yet the two morbid states are very different, and they require very different modes of treatment. As long as the tissue of the Thyroid gland is not decidedly altered, but is merely hypertrophied, we may reasonably expect to disperse the swelling by judicious treatment perseveringly employed. Not so, when any actual disorganisation has taken place. The diagnosis is usually sufficiently easy. The experienced practitioner will not confound the hard, irregular, and lobulated masses, which are the result of the degeneration of the thyroid gland, with the smooth and uniform rounded tumours, unaccompanied with any change in the colour of the skin, and in which a fluctuation is more or less distinctly perceptible. Sometimes, indeed, the gland, situated immediately in front of the neck, is parsemée with cysts which gradually dilate until they acquire an immense size; but even then it will be generally not difficult to distinguish their origin and real nature, and to discover in their circumference some parts of the organ in which they have become developed. One cyst may attain such dimensions that it compresses the surrounding parts so much as even to cause their atrophy—a condition which probably existed in the second case which we propose to relate. The parietes of the cyst present, in the majority of cases, so considerable a density or firmness that we are obliged to renounce the treatment by injecting a stimulating fluid into its sac; for this would only induce inflammation of the tumour, without being followed by any adhesion of the opposite surfaces, or obliteration of the cavity. M. Maunoir was the first to recommend the use of the Seton; and most surgeons have followed his practice. In the following two cases, however, the knife was used instead; the success obtained fully justified the propriety of this mode of treatment. Case 1.-A lady, 30 years of age, had for a length of time been distressed with sharp pain in the cervical region; her sleep was much disturbed, and her general health a good deal affected. Ever since the catamenia first appeared, there had been a fullness in the situation of the Thyroid gland. For many years it produced no inconvenience; but of late the patient was much incommoded by it. M. Fleury, when he first visited her, learned that, for some days previously, her breathing had become so much embarrassed that her attendants were afraid of suffocation. At this time the tumour of the neck was as large as the head of a full-grown child; it was quite smooth and uniform on the surface; the teguments were unaltered, except immediately in front, where they were attenuated and of a purplish hue, indicating incipient ulceration, and did not adhere to the subjacent mass, which appeared to be closely attached to the parts on which it rested. An indistinct feeling of fluctuation was perceptible on moving the tumour to and fro. On making an exploratory puncture, a few drops of a brownish-coloured serosity flowed out; the opening was enlarged with the bistoury, and a large quantity of this sort of fluid, holding in suspension a number of dark coagula, escaped. The patient experienced great relief from the removal of the pressure on the trachea and œsophagus. Some time afterwards the following operation was performed, with the view of effecting a radical cure of the malady. Two semi-elliptic incisions were made so as to embrace the attenuated portion of the skin on the front of the neck; the integuments were then dissected back from the tumour on either side, and as much of the parietes of the cyst was excised as possible, with curved scissors; but its posterior wall adhered so firmly to the trachea that it could not be separated with safety. A very great number of blood-vessels required a ligature; many of them had become enlarged to a very considerable size. The wound was then filled with lint, and a roller was passed lightly round the neck. In the course of a few days, a healthy suppuration was established, and the internal surface of the wound began to be covered with granulations. A month after the date of the operation, the patient was able to leave her bed-room, and was quite free from the horrible pains from which she formerly suffered; all the inconvenience that remained was an unpleasant stiffness in moving the neck. Case 2.-A young woman, 23 years of age, had for 10 or 12 years before she consulted M. Fleury, been affected with sharp pains on the left side of the neck, which was considerably enlarged. Immediately in front of the trachea there was a tumour as large as a full-sized orange, and which, independently of the deformity thereby occasioned, distressed the breathing at intervals; and sometimes so much as to oblige her to remain in the upright position during the whole of the night it appeared to adhere firmly to the air tube. As I thought that I could feel a fluctuation, I proposed to practise an exploratory puncture. A long narrow bistoury was therefore introduced; and from the wound there issued a small quantity of a creamy-looking whitish fluid. As little or no relief was obtained from this operation, I determined to adopt a similar line of procedure as in the former instance. A vertical incision having been made along the entire length of the tumour, the cyst was freely opened, and gave vent to about a glassful of the same sort of fluid as had flowed out before. On introducing the finger, I felt a large sac, whose cavity extended upwards above the larynx and downwards to the sternum; its walls were very hard and resisting, and its inner surface was lined with a fibro-cartilaginous covering. This large pouch was filled with lint, after several small arteries were secured by ligature, and a gentle compression kept up by a roller passed round the neck. A copious and rather foetid suppuration ensued, and continued for several days; but the character of the discharge gradually improved, and the state of the patient was altogether more satisfactory. Repeated injections of chloruretted water were found to be of great use. At the end of the fifth week, it was not necessary any more to introduce lint into the cavity; and all that was required was merely to leave a small portion of it in the orifice, in order to maintain this sufficiently open. Two weeks subsequently, the suppuration ceased entirely, and the wound healed. M. Fleury considers these two cases as sufficient to show that surgeons should not follow M. Maunoir in unreservedly condemning the treatment of Hydrocele of the neck either by simply incising the cyst and discharging its contents, or else by removing a certain portion of its parietes at the same time. It will be generally prudent to excise a small portion of the sac immediately in front; otherwise the wound will be apt to contract so much as to interrupt the free evacuation of the discharge.