scrotum did not prevent the occurrence of extensive sloughing, which, however, was the immediate consequence of the blow, and not of the extravasation. On the 24th, when the pain and redness about the pubes indicated still further extravasation, a free incision in perineo was resorted to, although Mr. Key feared, at the time, that the mischief proceeded more from the sloughing of the parts about the urethra, than from impediment to the exit of the urine. This opinion was unfortunately correct, for the infiltration extended between the muscles and peritoneum as high, nearly, as the diaphragm, showing that the fascia which forms the boundary between the perineum and cellular tissue of the pelvis had sloughed. Under these circumstances, it was deemed proper to make a free opening for any matter which might form, and support the powers of the constitution. This was all that could be done, and this was of no avail.

The case is reported in a very creditable manner.

FATAL DISEASE OF THE BRAIN MISTAKEN.

A gentleman (Mr. B.) aged about 30 years, had a fall from his horse, about the month of December, 1826, by which he was stunned, but from which he soon revived, and took no farther notice of the accident. In February of 1827, he began, for the first time, to feel deep-seated pains in his head, especially towards the occiput, and, soon afterwards, sickness at stomach, and even vomiting. These complaints gradually increased, and resisted every remedy. In the beginning of September he came up from the country to London, and went to a celebrated and eccentric surgeon. He was then very ill, and his wife told the surgeon that her husband was dreadfully afflicted with pain in his head, and sickness at his stomach. "Say no more," said the surgeon-" I see what is the matter. Put out your tongue. Take this prescription, (giving him bluepill at night, and black draught in the morning,) and go home." He would not

hear a single word of the patient's history, nor examine into a single symptom except the state of the tongue. In a week, the gentleman was much worse, and the writer of this article was sent for. The countenance of the patient, the vacant stare of the eye, and the difficulty of articulating his words, gave strong reason to suspect disease of the brain. On further examination, it was found that Mr. B. was totally blind of the left eye, and deaf of the left ear. There was considerable difficulty in clothing his ideas in language

and, indeed, there was also much confusion of thought, and some loss of memory. The pains in the head were excruciating, and generally produced vomiting once or twice a day. The pulse was extremely small, and very slow-sometimes irregular-the body was emaciated-the appetite almost gone-the bowels torpid. The pupil of the left eye was more dilated than that of the right, and little obedient to the light. There was no paralysis; but there was great debility of the limbs, with staggering, on attempting to walk. There were also cramps felt in different parts of the body, which, in a few weeks afterwards, amounted to convulsions resembling epileptic fits. After this examination, and receiving the account of the fall, no man could doubt that the disease was seated in the head, and that the sickness of stomach was merely symptomatic of the cerebral disease. The diagnosis and prognosis were stated to his wife, who was greatly shocked at the intelligence, the surgeon having assured her that it was merely disorder of the stomach. Counter-irritation in the neighbourhood of the head -leechings-cold to the scalp-and gentle aperient medicines gave a temporary relief, and entirely removed the gastric irritability, which never afterwards returned. But in a few weeks the cramps rose gradually to convulsions-the emaciation increased-the head-aches continued-the pulse became as feeble as a thread-and, on the 5th December, death put a period to his sufferings. During the two months preceding death, he was daily visited by Mr. Stevenson, surgeon, Edgeware Road, and the reporter only saw him once or twice a week.

On the 6th December the head was examined. On removing the calvarium the convolutions were seen to be much flattened and compressed, which prepared. us for some tumour or hydrocephalic dis

tention. The hemispheres were very firm, which firmness gradually decreased as we receded from the surface, and approached the corpus callosum. This part of the brain was very soft. There were four ounces of clear water in the yentricles. The septum lucidum was gelatinous, and there was a large perforation in the situation of the foramen of Monro. The iter ad infundibulum was so enlarged that the finger might be readily passed down to the sella turcica. All the parts in this neighbourhood were in a state of complete ramollissement. The thalami nervorum were very much softened, and the tractus opticus was completely rotten. The optic nerves, especially the left one, were greatly wasted. On taking off the tentorium, a tumour composed of a cluster of hydatids, apparently with some tubercles intermixed, was seen closely adherent to the petrous portion of the left temporal bone, and pressing upon the left lobe of the cerebellum, as well as upon the medulla oblongata. It had completely annihilated the seventh pair of nerves on that side-and it had raised up the fifth pair of nerves, which were seen stretched tightly over the protuberant morbid mass. It was about the size of a small pullet's egg.

