him at my house for the purpose of obtaining further advice. He seemed evidently benefited in appearance and strength. A continuance of the remedies was advised; substituting for the calomel grs. iij. of mass. hydrg. and the extr. taraxac. for the fresh juice. The seton was again recommended.

"With sentiments of the highest respect, "I am your friend,

"F. A. VANDYKE."

"Hawthorn Cottage, Oct. 14th, 1833.”

August 25th.-Mr. Miles had a renewal of his attack of hepatitis: a considerable tumefaction of the right side was apparent, attended with extreme pain. The ordinary depletory remedies were resorted to by Dr. T. Harris, who, in consequence of my being from town, was kind enough to take charge of the patient. He was leeched on the side freely; a blister plaster was then applied, and the blistered surface kept open; it being dressed occasionally with morphia to diminish the intensity of the pain which shot down from the liver to the right iliac region. The administration of blue mass with morphia was also instituted; the mass being given to the amount of two grains daily.

On the 2nd of September I resumed the charge of the patient, and continued with but little interruption the treatment which had been instituted by Dr. Harris. The descent of the liver below the right margin of the thorax amounted at that time to three or four inches, and it formed a very conspicuous indurated swelling. About the 20th, fluctuation was perceived, and became each day afterwards more distinct. Occasionally excruciating paroxysms of pain came on, which were generally relieved by an opiate. The patient in the meantime evidently declined in health, and became subject to exhausting perspirations. Under these circumstances, we looked anxiously for the spontaneous evacuation of the abscess through some of the common routes for such matter, but, being disappointed in this, the expediency of operating through the side was suggested, as it was clear that death must come in a short time without relief. The great objection to the operation was, however, ignorance of the fact, whether an adhesion had formed between the liver and the anterior side of the abdomen, and, if this were

not the case, the unavoidable risk of opening the cavity of the peritoneum, and the probability of some of the matter of the abscess running into it and producing inflammation.

The case being in this unpromising condition in every view of it which could be taken, a choice of evils only was left; and with the consent of the family, and the advice and assistance of Dr. Harris, the operation was undertaken Oct. 1st. An incision was first of all made horizontally on a line with the anterior end of the eighth rib on the right side, a little in front of its cartilage, and through the side of the abdomen, which brought the liver into view; the latter was seen to rise and fall with the diaphragm in respiration ; morever, a knife handle was introduced between the surface of the liver and of the contiguous part of the abdomen; these two facts made clear the thing apprehended, to wit, want of adhesion. In this dilemma I determined to stitch the liver to the side, which was accomplished with a large crooked needle, armed with a ligature of kid skin, and of bulk sufficient to fill up the hole made by the needle. One stitch was made in this way parallel with the upper margin of the incision at the distance of four lines from it, and another in the same manner below. The liver being thus fixed closely to the side, a trocar and canula were plunged into the abscess, and five gills of purulent matter were immediately discharged to the great relief of the patient; the matter continued to flow during the night, so that three or four more gills were discharged. The operation being ended, a bandage was put around the abdomen so as to keep its viscera as still as possible. The canula was left in for fifty-four hours, and then a piece of a flexible catheter was substituted. The abscess discharging all this time small quantities of pus and serum mixed.

On the second day the bowels became tympanitic, and there was hiccup, with colicky pains. On the third day there was a manifest declension of strength, and it became evident that the previous exhaustion of the patient must render the operation nugatory. The symptoms of debility increased, and the patient died on the 5th inst. No sign of peritonitis followed this operation.

In twenty-two hours after death an exa

mination was made. A recent adhesion between the liver and side had occurred immediately around the puncture of the trocar, and which along with the stitches had prevented any pus from getting into the cavity of the peritoneum. The latter membrane was entirely sound, and had no appearance of being irritated by the operation. The cavity of the abscess was collapsed very much, and contained sheds of coagulating lymph mixed with pus, amounting in all to about one gill; its parietes were lined by a membrane. The right lobe of the liver being the seat of it, the anterior half was gone, but it appeared to be rather by pressure and absorption than by dissolution, as no remains of the liver were seen in the discharges. There was no preternatural adhesion of the liver to the parietes of the abdomen, excepting what was made by the operation. The left half of the stomach was destitute of mucous coat, it having been dissolved completely, so as to exhibit the cellular coat naked.. Six inches of the beginning of the colon were studded with alcers having red, injected, and elevated edges. The small intestines were sound.

Though life was not saved by this operation, evidently owing to the exhaustion of the patient at the time of its performance; I yet consider it as illustrating the fact, that hepatic abscess may be managed by opening it, even when adhesion to the side has not occurred, provided the liver be secured in the way described, or by an equivalent process; and, after a deliberate review of the case, I only regret that I did not resort to this treatment when the abscess first fluctuated.

