fever; whether its accession is spontaneous, as in whitloe; or occasioned by the infliction of wounds, as by accidents, and in operations.

From this view, and enumeration of facts, it is, I think, rendered highly probable, if not demonstrated, that the whole of the constitutional symptoms in this case, had their origin in the affection of the extremities; and, therefore, that removing inflammation and pain from the extremities, could produce no constitutional injury.

It is the general opinion, and it has been sanctioned by the first medical authorities, that duration of inflammation in the extremities for a considerable time, is equally conducive to the health of the body, and to the vigour of the mind. This con'ceit, for it deserves no better a name, tends more than all other considerations combined, to reconcile gouty patients to protracted sufferings. But if confinement to a room for weeks and for months together, is more conducive to health than moderate exercise in the open air, then a sedentary life, indolence, and inaction, should never be enumerated among the sources of disease. The truth is, emancipation from pain becomes positive pleasure for a time; and a person just relieved from long confinement, must be more feelingly alive to every external impression, than if his liberty and health had suffered no interruption.

The modus operandi of compression and percussion in the cure of gout, is doubtless the same as takes place in the cure of rheumatism; that is, they produce their beneficial effects in both diseases, by promoting circulation in the vessels of the affected parts. This is as obvious to the senses in gout as in theumatism; for in both the preceding cases, the swelling and redness visibly decreased while the patients were in my hands. From hence it might be inferred, that both diseases acknowledge the same proximate cause; but I shall say nothing on this subject at present.

Of the topical application of cold in gout, as recommended by Dr Kinglake, I have no experience. This much only I would observe, that cold applied to the extremeties, even when free from disease, has often powerful effects on some of the internal organs, the bowels for instance. No objection of this

kind can be had to compression and percussion; their operation is the most simple and harmless that can be conceived. The nerves, which are the medium of pleasure and of pain, may be so affected by temperature, as to excite morbid sympathy in distant parts; but this cannot happen from compression and percussion, if applied by a skilful hand. Their only effect is, to remove and to obviate congestion. Whenever the former is accomplished, pain ceases. Is it not, therefore, as plain as cause and effect, that congestion is the cause of the pain? Now, is it to be believed for a moment, that, in relieving the nerves in any part of the extremities from pressure, we run the risk of exciting inflammation and pain in the stomach, or any internal

organ?

We have an instance, most apposite to our present purpose, of the power of compression in removing pain, and obviating inflammation in whitloe,-one of the most excruciating diseases to which the human frame is liable. But, whatever the peculiarity of the inflammation that takes place in this complaint may be, certain it is, that it may be prevented by compression, timeously applied. I have done it in many instances, *-even when the finger was livid, from the veins being unable to return their blood. This practice I call new likewise, for I never met with it in any author; and I was led to it from observing the effects of compression and percussion in other topical inflammatory affections, as recorded in the work referred to in the beginning of this paper.

VIII.

Cases of Laryngitis. By Dr NINIAN HILL, Greenock.

ON Monday, the 9th of October last, I was called to

ON

ætatis 36, a woman of the sanguine temperament, tall stature, spare habit of body, but strong; who had always enjoyed good health. Had been of late much exposed to fatigue and anxiety in attending two of her children, who were convalescent from scarlatina, with extensive and alarming ulceration of the throat; she had also been exposed to cold, from having been obliged to keep the window and door of her bed-room partially

It is my intention to give, on some future occasion, of whitloe, cured by compression.

few cases