The loss of hearing is thus readily accounted for on the left side; but how was

it that we had no distortion, paralysis, or loss of feeling in any part of the face, although the 7th pair of nerves was destroyed, and the fifth pair were greatly stretched and driven out of their natural situation by the tumour?

Considering the wanton manner in which the feelings of patients are sported with by some medical men-and reflecting on the foregoing sample of indiscrimination-nay, of positive error, arising from a preposterous adherence to a preconceived doctrine that blinds the eye to every object, we should feel it, in some degree, criminal to conceal such a monstrous mode of prescribing for dis eases of the most dangerous or fatal na ture, without giving one's self the least trouble to investigate the history, symptoms, or seat of the complaint. We hope this will meet the eye of the surgeon who so unceremoniously decided on the nature of the above mentioned unfortunate gentleman's fatal malady. His feelings would not be enviable, we imagine, if he suf

fered himself to reflect, for a moment, on the terrible consequences which must often result from such a mode of carrying on the practice of medicine.

THAMES WATER.

We understand that the Committee of Inquiry into the purity (God help us!) of the water supplied from the river to the inhabitants of this metropolis, is now sitting. We hope and trust they will do their duty. We have reason to believe that active exertions are making to enlist chemistry against cleanliness-and to persuade the town that, "what will not poison must fatten." We shall keep a very sharp look out upon the transactions of this Committee, and we promise to dissect the results of their inquiry with the sharpest critical instruments in our possession.

SYMPATHETIC APOPLEXY.

Some people are as tenacious of life as worms, or as animals which we may divide into pieces without destroying vitality. A gentleman, who had long shown symptoms of what Rostan and others

would have termed "Ramollessement du Cerveau," fell down, the other day, in a fit of apoplexy, at the age of 68, and not the slightest impression was made by cupping, leeching, blisters, enemas, and all the means which a trio of physicians (including Dr. Warren) could suggest. Mapleson left the patient for dead, after taking four ounces of blood from the head; and he was apparently in articulo mortis, after 48 hours of general paralysis, total insensibility, stertorous breathing, glassy eyes, and "dead rattles" in the throat! The physicians parted-to meet no more-at least in that case. The ordinary physician took his leave at 12 o'clock at night, requesting to be informed in the morning, at what hour the patient died. No message having been sent, the physician called in the morning, and found to his no small surprise, the patient at his breakfast, quite sensible, and with the full power of all his muscles!! The patient, soon after this, disgorged some pints of fetid bile, and had no return of

apoplectic or paralytic symptoms. This is one of the many cases, where irritation of the chylopoietic nerves will simulate diseases of the most fatal character-and especially those of the brain and nervous system generally. Nothing is more common than partial paralysis, particularly in children, from indigestible matters in the primæ viæ; and we are convinced that many of those apoplectic attacks, from which we see people quickly recover, without any remaining paralysis, are dependent on gastric or intestinal irritation. The foregoing case is a good example.

LIBERTY OF THE PRESS.

We need hardly appeal to our readers, as to the fact of our having long and steadily resisted the calumnies and misrepresentations of the LANCET. For this we have been the constant theme of vituperation in that journal, for years past. Every one knows how Dr. Johnson has been abused, nick-named, and vilified in the LANCET; but few are aware that he is now threatened with the fourth law-suit, for daring to retaliate on a journal that is always bellowing forth about the LIBERTY OF THE PRESS, while abusing all, except the members of its own junto.

