ing steered a course so generally free from recrimination. We willingly give insertion to the following letter from Dr. Smith, and shall not accompany it by any comments.

TO THE EDITOR OF THE MEDICO-CHIRURGICAL REVIEW.

Dear Sir,

Perhaps you will allow me to correct a mistake into which you have inadvertently fallen in the concluding part of your review of my work on Fever, in commenting on the case of Dr. Dill. The mistake relates to the period of the disease at which you were called to see our mutual friend. You did not, if you remember, visit him "in the midst of the active discipline" to which he was subjected, but at the close of it; the case at the period you saw him, as you intimate, admitted of no further depletion, and no more blood was taken after that time, until he relapsed at Brighton. It is scarcely necessary to add, that the statement at the foot-note of my Treatise of the total quantity of blood abstracted (120 pounds) is a misprint for 120 ounces.

The detail of the early symptoms of this case is given at page 109 of the Treatise, while the account of the treatment is postponed to page 398, and, for the sake of brevity, the symptoms were not again recounted; but I must have been wrong in separating, at so great a distance, the symptoms from the treatment, since it has been the means of leading so acute a reader into a misconception of the stage of the disease to which the active treatment was confined.

The same reason, I hope, will account for your having thought that I could scarcely foresee, at the period at which I first abstracted blood, the severe fever that was at hand: but, if you will take the trouble to turn to page 109, you will perceive that, on the afternoon of the first day of the disease, there was present an assemblage of symptoms which clearly indicated the approach of a high degree of cerebral affection, and that accordingly, on the morning of the second day, the symptoms of intense disease of the brain were urgent: these, though occasionally mitigated, remain

ed unsubdued through the third and the fourth days, and required the copious depletion that was resorted to; but, on the evening of the fourth or the morning of the fifth day, when you first saw Dr. Dill, they were overcome, and from that period no active remedy, excepting the cold dash, was employed. The patient was convalescent and sitting up in bed on the 8th or 9th day of the disease, a most remarkable occurrence after such an attack, and one which certainly would not have been witnessed had the malady been allowed to produce organic change in the brain, or had the means employed to prevent this result been pushed either beyond the strength of the disease or that of the patient.

Permit me to add, that this form of fever is not, I apprehend, generally understood; and yet the life of the patient depends upon its being discriminated at the very onset of the attack; the postponement of the proper remedies, for the space of a few hours, will make all the difference between life and death. In the commencement of fever, a slow and oppressed pulse, or a slow and intermittent pulse, accompanied with suspirious respiration, or respiration interrupted with frequent sighing, denotes one form of the acutest cerebral disease ever witnessed in the fevers of this country. If, in such cases, copious bleeding be not employed on the first or second day, the patient will generally be in a state of hopeless typhus on the fourth or fifth. In the convalescent stage of fever, on the contrary, a slow and intermittent pulse affords the most favorable omen: and it is one of frequent occurrence. As I had not seen it noticed in any book, nor heard it spoken of by any physician, I was at first not without apprehension for the fate of the patients in whom it occurred, although I could perceive no unfavorable symptom accompanying it. But I soon observed that it was the sure sign of a safe and steady convalescence. Of all the relapses that I have witnessed, I do not remember one in which this state of the pulse existed. It is not a little remarkable, that the same external sign thus indicates two such opposite states of the system, as that present at the commencement and

at the termination of fever, and should afford two such opposite prognostics. I have to regret that my endeavour to enable my readers to distinguish and to contrast these opposite states, in order to prevent groundless apprehension in the last case, and to create immediate alarm in the first, has been attended, in one instance at least, with little success; for one of your contemporaries, after citing my statement, that at the termination of fever a slow and intermittent pulse is a sign of a sure and steady convalescence, observes -"we must pause here, and remark that an intermittent and slow pulse has been long looked on as a very unfavorable symptom in fever, and so the author admits in a subsequent page—an oversight for which we cannot account.'

