257.-On the Treatment of Chorea. By M. A. TROUSSEAU and Ch. LASÈGUE.-In the last Number of the RETROSPECT we gave Dr Todd's account of chorea, and his observations on the interesting relation which subsists between that disease and affections of the heart. That connection Dr Todd accounted for by assuming the dependence of the two diseases on the same morbid diathesis the rheumatic; the unhealthy condition of the blood being the exciting cause of an insidious endocarditis in those labouring under chorea. Our readers will recollect that similar views of the connection between chorea and rheumatism were brought before them, upwards of two years ago, by Dr Begbie (MONTHLY JOURNAL, April 1847), who adduced some striking facts to prove that many of the sufferers from chorea inherit the rheumatic diathesis, or have themselves suffered from rheumatism, either in an acute or chronic form, and that in both of these classes the affec

tions of the heart had been manifested.

The paper of MM. Trousseau and Lasègue now before us-affords new proofs of the correctness of Dr Begbie's theory. These authors have had numerous opportunities of observing affections of the heart occurring in chorea, which they allege to be similar to those which supervene on acute rheumatism. Their more immediate object, however, is to direct attention to the employment of nux vomica as a remedy in the treatment of chorea. The preparation they have used is the sulphate of strychnine-a preparation of the alkaloid, very soluble, and consequently easy of administration. Of the sulphate they directed a syrup to be prepared, in the proportion of 5 centigrammes (ths of a grain) of the sulphate of strychnine to 100 grammes (3 oz. 2 drs.) of simple syrup; and this is the exact form they have employed, augmenting or diminishing the amount of the sulphate, according to the effects produced by its administration. Being a powerful remedy, and one whose immediate effects on particular constitutions will vary, its first doses should be small, and carefully regulated. In children of from six to twelve years of age the authors have commenced with six teaspoonfuls during the day; in adolescents, six dessert spoonfuls; in adults, three large spoonfuls. The doses are equivalent in the first case to thirty, in the second to fifty, and in the third to sixty, grammes of the syrup twenty grammes of which contain about one centigramme (4th

of a grain) of the salt of strychnine. These doses were increased or diminished, according to the effects produced; sometimes the same dose was continued for a few days. Under the influence of the remedy, there is produced a perceptible rigidity of the jaws, the neck, back, and limbs. This state does not continue long; there exist along with it a tendency to sleep, and a slight degree of fever. It is on the occurrence of these physiological effects that the authors have found the disease to yield and decline; and they have, therefore, recommended the persistent use of the strychnine until they are induced. Several interesting cases are related in confirmation of this point. The employment of the ordinary constitutional means is insisted on during the treatment of chorea by strychnine. In cases of chorea, where a state of partial paralysis had supervened, the authors have employed this remedy, and tested its efficacy.-L'Union Médicale, June 1849.

258.-Puerperal Convulsions; their dependence on Toxemia; explanation of their more common occurrence in Primipara. By Dr CORMACK.-Dr Cormack details the history of three cases of puerperal convulsions, which had occurred in his practice. The main object of his paper is to point out the connection between renal congestion and puerperal convulsions, which exists in a very great proportion of cases. He considers puerperal convulsions to be

though not always, yet generally-the toxicological results of non-elimination of the excretions of the blood; and that, in by far the greater number of cases, this non-elimination depends on renal congestion, caused by the pressure of the gravid uterus. Edema and albuminuria are frequent concomitants or precursors of convulsions, as shown by Dr Lever and by MM. Devilliers and Regnault. The gravid uterus, or any tumour pressing on the renal veins, must cause congestion of the kidneys and consequent toxæmia; and this is the more injurious to the pregnant woman, as her blood requires an extra degree of depuration both from excrementitious matter from the foetus, and also from the elements of milk. Retention of these should, Dr Cormack thinks, be considered as the cause, not only of convulsions, but also of various other distressing symptoms occurring in pregnancy. Uterine epilepsy probably often arises from toxæmia; and the suppression of the lochia may induce post-partum puer

