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PRACTICAL OBSERVATIONS ON THE HISTORY, CAUSES, AND TREATMENT
402 and Castille. The existence of mortification is not acknow- lower !q Is it the old Hunterian one, of waiting for the
cessa-
ledged, because the part is neither rel nor black, which it is tion of the mortification, under the means employed, and the presumed all mortifications ought to be. It is, in reality, the formation of a line of demarcation between the dead and the reverse, or quite white. It is as bad a thing in chirurgery as living parts, when an amputation may be performed, but which time rarely arrives before the patient diesor is it the precept that rara avis, a black swan, was formerly in ornithology. In all cases like those I have referred to,-and I have re- I have laid down for you, of amputating immediately, and ported many in my record on wounded arteries,-the foot first below the kneei My decision is for the latter, and I hope it suffers, and the failure of the circulation is usually remarked will always be yours. I must impress upon you, however, that although mortificain the great toe, or in the ends of the other toes. It may so remain for days, and then extend as far as the instep, or ancle, tion too frequently follows an injury of the main artery, when when it frequently stops for a short time, and then proceeds suddenly committed, and without any previous disease in the as high as the calf, after which life is soon destroyed. In limb, it does not always do so; and that attention to the direc. many cases the extension of the mortification is more rapid at tion I have elsewhere given, of keeping up a gentle but con. the beginning, and soon proceeds as high as the calf of the tinual friction, by the hands of assistants, on the lower part leg, at which part nature seems often to make a great effort of the extremity in danger, may tend to prevent it. It is a to resist its further progress. The fact I state; the cause, I proceeding which should never be omitted in any case where presume, must depend on the circulation around the knee, a doubt exists as to the probable occurrence of the mischief but whether that be the right one or not you must receive it, which may be expected. I think, gentlemen, you have enough for one day, and more for the very lady-like reason that it is so, and that you have not for the present a better reason to adopt. It is on account particularly if you will permit me to say, without intending of the fact that I have selected this part as the one at which offence to any one, whether teacher or student, that few, very amputation should be performed, before many people would few, of the candidates for the diploma of the College of Sur. know why it should be done at all, who overlook the wound of geons, who appear before me, as one of their examiners, the artery in the thigh, or who do not understand the baneful know scarcely anything of what I have been endeavouring to influence it exerts on the parts below. Amputation at or explain to you. Indeed, if you will further permit me, I will above the middle of the thigh is a very dangerous operation hint to you, with the greatest possible delicacy, that very few at all times, and a very unsuccessful one in all cases of wound gentlemen of the present day appear to pay that attention to of its artery, accompanied by mortification of the foot and leg. their studies they did formerly; and the consequence is, that The person does not die under the operation, but the stump there are many not so well informed as students were twenty does not take on the action necessary for his recovery. The years ago, although three years of hospital and anatomical mortification had become constitutional instead of being local, study are now required, instead of two. I do not like to before the operation was done. The stump swells, opens out, express an opinion as to what the cause of this may be, but I looks white, and discharges usually but little, and never will do my endeavour, with the aid of the surgeons and healthy matter. The system generally suffers in proportion, teachers of this hospital, to prevent its occurring to you. and the patient rarely survives beyond three or four days, if he live so long. To prevent this result, amputation is to be per-
as soon as mortification is so established as to be no PRACTICAL OBSERVATIONS ON doubtful. Under the most favourable circumstances THE HISTORY, CAUSES, AND TREATMENT the person must lose his toes, or his foot at the ancle, and an OF SOME OF THE a little room an for artificial amputation higher, leaving leg, does not make the matter worse, more particularly as the MORE IMPORTANT DISORDERS AND DISEASES cases of recovery, with the loss of the toes or the foot at OF EUROPEAN INVALIDS ON THEIR RETURN the ancle, are not forthcoming, to prove the propriety of doing TROPICAL CLIMATES. FROM nothing, or of waiting for what is called a line of separation. Now, then, gentlemen, how to know your mortification, BY JAMES RANALD MARTIN, F.R.S., both by negative and positive signs. The patient is not aware SURGEON, BENGAL ARMY, RETIRED , LATE PRESIDENCY-SURGEON, AND SURGEON TO THE NATIVE HOSPITAL, CALCUTTA. of anything being abnormal in his foot, the sensibility and capability of motion being nearly as natural as usual. The IN another work,* and to which I here occasionally refer, I temperature of the part, under the ordinary circumstance of being in bed, is scarcely diminished-often not perceptibly so have endeavoured to explain the origin of those formidable to the touch of the observer; and when it is less, it is not diseases which, under tropical influences, affect the stranger beyond a degree or two of the thermometer. It is the change European, and to trace them to the physiological actions inof colour which marks the commencement of the mischief to duced by an unnaturally high range of temperature, and other the initiated. The flesh-colour has changed to the white of a causes, disturbing, during a residence generally protracted, bad tallow-candle; and as the mischief advances on the instep the various functions on whose just balance health must every’ to the leg, this white becomes spotted like the best mottled where depend. I purpose now to examine the converse of all this-the reeoap. It does not turn a red or purple black, like that of humid mortification, unless the