-Annales de la Chirurgie. M. Bouchacourt has recently published two cases of encysted Goitre, or Hydrocele of the neck, of which he effected the cure first by puncturing and then (immediately afterwards) injecting a solution of Iodine-one part of the tincture to two, three, or four parts of water. In both cases, suppurative inflammation ensued, and the swelling required to be subsequently opened, in one instance with the knife, and in the other with caustic. In the latter case, the progress was slow, and for a length of time anything but satisfactory. Several months elapsed before the cure was complete. On the whole, we (Rev.) cannot regard the recorded experience of M. Bouchacourt as very encouraging as to the effects of the treatment which he recommends. He acknowledges that he was indebted to M. Velpeau for the suggestion of using the Iodine injection in such cases.— Bulletin General de Therapeutique, Sept. 1844. อ GREAT MALFORMATION OF THE HEART; A SINGLE AUricle During the first six weeks of life, the child, (the subject of the present case) seemed to thrive perfectly well; but then the breathing became difficult, and the surface of the face and body to exhibit a blueish hue. At six months, she was seized with convulsions, which were followed by hemiplegia of the right side. This, however, gradually became less and less, and eventually the young sufferer recovered so well, that she could walk about with ease, after the right tendo Achillis (which had become contracted) was divided by M. Scoutteten. The dyspnoea and cyanosis were always increased upon any exertion; the blue tint was more prononcé on the right side. In her sixth year the girl died of an attack of Bronchitis. Dissection-The substance of the two ventricles of the heart was nearly of the same thickness throughout. The septum was almost entirely awanting, there being no trace of it except at the lower part. The orifice of the pulmonary artery was separated from that of the aorta only by a small spur, which formed the upper part of the circumference of the interventricular opening. There was only one auriculo-ventricular orifice, common to the two ventricles and two auricles. These last-named cavities were separated from each other by a thin septum, which did not reach as far as this orifice, and therefore was incomplete. The foramen Botalii also was so open as to admit the point of the little finger. Thus it was that a free communication existed not only between the cavity of the ventricles and that of the auricles, but also from one auricle to the other. The auriculo-ventricular orifice was provided with a large triangular valve, that was attached to the anterior three-fourths of its circumference, and fixed at its apex to columnæ carnea on the posterior part of the ventricular parietes. A few columna, proceeding from both ventricles, were attached to the two lateral borders of the valve. In this case, therefore, although there were distinct vestiges of four cardiac cavities, we may fairly say that the heart was simple-i. e., consisting of one ventricle and one auricle-as it exists in Batrachian animals. The presence of a single auriculo-ventricular orifice can leave no doubt on this point.-Gazette Medicale, No. 7, 1845. FRENCH OPINIONS ON THE TREATMENT OF TYPHUS. "In the treatment of our fevers, we have daily occasion to witness the pernicious effects of an irrational practice. There are still many physicians amongst us who almost invariably have recourse to the use of blood-letting and other debilitant remedies. The effect of such a course is inevitably to render the convalescence exceedingly tedious and often very imperfect. Many simple cases are thus converted into troublesome and unmanageable ones, in consequence of the impaired energy of the vital forces that has been induced. When the occurrence of the symptoms of adynamic weakness forces such practitioners to discontinue the use of their lowering regimen, they generally resort to the use of blisters and the administration of tonic medicines. Let us briefly review some of the features of the disease. There is usually a more or less considerable derangement of the stomach and bowels at first. Fortunately we have a remedy, or rather a class of remedies, which is exactly suited for the relief of such symptoms-we allude to emeto-cathartics: they generally act almost magically in removing the symptoms of the first stage of such fevers. After due evacuations both upwards and downwards, not only does the pyrexia usually subside, but all the phenomena of congestion and local irritation, that may have been present, are more or less com pletely relieved. The same decided and prompt benefit cannot indeed be expected from the use of these remedies, if the fever has already existed two or three days before they have been exhibited, and if any delirium be present: but even then the relief is sometimes very notable; the headache, stupor, and general prostration not unfrequently ceasing, or, at all events, being very materially diminished, after the action of the vomiting has entirely ceased."