peral convulsions. When convulsions recur after delivery, we must suspect structural renal disease. The explanation of delivery generally arresting convulsions is not so much that uterine irritation is lessened, as that the hyperemic state of the kidneys is relieved. The most common subjects of puerperal convulsions are strong healthy young women, pregnant for the first time; and an examination of the cases recorded by authors proves this fact. In them the abdominal walls are most unyielding, and unable to relax under the pressure of the gravid womb. Cases of puerperal convulsions in subsequent pregnancies might be either toxemic or non-toxemic. The toxemic cases may be classed under the following heads:-1. Persons who have never gone to the full time; 2. Persons of extreme muscular development; 3. Persons suffering from structural disease or obstruction of the kidney; 4. Excessive volume of uterine contents, including twin cases, &c. Dr Cormack is desirous of drawing attention to toxæmia as a cause of puerperal convulsions, and also of recognising non-toxemic convulsions. He thinks that Dr Tyler Smith, who has treated this subject more philosophically than any preceding writer, has, while recognising toxæmia, attached too little importance to it. -Proceedings of Westminster Medical Society, in Med. Gazette, June 15, 1849.

259.-Notes from the Clinical Lectures of M. Bouillaud. By M. LEFEVRE.-Pneumonia. In ten cases of this disease, four were double, two occupied the whole extent of the right lung, three the base, and two the summit. In all it was clearly marked, in eight being in the second stage, in one in the third, and in one in the first stage. A table is given in which are the names of the patients, the stage of the disease on admission, the number and extent of the bleedings and cuppings, the number of blisters, the seat of the disease, the complications, and the date of recovery, with the view of showing that M. Bouillard's method of jugulating pneumonia, although unique, is not uniform, and that the quantity of blood he takes in a given time is determined by the severity of the inflammation, and by the age, constitution, and temperament of the patient. The conditions of the disease and of the patient being given, we may, however, determine approximately, according to his views, the amount of blood to be abstracted.

It has been often stated that M. Bouillaud's success depended on the fact of his patients being adults, and on the mildness

of the majority of his cases; but in the table to which we have referred, one of the patients was seventy-three years of age; and, although the inflammation was very intense, and occupied the summit of the lung, it lasted only four days; and further, we have already shown that in many of these cases the disease was far from mild. The success of his treatment seems illustrated by the fact, that the duration of the disease in eight of these cases treated by his method, was, on an average, only six-and-a-half days, the period of treatment being less than four days, while in the two others it was six and twelve weeks. We need hardly remind our readers that the peculiarity of Bouillaud's treatment consists in the repetition of blood-lettings. In one of the cases recorded in the table to which we have referred, and in which the patient entered the hospital on the third day of the disease, the pneumonia being double, four venesections to the extent of eighty ounces were practised, there was a cupping to sixteen ounces, and two blisters were employed.

Pleuritis.-During the same period six cases of inflammation of the pleura were admitted; and in this affection, according to Bouillaud, his system of blood-letting is equally valuable. Certain complications may, however, render it necessary to modify the treatment.

Bronchitis is one of the most common complications of pleurisies and pneumonias, and as it adds in some degree to their severity, it becomes a question, how far the ordinary treatment of those diseases requires any modification. Bouillaud takes some unnecessary trouble to show that there is nothing specific in affections of the mucous membranes, and that bronchitis, being an inflammation arising from cold, like pneumonia and pleurisy, must be combated in a like

manner.

Bilious pneumonia and pleurisy are common, but the green expectoration, regarded by some authors as characteristic of these affections, is often absent.

These bilious pneumonias and pleurisies are due to the extension of the inflammation to the peritoneal investment of the sub-umbilical region, and not, as Stoll and others have maintained, to any peculiar state of the prima viæ, and their contents.

In all the patients thus affected (being four in number) the following symptoms were more or less prominent; a bitter taste in the mouth, the tongue covered with a whitish-yellow fur, hiccup, singultus, bilious or mucous vomitings, a more

or less jaundiced appearance of the skin and conjunctivæ, greenish urine, gelatiniform expectoration: the blood-clot of a yellowish-green tint, especially in its upper layer, and perhaps the character of inflammatory blood while the serosity communicated a yellow tint to linen immersed in it.