part putrefies under the appli- verse of everything that holds under tropical influences-to cation of hot poultices &c., but gradually shrinks and dies. describe the inertia, approaching to a collapse of the vital The long tendon of the great toe seems to stand out along its functions, which follows as a necessary consequence of the back, and the skin becomes brown over it, and shrivelled. The previous violent tumult of action and of function-and to deperson, nevertheless, can bend and extend the toe, and feel and ’, scribe, both the condition of the tropical invalid on his return describe his sensations when it is touched. There is no red- to his native climate, and his treatment there. The courses of investigation here spoken of are surrounded ness at first, marking the spot beyond which the commencing mortification does not extend; there is merely the difference with the difficulties inherent in everything that relates to between the natural and the altered colour of the parts. This climate as a science; but fully impressed with these great is followed by some little swelling and slight redness, the pre- disadvantages, I am nevertheless more and more persuaded, cursors, in general, of the further progress the mortification is by every-day experience, of the necessity of prosecuting such about to make. As time passes away, the course of all the inquiries in the manner here proposed. I believe it to tendons in the foot is marked by the discolouration of the skin promise a superior usefulness in result, whether we regard over them, and the whole skin gradually becomes browner, the advancement of the preventive or the curative departdark-coloured, and dry, unless artificial heat changes the che- ments of our profession. mical action going on in the part, dead as to circulation, but A familiar acquaintance with the most concentrated forms yet alive as to motion and sensibility, although both are at this of disease, as they prevail in tropical climates, assists materially towards a just appreciation of those that lie between, or period impaired. This mortification is local, in the first instance; how long it of minor degrees of disease, as they prevail in more temperate may remain so depends, in a great degree, on the excitability regions. Observation of the nature and power of external of the constitution of the patient, and is of longer or of causes in the production of disease within the tropics assists 8àorter duration. There is always, however, I shall say, as a us also to form a more just estimate of the power of other and general rule, sufficient time for its continuance as a local dis- different circumstances of climate, whether morbific or sanaease, to allow of the commencing mortification being clearly * The Influence of Tropical Climates on European Constitutions. By perceived, and its probable extent ascertained, at an early James Johnson, M.D., Physician to the King, and James Ranald Martin, period. late Presidency-surgeon, and Surgeon to the Native Hospital, Calcutta. What, under these circumstances, is the precept to be fol- London, t84).
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tive, in our native country. " To know the cause of disease imIs may be said with truth, that no one who deserved its considersometimes to be able to cure, often to be able to prevent it."’* ation was ever otherwise treated by the community of the InThe subject is of great and of increasing importance, also," dian presidencies. seeing that the numbers are annually increasing who, froma If we look to the physical condition of the youth, it is at choice or necessity, betake themselves to the intertropical1 first, under favourable circumstances, no less cheering. All possessions of this empire. This consideration, as well as the the functions of life receive an impulse from the agency of great difficulties above alluded to, renders it a matter 01f heat, while the susceptibility to impression is increased in the serious regret to me, that in such an undertaking I am nott like proportion. The comforts, and even luxuries, of life are aided by the experience of other and more competent au-within his reach if he will be but prudent; for want of any kind in India is unknown, except to the heedless or the proflithorities. With exception to the admirable " Observations" of my7gave. Disease, tropical disease, too, is as yet a stranger to late friend, Dr. James Johnson, the subject as here proposedi him; and, if in thearmy, he has not campaigned, or served in to be treated is almost, if not altogether, new. It is incumbentt unhealthy countries, or during the most unhealthy seasons, on me, therefore, to explain the grounds on which I pretend1 the equable determination to the surface of the body, produced to undertake the discussion of it. by an elevated range of temperature, tends, along with the During a residence of two-and-twenty years in various parts9 increased excitability of the nervous and vascular systems, to of India, and in some of its worst climates, I had extendedi raise the animal spirits, and impart a feeling of invigoration opportunities, in peace and in war, during seasons of prosperityr and health delightful to the senses. But time passes on, and and adversity, in hospital and private practice, to witness the) even if, through the contingencies of service in various regions, influences that affect the health of both Europeans and1 or through his own imprudence, disease has not ensued, the Natives. I have seen how the masses and how the individualsi lengthened application of these operations of climate, which were affected, how they lived and prospered, how they at first appeared benefical, are sure to impair the health, and sickened, recovered, or died-the habits of life and the causes; that, too often, with a termination so suddenly fatal, as at once of death, in short, of the Asiatic and European races. I have to shock and terrify all who behold it. had the further advantage of witnessing the influences that tendI It will now be proper to look in some detail to the operation to produce like results in the native climate of the European of those causes which tend, by their protracted application, to on his return home, and it is this last circumstance that deteriorate or destroy the best of European constitutions ; bespecially encourages me to make the present attempt, trusting cause