Out of the last 300 patients admitted into the London Fever Hospital, I have examined the number not bled, the number bled, the number of ounces of blood abstracted from the whole, the mean quantity taken from each, and the duration of the fever and the event in both sets of cases: the result is curious and instructive. Out of these 300 patients 158 were not bled; 11 were cupped; 131 were bled from the arm; while, in all, leeches were occasionally applied, but these have not been taken into the account. Of the 158 that were not bled there died 38, or one in four. Of those who recovered, there were dismissed from the hospital, after having been under treatment in the house one week, 21-two weeks, 50-3 weeks, 38, and four weeks and longer 49. From the 11 that were cupped, the total quantity of blood abstracted was 133 ounces or 12 ounces for each; of these patients five died, or nearly one half. From the 131 that were bled from the arm, the total quantity of blood taken was 2557 ounces, or from 19 to 20 ounces from each: of these there occurred 12 deaths, or one in I nearly. Of those that recovered, there were dismissed from the hospital in the first week 12-in the second

week 40-in the third week, 41-in the fourth week or later 38.

The proportion of deaths in the list of those not bled, and of those cupped, is without doubt increased, by its containing those who were received into the hospital at too late a period of the disease to admit of general bleeding; but, on the other hand, the proportion of recoveries, and the rapidity of recovery, are augmented by its containing those in whom the disease was so mild, as to require neither bleeding nor any active remedy; while the 131 that were bled offered a fair average of the state of fever, as it occurs for treatment to the physician in ordinary practice, but not as it occurs to the general practitioner, who, in consequence of seeing his patients at a much earlier period of the disease than the physician, can abstract blood with incomparably greater advantage. Were this truth duly impressed upon the mind of this part of the profession, and could they be induced, during the first, second, and third days of the disease, to use the lancet with cautious boldness until the pain of the head is subdued— the mortality of fever would be diminished at least one half, and its duration a week or a fortnight. I am, Sir,

ROYAL COLLEGE OF SURGEONS. MR. GUTHRIE Completed his Surgical Lectures at the College on Saturday, the 15th instant. Having noticed the injuries of the head, of the chest, and the diseases of the urethra; on the last day, he shewed the instrument used for breaking a stone in the bladder, with an improvement which, he said, was of the utmost importance, rendering it a perfectly safe instrument, which it was not before. It could now be taken to pieces in the bladder, and each piece might be drawn out separately, so that no accident could now arise, capable of

that he was led to make this improve

hearing of the right ear. The pulse had fallen to 70. The blister was repeated to the head, and he was ordered gr. ii. calomel three times a day. In the course of a week his mouth became affected, and the medicine was therefore omitted. He continued daily to improve, and was dimissed well on the 8th June, having been a patient in the hospital exactly a month. At this date, the features did not appear at all to be distorted, except when he laughed or attempted to smile. He did not recover the sight of the right eye."

The case is not drawn up with much care, for in one place it is said that the vision of the right eye was destroyed, and in another, of the left. Such carelessnesses as these are always reprehensible. Dr. Auchincloss observes, and every experienced surgeon will agree with him, that the case was evidently one of concussion with partial pressure from extravasation. The recovery from the state of insensibility and the continuance of partial palsy of the face with hemorrhage from the ear are sufficient evidence on these points.

"This person was not admitted till after the eighth day, by which time the inflammatory stage subsequent to the accident, had subsided under the usual means. The principle observed in the treatment was to excite absorption, if the symptoms depended on effusion, or, supposing these to be the consequence of concussion, to rouse the tone of the nerves. Both ends, probably, were accomplished by the measures had recourse to ;—namely, counter-irritation, and the exhibition of mercury.

"On the fourth day from admission, there was a return of feverish symptoms, with pain in the situation of the ear, which readily yielded to a full bleeding. This perhaps depended on an inflammatory state of the brain, excited by the effused blood. In cases of effusion into the substance or on the surface of the brain, we often meet with accessions of inflammation, occurring in the progress of its absorption. In this respect, the presence of the fluid seems to act merely as a cause of irritation, and may therefore be compared in its operation to that of an exostosis, or any other tumour, in producing fits of apoplexy, &c.

“One other circumstance in this case rather uncommon, may be mentioned, viz.—that the motions of the iris of the blind eye remained perfectly free. From this it is evident that the mobility or immobility of the iris, is by no means an index of the sensibility of the retina, at all to be depended on. This is owing to the iris being supplied by the ciliary nerves, which proceed from the lenticular ganglion. I have frequently met with cases of amaurosis with active pupils, and vice versa,—an immoveable state of the pupil with perfect sensibility of the retina."