[The reporter gives a case of bilious pleuro-pneumonia in the second stage, occurring in a man, aged 20 years, who was admitted on the 6th of May. We shall give the amount of blood extracted; the remaining treatment being very secondary. We may observe that on the day of his admission and the previous morning, there was considerable epistaxis.

May 6th.-Bled to 16 ozs. in the morning, and 12 oz. in the evening.

May 7th.-Bled to 12 oz. in the morning, cupped to 12 oz. in the afternoon, and again bled to 12 oz. in the evening.

May 8th.-Ordered to be bled to 12 oz., but only half that quantity was taken.

May 9th. No venesection performed, and as we find that, on the 10th, "Il se trouve très bien we may conclude that he suffered no material injury from having accidentally preserved six ounces of blood on the 8th. As we read that the convalescence was prompt, and that he had no relapse, we have no right to deny "that this case shows the efficacy of properly arranged (convenablement formulées) venesection in bilious pneumonias and pleurisies." Still, we cannot help expressing our conviction that a less heroic treatment might have been followed with at least equally good results.]

Amongst other complications, we may mention the frequent coincidence of pleuropericarditis with pneumonia and pleurisy of the left side. In these cases the sounds of the heart should be daily attended to. The treatment is the same as in the preceding complication.

The reporter lays great stress on the cures of pleurisy being more rapid and complete when treated according to M. Bouillaud's method, than when milder means are adopted.

Another complication of pneumonias and pleurisies, depending on their position, is delirium. This delirium occurs in the ataxic variety, and is observed to correspond with inflammation of the summit of the lung. And here M. Bouillaud is equally energetic regarding the superiority of the system of blood-letting over the ordinary administration of antispasmodics,

&c.

There is a typhoid form of pneumonia in which we have two morbid processes going on simultaneously, namely, inflam

mation of the lungs, and entero-mesenteritis; and here, according to M. Bouillaud, his system of blood-letting is equally efficacious as in the preceding forms, provided the intestinal glands have not reached the stage of ulceration. " Here," says the reporter," as in all the other cases this system presents a double advantage; dissipating the entero-mesenteritis as it dissipates the pneumonia and pleurisy, it does not require us to neglect one organopathic condition at the expense of another, and enables us to dispense with the employment of purgatives and enterocathartics, which always give rise to a congestion of the portal system, and consequently increase mechanically the vital congestion of the intestinal follicles. Now, if experience has shown that, under the influence of purgatives and emetics, the affection termed typhoid fever, or enteromesenteritis, is neither materially modified in its progress, nor abridged in its duration, and that it is impossible to give a certain prognosis; observation has also proved the very opposite in reference to the new system of blood-letting in wellmarked cases of entero-mesenteritis during its first period."

Typhoid or true adynamic pneumonia, is most common in aged persons. The local phenomena of inflammation of the lungs and pleura are primary; the characters of the typhoid or adynamic state being generally secondary, and neither connected with inflammation of the intestinal follicles, nor with any of the other general or local conditions which give rise to that condition, excepting the alterations induced by the pneumonia or pleurisy.

In pneumonia of the third degree, the most prominent typhoid or adynamic symptoms are the expression of depression and stupor, prostration of muscular power, dryness of the lips, tongue, and teeth, which are covered with sordes, the dry and dusty condition of the nostrils, insensibility to the calls of nature, bed sores, &c.; indeed, these symptoms may be regarded as indicative that the suppurative stage of pneumonia has commenced. To take blood in this case, even M. Bouillaud grants, might prejudice the patient, and bring his favourite remedy into disrepute; he observes, however, that a blood-letting is sometimes necessary to fulfil certain general indications.