a practical acquaintance with these causes, and with that, ere long, I may be followed by more experienced and their modes of operation, is absolutely necessary to a right more competent observers from amongst my brother officers understanding of their effects. In India, we find that no of the medical departments of the Indian army. amount of talent, or of general and professional knowledge, Without holding continually in view the various antecedent can compensate for the absence of local experience in the changes of circumstances, and of climate, specially, to which treatment of its diseases; and it is hardly necessary to say the European is exposed, during the whole period of his resi- that the same kind of experience is quite as necessary to the dence in tropical regions, and that the very converse of almost just management of their sequelae in Europe. A careful conall the moral and physical circumstances under which he had sideration of all the influential circumstances, moral and lived in hot climates obtains, on his return to his native physical, under which the European lived within the tropics, country, it is difficult, if not impossible, to obtain a just and (" Whilst he did climate there," as Shakspeare expresses it,) comprehensive view of his actual condition of health. This will go far, however, to supply the want here mentioned; and truth, which can admit of no denial, will, it is hoped, be re- it is in the hope of contributing in some degree to this end ceived, in excuse of the following details. And let no one con- that I venture to submit the following observations. The most immediate of the tropical influences on European sider these subjects tedious, or unimportant, but rather that constitutions are evidenced in the excited conditions of the the manner of their exposition is so.t The return of the tropical sojourner to the land of his nervous and vascular systems, while the most important are fathers, strange as it may seem, is not unaccompanied by those affecting the functions of the skin, liver, lungs, and serious risks to his health, and by many moral considerations kidneys; and owing to the extraordinarily high range and of a painful and distressing character. rapid changes in the temperature, humidity, and other qualiSince the day when, as a mere youth, he bade adieu to his ties of the atmosphere, all these important influences are sorrowing relatives, quitted the protection of the paternal exemplified in extreme degrees. During the Hot and Rainy Seasons, which in Bengal extend roof, and his native climate, he has undergone changes in his moral and physical nature but little considered or understood from the beginning of March to the end of October, the deterby his kinsmen and countrymen in general, amongst whom he mination of the fluids generally is to the surface, accompanied now finds himself, in middle, or more advanced life, differing by an increase of the nervous excitability and animal heat; in habits, associations, and pursuits, from those around him- by an acceleration of pulse, and a prodigious increase of the his nearest relatives departed, and he an invalid and a stranger pulmonary and cutaneous exhalations, the latter amounting, in the land of his birth. This is a great and sad revolution in in the rainy season, to an exhausting discharge, as if the very life, whether we regard it in a moral or a physical sense, and serum of the blood were exuded. At this latter season, the medical officer who has observed its causes abroad, and its through the saturation of the atmosphere, its vivifying proconsequences at home, can bear testimony to severe and com- ’, perties are diminished, while the excessive decomposition of plicated sufferings on the part of a highly intellectual portion animal and vegetable matter gives to the air in some of the of our community. I most unhealthy localities the properties of a tainted vapour The youth, on his arrival in India, is at once placed in a so- bath. The perspiration is not carried off by evaporation, ciety wherein the social affections and the domestic habits while the transudation is enormously increased-thus, heat of our native country are cherished and cultivated with a accumulates in the body, and the local action of cold produces luxuriance characteristic of the climate, and of which no other serious consequences, rendering the system susceptible of the least impression from cold, or malarious influences, with a country, perhaps, has offered so distinguished an example. At a distance of twelve thousand miles from the British strong tendency to congestion in all the abdominal organs. The excessive watery discharge from the skin during this shores, and separated for more than half our lives from all those who, in our early youth, were most cherished, it is but season must of necessity have the effect of rendering the natural that in India we should cling together the closer that venous blood unnaturally dense, and of thus causing the all feel in common-the old Indian and the new comer-the European to be more liable to congestive forms of disease. utter uncertainty of again revisiting the homes of our youth. Dr. C. J. B. Williams refers the disposition to liver complaints, Such is the state of feeling in the East; and throughout the dysentery, and cholera to the stimulating properties of the whole period of an Indian’s career, whatever his line of ser- blood, deprived, as we have seen, of more than its usual vice, he lives in a society whose generous kindness in pros- amount of water, and of less of its hydro-carbon. Such, briefly, are the hot and rainy seasons of tropical perity, and whose soothing attentions in adversity, or in sickness, are unequalled ill any other quarter of the world; and it climates, and such are some of the reasors for their proverbial unhealthiness. The mind even seems to partake Lecturer on the Principles and Practice of Physic. By Thomas Watson, in the general relaxation and lassitude, being unfitted for M.D., &c. t The ohject of these cursory remarks is, to point out the injurious revigorous or sustained efUji’ts of any kind. During the eight sults folloBVin upon exposlU"e to extremes of climate. Were it proposed, months here uuder consideration, the sleep is seriously dishere, to speak of the remedial powers of climate, I should quote largely turbed-a circumstance in itself sufficient to account for from the valuable scientific and practical work of Sir James Clark, on The Sanative Influence of Climate"-a wot deserving the careful consideraticn many of the attendant evils. of all classes of the community. The " cutaneo-hepatic sympathy" of Dr. James Johnson is r