CASE IN WHICH SAND WAS VOIDED BY THE MOUTH, RECTUM, URETHRA, NOSE, EAR, SIDE, AND UMBILICUS, AND ATTENDED BY VARIOUS OTHER ANOMALOUS SYMPTOMS.

BY C. TICKNOR, M.D., OF NEW YORK.

MISS LUCY PARSONS, of Egremont, Berkshire county, Massachusetts, when about eleven years of age received an injury by the fall of a barrel across her loins, which was followed by exquisite pain, and an almost total loss of the power of locomotion. The pain after a time subsided, and the ability to walk gradually returned, though partial paralysis of

VOL. VI.

the lower extremities, accompanied with severe pain, would almost immediately recur after much exercise. This state continued till about seven years after the receipt of the injury, when some portion of the surface was attacked with an erysipelatous inflammation, which, by metastasis, fixed itself upon the abdominal viscera. The patient now suffered excruciating pains, particularly of the right lumbar region, together with all the various symptoms of diseased stomach and bowels, was unable to walk, and mostly confined to her bed, till I saw her in the autumn of 1831, more than twenty years after the attack of erysipelas.

My brother first saw the patient in consultation with her attending physician: he found her labouring under a profuse diarrhoea, which threatened a speedy termination to all her sufferings; food would pass in ten minutes, to all appearances precisely as it was taken into the stomach, without smell or change of colour. At this time a few grains of calomel put a stop to the diarrhoea, and the patient remained one hundred and nine days without any fæcal evacuation per rectum. The most active cathartics had no other effect than to cause pain and irritation of the bowels, and a vomiting of their contents. An injection thrown into the rectum would be vomited in a few minutes, having the same appearance as when administered, and free from any admixture of fæces. During this period of one hundred and nine days the patient experienced a regular vomiting each day of the food, properly digested, which she had taken the preceding twenty-four hours. About this time there was something of a peculiar appearance in the matter vomited, which, on washing, proved to be sand; and on examination it was found that sand was also discharged with the urine. The bowels resumed their office, and it now became the turn of the bladder to have its contents expelled by vomiting; the patient experienced a strong desire, without the ability, to pass the urine by the urethra; and, on trying to introduce a catheter, the passage was found occupied by a hard substance, which rendered the operation impossible. The urine was now vomited for several days, though it occasionally passed per rectum, mingled with sand, till a quantity of sand stones, or lumps of concrete sand, were

C

10th. No spasms since last date till to-day; omitted the pills yesterday, and to day the spasms returned; no natural evacuation from bowels or bladder since 20th July; contents of both are vomited; appetite tolerable; has ridden out several times since last visit; left leg continues flexed. Treatment the same. October, 1833. Have not seen the patient for more than a year: her sister gives the following account of her condition during that interval. Her bowels soon became quite regular, and so continued for some time, then relapsed into their former obstinately costive state, when their contents have been vomited; appetite has been generally good; left leg during the whole time has continued flexed, and attempts to extend it have invariably caused frightful spasms; has ridden out frequently, done a good deal of needle work, and may be said to enjoy comparatively good health. I ought to add, that during the whole illness of this patient her catamenial evacuations have been generally regular, though at times rather profuse.

A lump of sand discharged from the bowels, which Dr. Torrey and Dr. C. A. Lee, of this city, had the kindness to analyse for me, proved to consist of silex and lime, and a few short hairs; the former making much the greater proportion. Professor Averill, of Shenectady, did me the same favour, with the same result.

Most of the facts related in the above case, besides being witnessed by my brother, Dr. L. Ticknor, of Salisbury, Conn., and myself, can be vouched for by the following gentlemen. Dr. Bolton, of Egremont, Dr. Kellogy, of Sheffield, Dr. Wheeler, of Great Barrington, Professor Averill, of Union College, Drs. Cleaveland and Flallenbeck, and Mr. Oliver Whittlesey, of this city.

The interesting features of this case will readily suggest themselves to the mind of every reader. It furnishes an extraordinary example of the amount of disease the system can sustain when nature is playing her wildest freaks.

la regard to the imposition which the patient practised, or at least might have practised, I may state that she has sustained a character for genuine piety, and to have lived with her two maiden sisters who have had the sole care of her for more than twenty years; they had a small estate, which, with frugality, would

support them all, and there can be no reason why she or her sisters should wish to deceive. I have hesitated about publishing the case, but I believe it a duty I owe to my profession not to withhold the facts, however they may be accounted for, or however little they may be believed. I have thought best to give the facts and the facts only-the patient is still living about fifteen miles from where my brother is practising, and he may yet detect her in her imposition if she is not put upon the look out by publishing speculations prematurely. Can these phenomena be accounted for without calling in the aid of imposition ?— American Journal of the Medical Sciences.