In ordinary cases of pneumonia in old people, Bouillaud applies his new formula just as in earlier life, the cases being excessively rare in which the organism is so deteriorated as to render it necessary to limit the number and amount of the venesections. In general, his system of blood

letting is well-borne by old people, and when carried to the extent demanded by the intensity of the disease, the inflammation is as amenable to treatment as in earlier life.-L'Union Med., 1848.

260.-On the Diagnosis and Treatment of Calculus in the Kidney.-M. RAYER, in a memoir on Pyelitis Calculosa, enters very fully into this subject. The following considerations may aid us in the diagnosis of this affection :

1. Lumbar pain (one of the symptoms) occurs in various species of acute nephritis, in hydatids of the kidney, in nephritic colic, in retention of urine without inflammation, in lumbago, in certain diseases of the spine, in psoitis, in aneurism of the aorta, in pregnancy, in certain uterine affections, in certain cases of partial peritonitis, and in inflammation of the cellular tissue outside the peritoneum.

2. In nephritis the pain is often very similar, although usually less acute. We may be guided in our diagnosis by observing whether there is purulent matter in the urine, and whether there is any tumour in the lumbar region.

3. Calculus in the kidney is distinguished from nephritic colic by the fact, that in the first the pain is more acute and more intolerable, and that it ceases the moment the calculus has escaped from the ureter.

4. When there is retention of urine, either complete or incomplete, it is not uncommon to hear patients complain of pain in one or both lumbar regions, the pain being so severe as to induce the belief in the existence of pyelitis or calculus; and yet, after death, no appearance of inflammation will be seen, the kidneys in these cases being apparently healthy, with the exception of slight atrophy of the cones, and pale rather than red. In this case death occurs suddenly from cerebral disturbance.

5. In lumbago the pain commonly affects both sides at once, and generally with the same degree of severity, and is always increased by moving the body; there is generally no fever, and it is often preceded by other muscular pains; in the case of a calculus, is almost always on one side alone; and, although it is augmented by contraction of the lumbar muscles, the augmentation is not to be compared to that occurring on contracting the muscles in lumbago.

There is seldom much difficulty in distinguishing between pain in the lumbar region and in the kidney.

6. In caries of the lumbar vertebræ the pain is dull and usually much less intense

than in the case of a calculus in the kidney. The caries is also distinguished by the alteration in the form of the vertebral column, and often by abscess pointing towards the groin or the nates, and frequently by more or less paraplegia, either with or without muco-purulent matter in the urine. Paraplegia, again, often induces retention of urine, which produces chronic inflammation of the bladder, and sometimes of the ureters, and of the pelvis of the kidney.

7. In psoitis the patient feels a dull pain in the side affected; the parts become afterwards more acute, extending from the lumbar vertebræ to the pubis, and the body being bent forwards and towards the diseased side. The movements of the thigh are very painful, and it is almost impossible to straighten the back when the body is once bent. The inguinal glands then become enlarged, and a collection of pus is formed under the peritoneum and the body of the muscle, often causing swelling of the limb.

8. Aneurisms of the aorta occasionally produce lumbar pains similar to those in the kidneys.

9. Certain diseases of the ovaries and partial peritonitis of the lumbar region, may simulate renal disease, and especially the affection we are now considering, particularly if they co-exist with acute or chronic cystitis.

10. The same remark applies to inflammation of the extra-peritoneal cellular tissue in the vicinity of the kidney.

The mere presence of pus in the urine does not afford much aid in the diagnosis of this affection. The following points are, however, deserving of attention. When there is neither pain nor swelling in the region of the kidney, the examination of the urine will enable us to distinguish between pyelitis and cystitis; when there is inflammation of the pelvis and calyces, there is dysuria with a deposit of pus ; when there is catarrh of the bladder, the urine is glairy and viscous. The glairy character of the urine may, however, occur in renal pus when alkaline urine is secreted; and, on the other hand, the pus in cystitis is not always glairy. We have no right to assume that pus comes from a kidney containing a calculus, unless pain has existed in the upper region of the kidney.