CASE 2. Concussion-Slight Compression-Secondary Symptoms. James Gorman, æt. 30, admitted June 4th, in a state of insensibility, with abrasion of the left cheek and dislocation of the left thumb. When placed in bed he lay in a semi-comatose condition, returning no answer when loudly questioned, moaning frequently, and restlessly tossing his limbs when pinched. Pulse 120, sharp; respiration slow; skin hot and dry. On the day preceding his admission he had leapt from the roof of a one-story house, whilst intoxicated, and pitched upon his head. Venesection to twenty ounces-sixteen leeches to the head, with cold lotions—purge of calomel and senna draught. The bleeding was repeated on the 5th, and on the 6th he was more composed, had a pulse at 90, and put out his tongue when requested; the pupils, especially the right, were dilated. On the 8th he was quite sensible, but complained of slight head-ache; pulse 70; tongue clean and moist. That night was restless, and on the 9th he had a vacant expression of countenance, with stupidity in answering questions. Blister to the head. In the night he was so delirious as to require a strait-jacket, but it was delirium without pyrexia. Blistered surface dressed with savine— calomel gr.ij.3tiis horis―low diet. The mouth became "smartly sore," the patient got daily better, and was dismissed cured on the 1st July.

In a fortnight he was re-admitted with vertigo, double vision on walking, and occasional pain shooting through the head. Cupped on the nucha, blis

tered, and ordered calomel pill thrice daily. In five days the mouth became affected and all the symptoms were much relieved. On the 29th the medicine was re-commenced, and a caustic issue established in the neck; violent ptyalism ensued, the symptoms wholly disappeared, and the patient was again dismissed on the 10th of August. On the 23d he was again received with nearly the same symptoms as before, but little or no pain in the head. The issue was re-opened, the mercury repeated, and a strong liniment applied to the head. The mouth becoming affected, the symptoms began to wear off;" the mercury was repeated, and the patient left the hospital on the 15th September. He shewed himself again in February on his return from Ireland, and stated that he continued to enjoy good health.

This is an interesting case, and in all probability slight extravasation or even laceration of the brain was joined with the concussion. The occurrence of what we have termed "secondary symptoms," and their apparent subjection to mercury, are not amongst the least important features. We say apparent subjection to the influence of calomel, for the evidence of its powers is not quite positive in the written details of the case. Let us hear the opinions of Dr. Auchincloss.

"The treatment was very simple. The man had suffered a severe mechanical shock, to which inflammation, as a necessary consequence, had succeeded. The chief indication then was to subdue arterial action. This was effected by bloodletting in sufficient quantities to control the force of the circulation, the advantages of which were strikingly apparent. Although rather a tedious case, it was otherwise very interesting. The frequent return of vertigo, double vision, &c. proves to me that it was in every likelihood complicated from the commencement with partial laceration of the brain, and slight extravasation of blood; or that perhaps effusion of serous fluid had happened after the cessation of the inflammation. I should imagine it more likely to have been caused by the first. One or other of these circumstances, however, suffici

ently explains the loss of memory, giddiness, double vision, &c. We often find similar effects to supervene on the cure of phrenitis, or in cases of fever where there has been a great flow of blood to the head, and more particularly in injuries of the head with decided extravasation of blood.

For the removal of these symptoms, the treatment consisted in obviating, in the first instance, the chance of the recurrence of inflammation, and afterwards in favouring absorption by counter-irritation. The former was accomplished by cupping and the use of purgatives; and the latter by the repeated application of blisters, and the formation of a caustic issue. After a sufficient trial, these were found to be perfectly ineffectual. Mercury as an ulterior measure was therefore had recourse to, and used freely and repeatedly with the best effect.

"As soon as the mouth got fairly under the influence of the medicine, the unfavourable symptoms uniformly began to subside. Their frequent recurrence convinces me that the brain perhaps may have been slightly lacerated, giving rise to partial effusion of blood, either at the time of the accident, or at a period subsequently to it. Instances of secondary hæmorrhage are certainly rare, though several are on record. The same line of treatment is applicable to both cases.”

CASE 3. Concussion-Scalp Wound Secondary Symptoms. John Curbaus, æt. 21, a slater, admitted Sept. 8th, with a wound an inch long through the integuments of the right eye-brow, and another over the right temple where the bone was exposed, and the probe could be passed for three inches upwards and backwards. He had little head-ache, but chiefly complained of a fixed pain in the hypogastrium with inability to make water, and a quick pulse. He had fallen from a scaffold two stories high on the preceding day, struck his head in the descent against the edge of a wall, and received a quantity of slates upon his back. Catheterism-edges of wound brought together by plaster-fomentations to the bellycastor oil. The fever being increased