The first action was brought against Dr. J. as Editor of the MED.-CHIR. REVIEW, in the Summer of 1826. A similar action was brought against the PRINTER, for the same libel-and that for the sole purpose of doubling the law expenses, for Dr. Johnson never attempted to evade his responsibility. These two actions cost Dr. Johnson 7001. A third action was brought against Mr. Highley, the publisher, for having sold to Mr. Wakley himself, a single copy of the uncancelled journal, which had been accidentally returned to his shop, as a back number, from one of the houses in Paternoster Row! With a great deal of difficulty, Mr. Highley got the action compromised, by paying 32 pounds sterling, which Dr. Johnson considered himself bound, in honour, to repay. The fourth action is an. nounced, for having, in our last Number, accused the LANCET, as a journal, of falsifying (through its reporters) the cases that occur in public hospitals-and of

paying the highest price to those reporters that show most ingenuity in garbling and distorting those cases occurring under physicians and surgeons, not of the JUNTO. Mr. Wakley takes all this to himself, though we have distinctly absolved him (and here repeat it) from these charges, and laid the blame on his reporters, his hireling writers-and on some others of the junto unknown or unseen. If Mr. Wakley will turn to page 247 of our last number, he will see, unless his vanity be much greater than his discernment, that we do not accuse him of brib. ing, with high fees, the falsifying report

ers.

"Will it be believed, that there are men, in this great metropolis, who rank high in medical science, but who are wicked enough to expend considerable sums in the reward of those who can invent the greatest, but, at the same time, the most plausible falsehoods, against the brightest characters in the profession ?" Is it possible enough to suppose that we mean him in that Mr. Wakley can be vain or shallow such passages? Could he get any man in London to say, in a court of justice, that he is the man alluded to? He knows full well he could not. In respect to the charges, then, against the LANCET, as a publication in which many are concerned, whose names do not appear, we retract not one iota of what we have advanced. If Mr. Wakley will still insist that he himself is the LANCET-a surgical INSTRUMENT, or a medical newspaper-why let him come into court in a shagreen case -or neatly folded up and stamped, price one shilling, and we swear by Apollo

"Solem quis audeat falsum dicere."

Yea, by every God in Heaven-except MERCURY, the God of false reportersand, therefore, perhaps one of the juntothat we will put a JUSTIFICATION on the record against the said LANCET, and verify our accusations by the greatest mass of evidence that ever came into the King's Bench or Common Pleas. Yes! and we will bring into court certain other personages, who, perchance, may wish themselves a thousand miles off on that fatal day!

"Give us the opportunity, (to use Mr. Wakley's own language, towards two of his EX-EDITORS,) kind, modest Editor, of publicly extracting from these wretches, (REPORTERS) a history of their own infamy, and we will ever after call thee-FRIEND.

1. PENNSYLVANIA HOSPITAL.

ON DELIRIUM TREMENS.

[By Dr. Coates.]

THIS mysterious and dangerous disease is very common in the United States of America, where the excessive use of ardent spirits is but too prevalent. The transatlantic physicians, therefore, have ample opportunities of studying the phenomena, the pathology, and the treatment of mania a potu, as it has been called. Dr. Coates of Philadelphia, has lately published a very extended and interesting memoir on this subject, in the North American Medical and Surgical Journal, from which we shall make some extracts in the present paper. We shall begin with the conclusions to which our author has come, from extended observation, reading, and reflection. These are in the form of aphorisms:

"1. The disease is a delirium, and not a mania; and this distinction should be attended to, both for medical and legal

reasons.

2. It consists in a heightened activity of the sensorium; and this appears to arise from the generation, in that organ, of an unusual vital power, which is not, as in common, exhausted by the narcotic poisons habitually used. This is not considered as an hypothesis, but the expres sion of a fact existing in nature.

"3. The delirium may be combined with other diseases and injuries, situated in many different parts of the body.

"4. When violent, it obscures and renders imperceptible most of the symptoms of the co-existing disease.

"5. It is doubtless necessarily accompanied, as all vital excitements are, with an unusual amount of the circulation of VOL. VIII. No. 16.

59

the blood in the organ affected; and is, from this cause, sensibly influenced by cups, blisters, and emetics. It is not so far checked by the use of emetics as to render these advisable as a leading means of cure. It is not sufficiently under the control of the general circulation to be cured by venesection, or to be sensibly relieved by it without such an exhaustion as is highly dangerous to life.

"6. It is entirely and absolutely under the control of opium; although the fevers and other diseases which are liable to accompany it may be by no means so.

7. It admits of very large doses of opium, which are not productive, either at the time or subsequently, of any injurious consequences, provided they are not repeated after a tendency to sleep is evinced.

