after-pain; in doubtful cases, his practice is "to lessen the force of the circulation by a bloodletting proportioned to the exigency."

Puerperal fever. From p. 665 to p. 682 there is a long note on the subject of puerperal fever. Dr. Meigs appears to be throughly conversant with the disease in its various forms, its pathological appearances, and the several modes of treatment. He differs from Fergusson, Collins, and others who regard puerperal fever as "something over and above the local disease," "something beyond inflammation of tissues," and states “that phlebitis of the recently discharged womb alone," "gangrenous inflammation of the inner pains of the uterus," or "inflammation of the peritoneum," all or either is sufficient to produce all the "frightful rapidity which attends the disease," and to cause "the rapid and sudden overthrow of all the functions." He extols most highly the small but excellent volume published by Dr. Gordon of Aberdeen in 1795, and like this physician places more confidence in bloodletting at the commencement of the disease than in any other remedy. Gordon insisted upon 24 ounces of blood being drawn "in the early stage, within twenty-four hours of the attack." Meigs is unwilling to adopt this quantity as "an universal rule," since "the same point is attainable in some by 24 ounces, in others by not less than 30, and in others by 12 or 15." He is guided by the "pulse, breathing, cessation of pain, voice, gesture, decubitus, physiognomonic expression, and general sensations of the patient." He differs from Dr. Collins of Dublin, (although professing the greatest respect for his opinions,) in the preferableness of leeching in the epidemic forms of the disorder, and especially on the ground that "the uterine and ovarian circulation is in nowise directly related to the circulation in the skin," and strengthens his remarks by referring to the observations of M. Baudelocque fils, in his 'Traité de la Péritonite puerperale.'

Swelled leg. At p. 683 he very properly corrects an error of M. Colombat, who states that in "milk-leg" the pain "commences in the groin and leg" and the swelling extends "from above downwards." Dr. Meigs says, and we think justly, that the swelling "is in a great majority perceived first in the calf of the leg, which becomes painful, hard, and swollen before the woman suspects that she has any pain at the groin or in the thigh."

ART. VI.

Medical and Physiological Problems, being chiefly Researches for Correct Principles of Treatment in Disputed Points of Medical Practice. By WILLIAM GRIFFIN, M.D., Member of the Royal College of Surgeons in Edinburgh, one of the Physicians to the County of Limerick Infirmary, &c.; and by DANIEL GRIFFIN, M.D., Member of the Royal College of Surgeons in London, Assistant Physician to the County of Limerick Infirmary, &c. London, 1845. 8vo, pp. 356.

THE following remark appears in the preface to this publication:

"There are two modes of treating all diseases, a right and a wrong one; and it is popularly believed that the science of medicine has long since determined between them; that in every dangerous case, or, at all events, in those of ordinary or frequent occurrence, the practitioner has only to refer to received prin

ciples or authorities on the subject, and that if he commits an error in his selection of remedies, it is entirely attributable to his want of information or ability. The uninitiated are little aware of the deep responsibility that rests with the young practitioner, when a decision is demanded of him on such occasions, or the profound judgment, as well as extensive information required to arrive at a correct conclusion between conflicting authorities of equal consideration."

It occurred to one of our authors [we cannot say whether it was the Castor or the Pollux of the Irish profession, as no signature is attached to the preface,] some years since, that it would be a most useful, practical, and interesting study to collect cases with reference to all the most important of disputed points in practice, and afterwards, as a sufficient degree of personal experience happened to be attained on any one of them, to review the opinions of all the best authors on the subject, and endeavour to solve that most difficult question-what is the correct principle of treatment? The idea was excellent, and the results of its accomplishment are in the work under consideration.

The first four problems are so closely related to each other, that we shall take them together. They virtually refer, as might be expected from the previous publications of the authors, to the diagnosis and treatment of spinal irritation, although the first seems to have no connexion with that form of disease. The four problems are:

"1. What principles should be kept in view by the physician in the treatment of enteritis?"

"2. How are nervous affections distinguishable from inflammatory ?" "3. What is the diagnosis of abdominal inflammations?"

"4. In spinal irritation, is there really any affection of the spinal cord, or of its membranes?"

ENTERITIS.-Treatment. The discussion of the first problem is not to the point. Its object is to show, that enteritis is best treated by opium. The history of a case so handled is preceded by extracts from systematic writers as to treatment by bleeding and purgatives, tending to show considerable discrepancy of opinion as to extent at least of depletion, and as to the time and mode in which purgatives should be administered.

Parr and Good advise moderate depletion as less likely to be followed by gangrene; Abercrombie advises more vigorous measures, and Elliotson directs the patient to be set upright, and bled "from a large orifice without mercy." The tone of confidence and decision usually adopted by the latter writer has gained him many disciples, but we suspect that mature experience will very much shake their trust in their leader, and we would refer to the last dictum of bleeding "without mercy," as one likely to be questioned. It is well known that cases of enteritis may be cured safely and quickly without any depletion whatever.