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404 well known, and so is the theory which considers that, while eases of the air-passages, lungs, and kidneys, are of but rare respiration is less perfectly carried on, owing to the rarefaction occurrence, while, on returning to Europe, dangerous diseases of the airavicarious decarbonization of the blood is established of these organs are so liable to occur. Fever is by far the most common result of the high temby a great increase of the biliary secretion. If, as supposed by Liebig, the function of the bile is, " to support respiration perature of our hot season in the East, complicated with disproduce animal heat, by presenting carbon and hydrogen turbance of the nervous centres and occasional determination and in a very subtile form to the oxygen of arterial blood," how to the liver. This fever is generally of the continued, occagreatly must the condition of the vital functions-respiration,, sionally of the remittent form, and of an ardent character. It the generation of heat, circulation, and secretion-be influencedl demands experience and care in the treatment. Cholera is by the palpably increased secretion of bile in tropical climates,, most prevalent and fatal in the hot months of April and May. followed as that excited action of the hot and rainv season is; In the succeeding rainy months, fever assumes a remittent ten- character with diminished vital action generally, and a danby a proportionately diminished action, and dency to congestive disease in the cold season ? Indeed, we are gerous abdominal congestion. In place of the burning dry everywhere, in hot climates, thrown back on the observation1 skin and racking headach of the fever of the hot season, we of that acute and accurate pathological observer, Dr. Johni have here a moist, cool surface, indicating a want of action in Clark, that of all the viscera in the human body the liver is3 the sudatory vessel, an oppressed pulse, and a tendency to the most formidable collapse. Dysenteries as well as fevers be. the most subject to disease. The blood being less arterialized in proportion to the eleva- come more frequent, severe, and complicated, as the season adtion of temperature, it is evident that in tropical climates theO) vances; the former implicating the whole of the abdominal lungs are relieved from some of the labour performed by themi organs. The diseases peculiar to the cold season are, congestive fever, in temperate or cold regions; and thus it happens that many persons enjoy good health in hot climates, who, from tendency of the continued form; intermittents, with the sequel of tumid to pectoral disease, could not have lived in Europe; indeed, or indurated spleen or liver; insidious, subacute, hepatic inmany persons in the curable stage of consumption-that is, flammation, terminating rapidly in abscess; dysenteries, frelabouring under the preceding stage, or that of " tuberculous quently complicated with hepatic disease,-all more or less cachexia," regain their healths and survive their relatives at acute, according to individual habit, or length of service in home. Those, on the other hand, who go to India with India. Apoplexies of the most fatal form known in India softened tubercles, or even in the stage approaching it, are only occur at this season, as do the paralytic affections so commonly associated with them. Chronic eruptions, in active develophurried into their graves. During the hot and rainy seasons here referred to, the ment during the two previous seasons, are now suddenly refunction of the kidneys is always diminished, while at the pelled, followed by congestion of some of the viscera. same time the urine is surcharged with saline and other im Having exhibited, in the rapid manner here sketched, the Dresmations. diseases to which the European stranger is liable, and the unnatural and over-excited in all his functions as powerfully deteriorating influences to which, during each year European subject has hitherto been viewed, we soon find him, of residence, he is exposed in the East, we shall now suppose under the influence of the Cold Seasons, affected in a manner him, after a sojourn of from twenty-five to forty years, recompletely the reverse. The now altered balance of the cir- turned to his native country. Here he enters at once, and culation and nervous function; the entire drying up of the sur- without preparation, on a season of eight months’ cold and face, and the corresponding congestion of all the viscera; the z’ moisture, in exchange for the same period of previous excesless arterialized and viscid state of the blood; the diminution sive tropical heat and excessive moisture conjoined. I am of the biliary, and the enormous increase of the renal secre- here speaking of the English season, from the beginning of tions ; the oppressed state of the cerebral, thoracic, and ab- October to the end of May. This is a great revolution in dominal functions, leading to the most formidable and com- climate, and it at once induces a corresponding physiological plicated diseases, and to the suppression of chronic eruptions change in the system, stamping the individual with a peculiar in a previous state of development : all render the cold season of physical character. The exhalent organs of the skin, which Bengal the reverse of healthy, except to those of sound con- for so long a succession of years had been called into the most stitution, or the newly-arrived European, or such as have not violent action, now become sealed, as if with a coating of suffered from the previous unhealthy seasons. varnish ; from the extreme of transudation he comes at once The fevers of this season, unlike those of the hot weather under the rigour and vicissitude of an English winter, to conand rains, approach gradually, insidiously, but not less dan- striction and dryness of the entire surface of the body. The gerously, than those more ardent and concentrated types of result of such changes it is easy to perceive. From the previous extensive, equable, and sometimes violent, fever last named. It will be