"8. The patient must sleep or die. There is no alternative. Yet the physician should personally watch the effect of very large doses of opium.

"10. Purgatives are of no use in this delirium; but it is necessary to prevent costiveness subsequently to the administration of opium. Purgatives may be necessary for diseases which exist at the same time; but when this is the case, they are, in general, most advantageously postponed till after sleep has been ob

tained.

"11. Gentle stimulants are frequently useful during the convalescence; but these should not resemble ardent spirits; and an excellent and sufficient one is capsicum. Nor should any ardent spirits, unless indicated by peculiar circumstances, be given during the paroxysm."

From the second aphorism, it will be seen that Dr. Coates considers " a heightened activity of the sensorium," as the pathological condition of the brain,

in delirium tremens, though the disease may be complicated with, or produce an increased activity of the circulation, or inflammatory action in the organ. We believe this pathology to be as near the truth as any that has yet been adduced, and therefore we shall not dwell on this part of the investigation, but proceed, at once, to the treatment.

In the United States, this is a combination of several modes of practice, varying with the existing condition of the patient. This is probably the best-but still, as Dr. Coates observes, it would be desirable to have some fixed principle for our guidance in pure and unequivocal cases. Thus it would be proper to have made up our opinion whether the disease be inflammatory or nervous, for if we proceed on the former principle, we shall do much mischief. If the disease be complicated with other affections, as bilious fever, pulmonic inflammation, &c. we should modify our practice accordingly. Bred up in the Pennsylvania Hospital, Dr Coates' first experience was with the stimulo-narcotic treatment-the narcotic, however, being in much smaller doses than are now employed. Our author was shocked with the mortality that obtained. He saw, for example, three men die in succession of delirium tremens, who came in with fractures.* Those who recovered, were invariably observed to fall into a long and quiet sleep, as a prelude to the cessation of the disease. Those who died never experienced this "solace of their woes" before dissolution.

"A patient belonging to the

upwards of a week, I judged that, according to ordinary experience, the patient must certainly die, unless he obtained sleep. I gave him six grains of powdered opium every hour, visiting him, and carefully watching the effect of the sedative at every dose. It was not till thirty-nine grains had been thus adminis. tered, that a decided tendency to sleep was observed. Rest, however, not being obtained, another dose was given, making forty-five grains; and full sleep was produced within another hour. Next morning, the patient awoke perfectly rational. Delirium returned, in a slighter degree, for several nights following; and minor doses of opium continued to be given for a long time after; longer than I now ever find necessary. But the patient's life was saved; and he recovered sufficient strength to struggle with a long and severe surgical disease, to regain his health, and return to his professional employments. He subsequently died of yellow fever, at New Orleans."

Another patient recovered by the administration of 400 drops of laudanum in five hours. The impression made by these two cases induced Dr. Coates to act afterwards on the principle "THAT

SLEEP MUST BE OBTAINED AT ALL HAZ

ARDS;" and this, we are informed, led to a success which, as time advances, has more strongly confirmed him in the belief of the propriety of the said principle. Wherever time has been allowed for the administration, by repeated doses, of a large amount of opium, this practice was alway successful in curing the delirium. In some cases, the patients ultimately died of inflammation in some viscus, but

a delirium tremens of extreme violence. From a form at the commencement entirely intermittent, his delirium had become continued, increased greatly in violence, and resisted the action of very large doses of opium, carried, in one evening, beyond the amount of twenty grains, and accompanied by considerable quantities of alcoholic drinks. In this situation, his pulse rapidly declining, while the delirium was regularly increasing, and after the disease had continued

*Was not this disease the " TRAUMATIC DELIRIUM" of Dupuytren, described in our last Fasciculus, page 435?

down. The following extract will give a sufficient idea of Dr. Coates' practice :

"To produce any impression of whatever kind, during this disease, opium must be given in doses increased enormously beyond those which are requisite alone, are, in a case of any severity, abfor ordinary purposes. Five or six grains solutely a nullity-they will not drive away a single spectre. The successful amount with me, has generally been from twelve, to twenty-eight, or thirty grains; but in an honest judgment, I can assign to it no limit. I have never seen, read of, or heard of, an instance in which it was productive of any harm."