Authorities take two sides on the use of purgatives in enteritis. Parr, Pemberton, and Good recommend mild purgatives at first; then, if necessary, the more active. Dr. Elliotson is confident, more suo, and we think most dangerous in his advice. "We should first," he tells us, "bleed freely, because purgatives will not operate until we have done that; we should then give a large dose of calomel, such as a scruple, by the mouth, and a strong purgative injection, with plenty of salts, or salts and senna, or colocynth, or oil of turpentine, and repeat the calomel in ten grain doses every four or six hours, giving purgatives in addition from time to

time." When we consider how readily enteritis may be mistaken for ileus, or spasmodic cholic, the danger of such treatment is manifest. Dr. Abercrombie recommends that the purgatives be not administered in the early stage. This plan of treatment is that, we believe, which the majority of modern physicians adopt.

We will now give an abstract of the case before referred to.

A lady, aged 32, affected with symptoms of enteritis, was bled to eight ounces, and two dozen leeches applied to the right hypochondriac and iliac regions. Two grains of calomel and one of opium were given every second hour. No relief following, the next day twenty ounces of blood were taken from the arm; aloes and henbane given to operate on the bowels, and a terebinthinate enema administered.

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On administering this last, the patient was seized with a dreadful forcing or bearing-down pain in the rectum, and passed nothing; the pain seemed as excruciating as any that could occur in violent labour, lasting for about twenty minutes, and was then relieved by the warm bath. In two hours afterwards, the administration of a simple injection of oatmeal tea was followed by similar suffering, and was in like manner retained. The permanent pain was at this period severest in the left iliac region and about the navel, where the tenderness on pressure was extreme; the countenance was more anxious; the tumidity of the abdomen was increasing, and the stomach beginning to reject the drink. In consultation with another physician, it was now agreed to take blood again, and eighteen ounces more were drawn, being the third general bleeding within twenty-four hours. Two grains of opium and a grain of calomel were given immediately after, and ordered to be repeated every two hours through the night. In the morning (the 4th) there was a considerable improvement; the abdominal tenderness was diminished, the pain and sickness of the stomach had very much subsided, and the injections had come away with some dark, thin, feculent matter. She still, however, felt pain and a sense of great weariness at the lower end of the sacrum, shooting up through her back, and she had a great difficulty in passing water. She now informed me that a few days previous to her present illness, she was attacked with a profuse leucorrhoeal discharge, attended by heat and sense of scalding, but that it had since abated or almost ceased. A fomentation to the lower part of the abdomen was ordered, and the opium was continued in twograin doses every two hours, without calomel. In the evening the improvement appeared progressive; the skin was cool, the pulse soft at 110, the tongue cleaner; the abdomen was still full, but it had nearly lost its tenderness, and she could turn in the bed with little pain." (p. 5.)

It was now discovered that there was a purulent discharge from the

rectum :

"On the next evening, as she lay on the sofa while her bed was making, she felt a solid substance passing from the rectum, which alarmed her terribly. It was found to be a rope of sloughy stuff, soft and purulent outside, but tough and fibrous within, not unlike the ischiatic nerve in a decayed state, suspended from the rectum for the length of a foot or more. On attempting to draw it away, it appeared to be still adherent within the gut, and she complained of pain. After a little, however, it was removed without much effort, and a gush of matter to the amount of perhaps two tablespoonfuls followed. The slough was about the thickness of the thumb or more, and was fifteen or sixteen inches in length. We at first supposed it was a portion of the small intestine which had mortified and been thrown off; but on close inspection no distinct traces of a canal could be found. Some time after an injection of warm water and sweet oil was administered, which came away in about twenty minutes mixed with some matter, but without any appearance of fæces. On examining the rectum, a rugged irregular edge

was felt on the posterior side, close to the sacrum, as if it was the termination of the part from which the slough had been cast off; the examination gave much pain, especially when the intestine was pressed upon within. Several days passed without much alteration in the case: there was matter daily discharging to the amount of three or four ounces, and there was at times severe dysury, at last demanding the use of the catheter." (p.7.)

Three days having elapsed since the pain and tenderness of the abdomen was experienced, and six since the bowels were moved, an aperient was requisite, and a dose of castor oil given, followed by pills of aloes and henbane. All the symptoms now recurred in a more aggravated form. There was increasing distension of the abdomen, the pulse became feeble and rapid, the thirst extreme, the vomiting frequent, the countenance was sunken, the look anxious, and the face covered with a clammy perspiration. Three grains of opium were given as a first dose, and two every second hour afterwards; a dozen leeches applied to the abdomen, and fomentations with decoction of poppy-heads. The effect was wonderful; the pain and tenderness gradually abated, the pulse became slower, the sickness ceased, and the expression of countenance improved. Matters went on well until the seventh day from that on which the bowels were last moved, without any evacuation. At that period, however, (as Dr. Griffin anticipated,) "the tenderness in the left ilium was again felt, and it was soon followed by pain and feverishness, with a disposition to vomit."