seen that congestion has repeatedly been mentioned as participating in the most dange- determination to the surface of the body, he is suddenly subrous of our diseases. That climate has a principal share in jected to an opposite action-an extreme dryness of the surproducing this unfavourable state there can be no doubt; but face, amounting, occasionally, to a furfuraceous desquamation admitting this, we must consider also that the absence of all of the cuticle, and at other times to a miliary eruption, acexhilarating exercise of mind and body, with their animating, companied by determination of the entire mass of the blood varied, and healthful influences, on all the functions, predis- inwards; a loaded condition of the great venous trunks of the poses much, when aided by a too full and stimulatng diet, to abdominal, thoracic, and cerebral cavities, with diminished this end; unhappily, too, the European resident in tropical power in the heart and arteries. climates has no sufficient remedy against the evils of this This is by far the most common result of exposure to the double inaction, except moderation in diet, which many will cold of an European winter and spring; but we occasionally not adopt; for during the hot and rainy seasons, the amount find its opposite-a relaxation of the surface, inducing a. of exercise necessary to health in temperate regions would copious and clammy sweat on the least exertion, accompanied here be impossible, and would be hurtful if even possible. by extreme languor of the circulation, with cold, damp extreThose who would preserve their health, therefore, must be mities. This state, which is confined to persons of leucotemperate-use such bodily exercise, as each season admits of, phlegmatic habit, is only to be removed by a complete restoand relieve their minds from the monotony of routine official ration to health. The nervous function, highly exalted during residence in duty by the inexhaustible resources of European literature, science, and elegant accomplishments. It is only thus that the East,becomes now proportionately obtundd and depressed. health, happiness, and reputation can be insured under theThese are great changes, and it is next to impossible that any accumulated disadvantages of our position in India, where man shall go through them with impunity; indeed, the first too commonly the whole time is given up to business. inspection of the Indian, on his return home, proves that he I shall now enumerate the disease peculiar to each season, has been subjected to changes foreign to his original nature. premising that it is to a long continuance of exposure to the He has now to undergo others which, through long acquired various causes stated, more than to their intensity, that w(habit, have become almost as foreign to him. must refer the greater portion of the injurious influences o:f most prevalent, under Passive congestion is the condition tropical climate on European constitutions. just stated; and no matter what his preIt has been seen that in hot climates the lungs are relieve< 1 vious disease in India, the morbid condition now superadded of a portion of carbonic acid through the inereased activity o t proves a serious difficulty to the invalid. If the patient sufthe cutaneous exhalations, while the kidneys and mucou s fered from tropical dysentery, his distresses are greatly aggrasurfaces are alike relieved of uric acid, urea, salts, and wate}’. vated during the long English winter and spring. The sufferers This state of activity, which holds, during eight months 4)f from fever, hepatic or splenic disease, are similarly distressed every year will explain how it is that in such climates di.,by severe abdominal congestion; and if the tendency, through
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plethora or other cause, be towards the cerebral cavity, position of the child. Dr. Smythe, of Lambeth, who kindly apoplexy is produced by exposure, or the absence of care, attended at my request, now arrived. Both feet,inone arm, the the pelvic during the season of cold and damp in Europe. When the fold of the funis, were at this time impacted liver becomes the seat of congestion, this morbid condition brim, the head doubled on the neck anteriorly, the breech
may be confined to the venous trunks, or to the whole secreting resting on the promontory of the sacrum. A full dose of parenchyma; or it may extend to both. In either case it is a laudanum was administered to the patient, and she was allowed to rest. Unsuccessful efforts were made to return the serious state of disease. I have seen many persons also, whose relatives at home arm, and traction was again employed, but uselessly. Another were weak-chested and consumptive, become subject to severe opiate draught was then given, and the use of the forceps .chest diseases from the same cause. In short, if the sufferings suggested to bring down the breech; but at that moment all were great, under the long continued exposure to the tropical difficulty vanished, and the child was brought into the world, at half-past heats, they are neither small nor unimportant under its oppo- dead, with the funis four times round its site in Europe-especially under exposure to damp cold, five o’clock. The expulsive pains had not been strong; the which exercises a peculiarly baneful influence. My experience placenta was removed by the hand, and external pressure Jiere in the last nine years would lead me to conclude that, if secured a safe and quick contraction of the womb. Renzarks.