Foreign Medicine.

Chorea in Children.

BY M. RUFY.

Out of 32,976 children, admitted into the Hôpital des Enfans (17,213 boys, and 15,763 girls), during ten years (from 1824 to 1833), 189 were affected with chorea, amongst which were observed 51 boys, and 138 girls. Contrary to the general opinion of authors, in the preceding number the disease was observed as frequently from 6 to 10 years, as from 10 to 15. In a table published by the reporter, we observe the disease attacking, from 6 to 10 years of age, 16 boys and 45 girls,-total 61; and from 10 to 15, 30 boys and 88 girls,-total 118. Feebleness of constitution and fright are the only well founded predisposing causes which influence the development of this affection. We have never observed in the Hospital of Children the disease transmitted by imitation. Out of 25 cases of chorea, we have seen it 9 times general, that is to say, occupying the superior and inferior extremities, the trunk and face. Five times it occupied the two superior limbs, the inferior not in the least partaking of the disease; five times the extremities of the left side, once the right; four times the left arm, once the right. In the cases of general chorea, twice out of nine cases the movements of the left side were more pronounced than the right. These results fully confirm the opinion of many authors, viz. that this affection more frequently attacks the left side. It has never been observed in this hospital to have c 2

affected alone the inferior extremities. The muscular agitation in general abates during sleep.

The length of time in the hospital, calculated from the above 189 cases, before the agitation is checked, has been about 31 days.

When chorea is chronic, that is to say, when it is indefinitely prolonged, its attack is generally partial, and the patient attacked is liable to a relapse. In the majority of cases, it exists without any complication, and more particularly without fever. It is seldom we have an opportunity of examining the anatomic lesions after chorea. In four cases observed by the reporter, the results of the autopsies have been negatory. Also in two other cases, which were communicated to him, no organic lesion could be detected, either in the encephalic substance, in the spinal marrow, or in their membranes. The affections that caused the death of the four observed by M. Rufy, are, for the two first, measles, peritonitis for the third, and, finally, chorea for the fourth. In this last, death: appeared to take place from asphyxia. The reporter of the above facts also names, that M. Guerunt has had more opportunities than any one of seeing children die from this affection alone, without any functional alteration, and by only an exasperated state of motility. In every case, death was speedy, and the symptoms at last were adynamic. Can we not suppose, that in these subjects death originated from the loss of nervous fluid, as in certain severe operations we observe patients die from pain?

MR. DERMOTT ON HOSPITALS AND DISPENSARIES.

To the Editors of the London Medical and Surgical Journal.

GENTLEMEN,-As the following observations refer to actual facts, your impartial liberality as Journalists will permit "a free discussion" of the important topic to which they allude. It is with some astonishment that I perceive you dispute the opinion which Lord Brougham expressed regarding Hospitals and Dispensaries.

The quotation, which you make from his Lordship's speech, was not intended by the

speaker, I should presume, to depreciate the charitable principle of disinterestedly bestowing medicines and advice to the sick poor, but evidently refers to the present abused state of those establishments; we full well know that no charities are prostituted more than hospitals and dispensaries; the glaring abuses in them are every day getting more and more palpable to the reforming community at large.

"Such hospitals as Guy's and St. Thomas's are, in the strict sense, useful" as real charities "so far as they are open to accidents," because accidents, and accidents only, are admitted without private patronage, or "letters of recommendation." These letters are a species of mock charity, which ought, for the credit of England, to be abolished. The use made of them by the majority of the Governors, entitled to them by their subscriptions, is to farm their domestics and servants, or those of their friends and customers, upon the institution. Very many of these letters, consequently, do not reach the hands of those absolutely poor.

In corroboration of this we frequently hear medical practitioners declaring how much these charities, so called, are abused by the many affluent masters of families sending their servants and dependents to these places, when they ought, as a matter of propriety, to call in the household medical attendant, General practitioners more especially complain loudly of the degree to which their practice is unjustly curtailed in this manner. Besides, as the "letters of recommendation," which each Governor is empowered to give, are very li mited in number, should he not recollect, that, by employing one in behalf of a domestic, advice for whom he can well afford to pay for, he is diminishing in the same ratio the number of those absolutely poor that can be relieved by the institution. Do we not know that it is perfectly possible for a poor sick person, we will say with pleuritis or phthisical symptoms, to campaign through wet for days after "letter of recommendation," and perhaps not succeed in obtaining it after all, or if he does, the complaint is probably so increased by this "letter-of-recommendation-hunting," as to terminate fatally. This petty patronage exists in the highest possible perfection, both in hospitals and dispensaries. It alone is suf

a