"There was now no doubt on our minds that the recurrence of the attack was attributable to distension and not to perforation of the intestine, as we had apprehended. After giving a large opiate, therefore, she was ordered a few grains of calomel, with mild doses of castor oil and jalap every second hour, until the bowels were freely moved. Great relief was obtained, but the pain and tenderness of the abdomen finally subsided on resuming the opiates for twelve or fourteen hours after the purgative had ceased operating."

The case now gradually but slowly advanced to recovery:

The

"A mild purgative was given at the farthest on every fourth day, which operated without creating pain or uneasiness, and by diminishing the interval gradually, the bowels were after a little brought to act daily with a small dose of rhubarb and cascarilla. She was still, however, unable to sit up in the bed, or to turn to either side on account of the excessive soreness inside the sacrum. motions continued to be smeared with matter; sometimes small bits of fresh slough came away; sometimes spoonfuls of healthy pus with stuff like jelly. Weak sulphate of zinc injections, and even those of simple water were made use of, but they gave great uneasiness, and served to do more harm than good. At this time, about eight weeks from the commencement of the attack, she became very hysterical, got fits of crying and laughter, which lasted for hours, and was sometimes slightly delirious. She had been kept very low all through her illness, but was now allowed nourishing diet, meat, and a little wine; there was an immediate improvement in all the symptoms; her strength and health mended; her mind became cheerful; the discharge of matter diminished, and at last was only occasionally observable. The soreness about the sacrum was also lessened so considerably that she was able to dress, lie on the sofa, and sometimes sit up for a short time. At the end of three months she could move about the room a little, and at the termination of the fourth she was perfectly recovered." (pp. 10-11.)

In commenting on this interesting case, we may fairly award to Dr. W.

Griffin the merit of saving his patient's life; but we should have been glad to have learnt more about this sloughing of the rectum. Why did that excruciating, dreadfully forcing pain come on immediately after the administration of the terebinthinate enema? Is it possible that the nurse perforated the bowel with the enema-tube? How was it that distension of the bowel in the left iliac region caused the sloughing of the rectum, and the rugged, irregular edge at the posterior side close to the sacrum? With regard to the principles of treatment in enteritis, Dr. W. Griffin is in favour of a free and early bleeding, and if this fail, bleeding must be abandoned as the main resource, and employed as auxiliary only. With regard to purgatives, he observes that in the greater number of cases of enteritis, the favorable termination is by a free evacuation of the bowels, and that before this occurs relief is seldom obtained. To the experience of this strong fact may be referred, he thinks, the popularity of the purgative treatment. But Dr. W. Griffin shrewdly remarks:

"Effects are too often, in the science of medicine, mistaken for causes. When cholera first appeared in this city calomel was profusely employed in its cure, and it was eventually found that patients who became salivated almost invariably recovered. This was esteemed proof positive of the efficacy of the treatment, and mercurials became more popular than ever. I found, however, on examining the registries of the hospital with which I was connected, at the termination of a month, that in the stage of collapse no more than one patient in ten could be brought under the influence of mercury, so that there were only four recoveries in forty. This told little for the remedy as far as cases in relapse were concerned, and I immediately set about ascertaining what the amount of spontaneous recoveries might be in the same stage. From all I could gather from the experience of others or my own, I began to suspect that they would reach nearly the same amount; and at last I became perfectly convinced that the actual fact was, the patients did not recover because they were salivated, but they were salivated because they recovered. Mercury in any shape, in the stage of collapse, was thenceforward discarded from my practice in the hospital, and though it excited some observation at the time, the subsequent experience of the profession at large bore me out in the decision. I cannot but feel that somewhat of the same error prevails with respect to purgatives in enteritis; the disease is not a very common one, and the experience of an individual could scarcely warrant him in offering opinions at all confidently, when they are opposed to general practice; but certainly all the information I can glean, or the experience which has fallen to my share, would dispose me to say that, in intestinal inflammation, the relief obtained is seldom the direct effect of the purgative, and that people do not recover because they are purged, but they are purged because they recover." (pp. 15-16.)

After a perusal of the preceding case our readers will readily imagine that Dr. W. Griffin is a warm advocate for the treatment of enteritis by full and frequently repeated doses of opium, and details several cases at length as illustrative of its success. There is some doubt on our minds as to the diagnosis of many, if not most of the cases of enteritis, and this doubt introduces us to the two next problems: How are nervous affections distinguished from inflammatory, and what is the diagnosis of abdominal inflammations?

Diagnosis. The term enteritis is, we believe, now generally understood to mean inflammation of that part of the peritoneum constituting the outer coat of the intestines. The characteristic symptoms of this as well as of other forms of peritonitis, are pain and tenderness on pressure of the