-Had there been continued expulsive pains for there really be any such immunity from cold during the first year of residence in England, as we hear spoken of so generally any length of time, and no assistance near, it is possible that in India, it is enjoyed only by the healthy and the robust. this woman might not have been delivered except by a more Numberless examples have satisfied me as to the truth of this dangerous alternative than that of turning; but we may often observation. A dry, or even frosty, cold is well borne, com- see a beautiful and conservative provision of nature, when, paratively, even by the enfeebled tropical invalid; but the the uterus failing to overcome the unseen difficulty and expel damp cold produces sensations of indescribable distress and the fcetus, the pains are less and less frequent, and sometimes depression in persons possessed of consid rable powers of re- entirely cease. It will also be observed that the fortunate sistance. Many invalids, again, in England in an period for turning had passed before my arrival. Several enfeebled state, seek what they call " the bracing air" of doses of calomel and opium were administered during the folBrighton and other such places during the winter and spring lowing three days, and the woman was spared a second danger months, in forgetfulness, or in ignorance, that, without a pre- by escaping peritonaeal inflammation. And this leads me to relate a case of that disease, which vious restoration of health, this said bracing is impossible of attainment. Many valuable lives are annually sacrificed in recently occurred in the person of a woman who watched her this vain endeavour. sister in the agony of labour, and being pregnant, was immeMore unfounded still is the prevalent notion amongst inex- diately seized herself. After delivery, no untoward symptom perienced and thoughtless lay persons, that on returning to arose until the fourth day, when a circumscribed abdominal England from hot climates they are to take leave of all their pain and tenderness were complained of, and rapidly increased. ailments, at the same time that they need take no care what- The lochial discharge was suppressed; the milk was not enThis is only another out of many tirely lost, but the headach was intense. The patient, already - ever as to their habits. .examples of the facility with which the mass of men receive emaciated, had paroxysms of severe pain; the countenance It is but the " they say it" was extremely distressed; the vomiting frequent; pulse 120. mere opinions as established facts. of the Spaniards, and that is enough for the unreflecting many. Calomel with opium were given, a blister applied to the "A moderate acquaintance with mankind," says Dr. James epigastric region, and rectified ether taken in effervescing Johnson, " is sufficient to stamp the truth of the remark, that draughts. The tenderness of the abdomen was excessive, but experience seldom instructs the mass." This is quite as true the fear of being touched or pressed was not confined to this as the observation of the older doctor of the same name, the part; in fact, there were symptoms of an hysteric character, moralist and lexicographer-viz., that there are some men who but most assuredly the danger was imminent. The opinion of In nothing are both re- Dr. Tyler Smith was obtained, who expressed to me his belief are incapable of acquiring experience. marks so just as in all that popularly relates to health, whe- that she would ultimately do well. A few leeches were ordered to be placed below the navel, the calomel continued, ther private or public. and the etherial mixture. The breasts were drawn, and the (To be continued.) bowels relieved by an enema of castor oil. After the subsidence of the inflammation, the patient was seized with painful diarrhoea and tenesmus, and this being relieved by reOBSERVATIONS IN MIDWIFERY. medies, she slowly recovered. 2Pema!?’-.ņThis mixed form of peritonitis is not frequent, BY W. MUTRIE FAIRBROTHER, M.D. and general depletion is borne with less than in any other variety of this disease. It is a great question how much Complicated Presentation;and a case of Peritonitis. policy is shown by resorting in the other puerperal forms of PRESENTATIONS of a mixed character, involving serious diffi- this fearful malady to prompt and extreme bloodletting. ’The - culty and danger, occasionally occur to those engaged in sequel of many recorded and related cases treated thus is not obstetric practice; while some which would otherwise present very satisfactory. no serious obstacles to the safe delivery of the parturient London-road, Southwark. woman become complicated by interference, being too long delayed. The following case contains some peculiarities worthy of notice :-REPORT OF A CASE OF COMPOUND FRACTURE Mary F-, aged twenty-six, having had previously five OF THE CRANIUM, AND HERNIA CEREBRI. natural labours, was attended by a midwife in this her last, —RECOVERY. who requested me to visit her patient at half-past twelve A.M., March 4th. I found the woman suffering but little from BY ROBERT W. CRIGHTON, M.D. Edin., L.R.C.S.E., uterine pains, which had been severe; the waters had broken DEMONSTRATOR OF ANATOMY IN THE MEDICAL SCHOOL, SURGEONS’ HALL, one hour before; pulse 100; countenance rather anxious, with EDINBURGH. slight shivering at intervals. Upon making a vaginal examiON the 4th of September last, I was called, at midday, to nation, one arm was discovered low down, the shoulder above J. C-,aged thirty, a saw-miller, of regular habits. it, and the other hand could be felt plainly; a coil of the visit funis had also prolapsed. The bowels having been lately , About an hour previously, while engaged at his occupation, relieved, the bladder was emptied by the catheter, and my he had been struck on the forehead by a piece of wood, right hand introduced into the uterine cavity, with a view to several feet in length, projecting from the circular saw while determine more accurately the position of the child. The in full motion, by which he was instantly prostrated. The head was felt lodging against the pubis symphysis, lightly hsemorrhage was reported by those who carried him from the grasped by that part of the uterus which surrounded it; so spot where the accident occurred as having been very profuse, that only at intervals could the hand be passed towards the and on first seeing him I found it had been to such an extent fundus, in order to bring down a foot and turn the child. The as to soak through the bed on which he was lying. umbilical cord, which was very long, gave some inconvenience He was then almost pulseless, and in a state of deep coma. by its position. A foot was brought down as far as prac- The wound inflicted on the forehead was somewhat oblique, ticable, and secured by tape, and now there was slight hmmor- extending from a short distance below the left parietal rhage. The other foot was found with some trouble, and con- eminence to a little beyond and above the same prominence siderable traction employed without materially altering the on the right. The lower part, for fully half an inch, was oc-
neck,
arriving
cessa-