The distinctive characters of renal tumours are then noticed by our author. The tumours with which renal abscess may be confounded, are those from enlargement of the spleen, liver, or gall-bladder; those from cancer and other diseases of the kid

neys, extra-renal abscess, abscess from caries of the vertebræ, fæcal abscess, &c. We cannot follow him in the diagnosis of these tumours, and proceed to notice the treatment of calculus in the kidney.

At the beginning of the attack, and in its first stage, the nephritic pains are relieved by warm baths and mucilaginous drinks, linseed tea, emulsions, small beer, and laudanum, &c.; by leeches, or, better, by cupping glasses applied to the painful part.

When the pain is very acute, and accompanied with suppression of urine, violent efforts at vomiting, and a tendency to syncope, relief is afforded by warm fomentation of assafoetida or henbane leaves; friction with the tinctures of opium and camphor, and the inhalation of ether, are serviceable. The expulsion of the calculus from the ureter is sometimes favoured by cold, the patient being stripped and his feet placed on the pavement. The expulsion is also favoured by the application of dry cups to the course of the ureter, or on the perineum.

When the primary symptoms have yielded, if the calculus be not expelled, and the urine is charged with mucus, we must explore the bladder, and if a small calculus be found, it must be extracted or broken, or its expulsion should be promoted by causing the patient to drink large quantities of spring or mineral water.

When gravel or calculi remain fixed in the calyces, &c., the inflammatory symptoms thus induced may be relieved by the warm bath, linseed tea, mineral water, or cupping.

do much. Alkaline drinks are certainly favourable when there are uric acid calculi, and in pyelitis produced by concretions; but experience shows us that in gravel (a condition in which this form of calculus most commonly occurs) the uric acid deposit, although temporarily removed by this means, soon recurs.

When we obtain chemical indications that the granular calculi are composed externally of phosphates, we advise the use of carbonic acid drinks; but it is certain that these seldom render phosphatic urine clear and transparent. Alkaline turbid urine is almost always the result of chronic inflammation of the kidneys; and we cannot expect to modify it by either vegetable or mineral acids. The treatment recommended for chronic nephritis ought to be adopted.

When the calculus is so impacted as to give rise to an accumulation of urine and pus in the cavity of the kidney, Rayer advises that we should attempt to prevent the establishment of acute inflammation in the part, by rest, by the daily use of the bath, by leeches, by topical emollients, and by well-regulated diet, prescribing venesection when symptoms of inflammation show themselves.

If, however, the tumour is habitually painful, notwithstanding the above treatment, if there is continual or hectic fever, if there is diarrhoea, &c., and if none of the pus find its way down the ureter, the operation of nephrotomy, with all its dangers and difficulties, must be resorted to.

With the view of diminishing the mucopurulent secretion which occurs in these cases, oil of turpentine has been found useful. Rayer speaks favourably of cubebs, copaiva, purified turpentine, &c., in diminishing the secretion, and checking the frequent exacerbation of renal pain. Linseed tea and infusion of aniseed, constitute the best drinks.

Another indication is the physico-chemical treatment of granular calculi. Certain drinks, which may be taken in large quantity, such as spring water, act mechanically in washing the calculi, carrying the smaller gravel through the ureters, and facilitating their escape by increasing the amount of urine. The action of these drinks is confined to so narrow a space, that comparatively little can be expected from them. Neither can chemical action

NO. IX. VOL. II.

We must not attempt the operation

1. When we are sure that both kidneyare affected, and probably contain calculi, provided there are no extra renal abscesses, which should always be opened without delay.

2. When the pus passes freely into the bladder, when there is no renal tumour, nor immediate fear of renal fistula, and especially when a favourable condition of the system leads to the belief that the other kidney is acting with increased energy.

3. When there exist, at the same time, uncurable lesions of the bladder, prostate, or intestines.--Condensed from Dr Bryan's Translation in the Phil. Med. Examiner, Oct. and Nov. 1848.

261.-On Melana in Children. By M. RILLIET.-M. Rilliet, one of the authors of the classical work on the Diseases of

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