-Gazette Medicale, Aout, 1844. We cordially assent to the practical truth and importance of these therapeutic instructions respecting the use of Emetics and Purgatives in the first stage of most typhoid fevers. We have often expressed our own opinions on this subject in the pages of this Journal, and strenuously urged our readers to recur to the practice recommended by the older physicians, and most religiously to eschew the evil ways of such advisers as the disciples of the Broussain school. Still, we are not inclined to go quite so far as our French brother, when he goes on to advise the administration (however guarded) of emeto-cathartic medicines in almost all stages of the fever of which he is treating. The paragraph, to which we object, runs thus:-" At a more advanced period of the disease, when the patients have fallen into an adynamic state, we must be more reserved in the exhibition of these remedies; not that they are not absolutely required or allow. able; but only because the state of extreme debility usually present demands that the patient's strength be somewhat revived before they be given. Such cases require the use of stimulants-such as blisters, sinapisms to the abdomen and extremities-before we have recourse to the heroic remedy. However, as soon as the patient's strength is recovered, we should not delay longer, but resort at once to the exhibition of an emeto-cathartic: it is the sure means of preventing a fatal tendency." This seems to us dangerous advice. It is very rarely judicious to administer emetics in the advanced stage of febrile affections, when there is considerable prostration of strength; unless, indeed, the symptoms of gastric derangement are very obvious, and Nature herself makes an effort to get rid of the peccant secretions of the stomach and duodenum by the way of vomiting. The present is one out of many instances that might be adduced to show how liable the French practitioners are to carry everything to extremes. A few years ago, the mere mention of an emetic in Typhus fever-which at that time was of necessity a gastro-enterite-would have been denounced by nine-tenths of the physicians in Paris as incendiary and most dangerous practice. Now-adays there seems to be a tendency to run to the other end of the race course; and we should not be at all surprised to hear of ipecacuanha and tartar-emetic taking the heroic seat which has been so long occupied by leeches and "boissons adoucissantes."-Rev., PROFESSOR CORNEALINI ON THE PROXIMATE CAUSE AND From an extensive experience in the wards of the Pavia Hospital-to which he is attached as the professor of clinical medicine-the author deduces the following conclusions respecting this not unfrequent disease:— 1. The essential nature of chlorosis consists of two pathological conditions, both of them appertaining to the solids ;-the first being an inordinate excitation of the heart and arteries, and the second a chemico-vital alteration of the assimilative functions of Chylification and Hematosis. It is not possible to determine which of these two conditions is the primary and causal one. 2. No plan of treatment is so certain and efficacious as the exhibition of steel in some form or another: the preparations of this metal acting curatively upon both of the pathological states now mentioned. 3. There is no very marked difference in the comparative efficacy of different chalybeate preparations, except in so far as relates to their solubility in the animal fluids, and perhaps also to their readiness to become disaggregated by the pro cess of digestion, 4. The addition of an acid decidedly increases the efficacy of steel remedies. 5. Steel-filings become converted, in the stomach of chlorotic patients, into the lactate of iron. 6. It is useless-and not unfrequently it is unsafe to administer very large doses of ferruginous preparations. Professor Corneliani has examined with great care the state of the blood in chlorosis; and most of his observations go to confirm the accuracy of MM. Andral and Gavarret's statements respecting the diminution of the normal proportion of red globules and hematosine. Annali Universali. THE ACTUAL CAUTERY SUCCESSFULLY EMPLOYED IN GANGRENE OF THE MOUTH, The case occurred in a female child, five years of age, during the convalescence from an attack of Typhus fever. The peculiar (by some deemed pathognomonic) offensive odour, that accompanies this species of gangrene, was remarked before any actual appearance of the disease was discoverable. There were four gangrenous patches on the upper and lower gums, besides one on the inner surface of the right cheek. Dr. Weber determined to apply the actual cautery to all the diseased spots, and the immediately adjacent parts. This was done, not without difficulty, as may be imagined; and the mouth was directed to be afterwards washed out every two hours with a decoction of Cinchona, to which some spiritus cochlearea was added. The offensive smell ceased immediately after the application of the cautery, and did not again return. On the third day, the sloughy parts began to detach themselves; at the same time, a few suspicious-looking spots were touched with the nitrate of silver. Several teeth remained "dechaussées," and at three points the maxillary (upper) bone was exposed. These necrosed portions, inclosing a molar tooth, and two smaller bits of the lower jaw were subsequently detached. During the progress of the case, an offensive purulent discharge took place from the ears, and nume rous small abscesses formed on different parts of the body. Dr. Weber does not think that, in this case (nor indeed generally), there was any reason to suspect that the gangrenous ulceration of the mouth was in any degree attributable to the action of mercury upon the system. He points out the analogy between this disease which he designates by the name of noma or corroding ulcer-and the pustule maligne, so accurately described by Boyer and other continental writers.Gazette Medicale de Strasbourg, Sept. 1844. M. CAZENAVE ON THE DIFFERENT SORTS OF CAUSTICS. The Powder of Dupuytren is composed of one part of arsenious acid and 200 parts of Calomel. It is a mild and very manageable caustic, that is useful in cases of Lupus in women and children, when the ulceration is superficial and of limited extent. If the diseased part be dry, it may be necessary to denude it by means of a blister, and then to sprinkle the powder upon the raw surface. A certain amount of heat and painful swelling is usually caused by this applica No. 100. 37 |