ledged, because the part is neither rel nor black, which it is tion of the mortification, under the means employed, and the presumed all mortifications ought to be. It is, in reality, the formation of a line of demarcation between the dead and the reverse, or quite white. It is as bad a thing in chirurgery as living parts, when an amputation may be performed, but which time rarely arrives before the patient diesor is it the precept that rara avis, a black swan, was formerly in ornithology. In all cases like those I have referred to,-and I have re- I have laid down for you, of amputating immediately, and ported many in my record on wounded arteries,-the foot first below the kneei My decision is for the latter, and I hope it suffers, and the failure of the circulation is usually remarked will always be yours. I must impress upon you, however, that although mortificain the great toe, or in the ends of the other toes. It may so remain for days, and then extend as far as the instep, or ancle, tion too frequently follows an injury of the main artery, when when it frequently stops for a short time, and then proceeds suddenly committed, and without any previous disease in the as high as the calf, after which life is soon destroyed. In limb, it does not always do so; and that attention to the direc. many cases the extension of the mortification is more rapid at tion I have elsewhere given, of keeping up a gentle but con. the beginning, and soon proceeds as high as the calf of the tinual friction, by the hands of assistants, on the lower part leg, at which part nature seems often to make a great effort of the extremity in danger, may tend to prevent it. It is a to resist its further progress. The fact I state; the cause, I proceeding which should never be omitted in any case where presume, must depend on the circulation around the knee, a doubt exists as to the probable occurrence of the mischief but whether that be the right one or not you must receive it, which may be expected. I think, gentlemen, you have enough for one day, and more for the very lady-like reason that it is so, and that you have not for the present a better reason to adopt. It is on account particularly if you will permit me to say, without intending of the fact that I have selected this part as the one at which offence to any one, whether teacher or student, that few, very amputation should be performed, before many people would few, of the candidates for the diploma of the College of Sur. know why it should be done at all, who overlook the wound of geons, who appear before me, as one of their examiners, the artery in the thigh, or who do not understand the baneful know scarcely anything of what I have been endeavouring to influence it exerts on the parts below. Amputation at or explain to you. Indeed, if you will further permit me, I will above the middle of the thigh is a very dangerous operation hint to you, with the greatest possible delicacy, that very few at all times, and a very unsuccessful one in all cases of wound gentlemen of the present day appear to pay that attention to of its artery, accompanied by mortification of the foot and leg. their studies they did formerly; and the consequence is, that The person does not die under the operation, but the stump there are many not so well informed as students were twenty does not take on the action necessary for his recovery. The years ago, although three years of hospital and anatomical mortification had become constitutional instead of being local, study are now required, instead of two. I do not like to before the operation was done. The stump swells, opens out, express an opinion as to what the cause of this may be, but I looks white, and discharges usually but little, and never will do my endeavour, with the aid of the surgeons and healthy matter. The system generally suffers in proportion, teachers of this hospital, to prevent its occurring to you. and the patient rarely survives beyond three or four days, if he live so long. To prevent this result, amputation is to be per-
as soon as mortification is so established as to be no PRACTICAL OBSERVATIONS ON doubtful. Under the most favourable circumstances THE HISTORY, CAUSES, AND TREATMENT the person must lose his toes, or his foot at the ancle, and an OF SOME OF THE a little room an for artificial amputation higher, leaving leg, does not make the matter worse, more particularly as the MORE IMPORTANT DISORDERS AND DISEASES cases of recovery, with the loss of the toes or the foot at OF EUROPEAN INVALIDS ON THEIR RETURN the ancle, are not forthcoming, to prove the propriety of doing TROPICAL CLIMATES. FROM nothing, or of waiting for what is called a line of separation. Now, then, gentlemen, how to know your mortification, BY JAMES RANALD MARTIN, F.R.S., both by negative and positive signs. The patient is not aware SURGEON, BENGAL ARMY, RETIRED , LATE PRESIDENCY-SURGEON, AND SURGEON TO THE NATIVE HOSPITAL, CALCUTTA. of anything being abnormal in his foot, the sensibility and capability of motion being nearly as natural as usual. The IN another work,* and to which I here occasionally refer, I temperature of the part, under the ordinary circumstance of being in bed, is scarcely diminished-often not perceptibly so have endeavoured to explain the origin of those formidable to the touch of the observer; and when it is less, it is not diseases which, under tropical influences, affect the stranger beyond a degree or two of the thermometer. It is the change European, and to trace them to the physiological actions inof colour which marks the commencement of the mischief to duced by an unnaturally high range of temperature, and other the initiated. The flesh-colour has changed to the white of a causes, disturbing, during a residence generally protracted, bad tallow-candle; and as the mischief advances on the instep the various functions on whose just balance health must every’ to the leg, this white becomes spotted like the best mottled where depend. I purpose now to examine the converse of all this-the reeoap. It does not turn a red or purple black, like that of humid mortification, unless the part putrefies under the appli- verse of everything that holds under tropical influences-to cation of hot poultices &c., but gradually shrinks and dies. describe the inertia, approaching to a collapse of the vital The long tendon of the great toe seems to stand out along its functions, which follows as a necessary consequence of the back, and the skin becomes brown over it, and shrivelled. The previous violent tumult of action and of function-and to deperson, nevertheless, can bend and extend the toe, and feel and ’, scribe, both the condition of the tropical invalid on his return describe his sensations when it is touched. There is no red- to his native climate, and his treatment there. The courses of investigation here spoken of are surrounded ness at first, marking the spot beyond which the commencing mortification does not extend; there is merely the difference with the difficulties inherent in everything that relates to between the natural and the altered colour of the parts. This climate as a science; but fully impressed with these great is followed by some little swelling and slight redness, the pre- disadvantages, I am nevertheless more and more persuaded, cursors, in general, of the further progress the mortification is by every-day experience, of the necessity of prosecuting such about to make. As time passes away, the course of all the inquiries in the manner here proposed. I believe it to tendons in the foot is marked by the discolouration of the skin promise a superior usefulness in result, whether we regard over them, and the whole skin gradually becomes browner, the advancement of the preventive or the curative departdark-coloured, and dry, unless artificial heat changes the che- ments of our profession. mical action going on in the part, dead as to circulation, but A familiar acquaintance with the most concentrated forms yet alive as to motion and sensibility, although both are at this of disease, as they prevail in tropical climates, assists materially towards a just appreciation of those that lie between, or period impaired. This mortification is local, in the first instance; how long it of minor degrees of disease, as they prevail in more temperate may remain so depends, in a great degree, on the excitability regions. Observation of the nature and power of external of the constitution of the patient, and is of longer or of causes in the production of disease within the tropics assists 8àorter duration. There is always, however, I shall say, as a us also to form a more just estimate of the power of other and general rule, sufficient time for its continuance as a local dis- different circumstances of climate, whether morbific or sanaease, to allow of the commencing mortification being clearly * The Influence of Tropical Climates on European Constitutions. By perceived, and its probable extent ascertained, at an early James Johnson, M.D., Physician to the King, and James Ranald Martin, period. late Presidency-surgeon, and Surgeon to the Native Hospital, Calcutta. What, under these circumstances, is the precept to be fol- London, t84).
formed
longer
i
’
403
tive, in our native country. " To know the cause of disease imIs may be said with truth, that no one who deserved its considersometimes to be able to cure, often to be able to prevent it."’* ation was ever otherwise treated by the community of the InThe subject is of great and of increasing importance, also," dian presidencies. seeing that the numbers are annually increasing who, froma If we look to the physical condition of the youth, it is at choice or necessity, betake themselves to the intertropical1 first, under favourable circumstances, no less cheering. All possessions of this empire. This consideration, as well as the the functions of life receive an impulse from the agency of great difficulties above alluded to, renders it a matter 01f heat, while the susceptibility to impression is increased in the serious regret to me, that in such an undertaking I am nott like proportion. The comforts, and even luxuries, of life are aided by the experience of other and more competent au-within his reach if he will be but prudent; for want of any kind in India is unknown, except to the heedless or the proflithorities. With exception to the admirable " Observations" of my7gave. Disease, tropical disease, too, is as yet a stranger to late friend, Dr. James Johnson, the subject as here proposedi him; and, if in thearmy, he has not campaigned, or served in to be treated is almost, if not altogether, new. It is incumbentt unhealthy countries, or during the most unhealthy seasons, on me, therefore, to explain the grounds on which I pretend1 the equable determination to the surface of the body, produced to undertake the discussion of it. by an elevated range of temperature, tends, along with the During a residence of two-and-twenty years in various parts9 increased excitability of the nervous and vascular systems, to of India, and in some of its worst climates, I had extendedi raise the animal spirits, and impart a feeling of invigoration opportunities, in peace and in war, during seasons of prosperityr and health delightful to the senses. But time passes on, and and adversity, in hospital and private practice, to witness the) even if, through the contingencies of service in various regions, influences that affect the health of both Europeans and1 or through his own imprudence, disease has not ensued, the Natives. I have seen how the masses and how the individualsi lengthened application of these operations of climate, which were affected, how they lived and prospered, how they at first appeared benefical, are sure to impair the health, and sickened, recovered, or died-the habits of life and the causes; that, too often, with a termination so suddenly fatal, as at once of death, in short, of the Asiatic and European races. I have to shock and terrify all who behold it. had the further advantage of witnessing the influences that tendI It will now be proper to look in some detail to the operation to produce like results in the native climate of the European of those causes which tend, by their protracted application, to on his return home, and it is this last circumstance that deteriorate or destroy the best of European constitutions ; bespecially encourages me to make the present attempt, trusting cause a practical acquaintance with these causes, and with that, ere long, I may be followed by more experienced and their modes of operation, is absolutely necessary to a right more competent observers from amongst my brother officers understanding of their effects. In India, we find that no of the medical departments of the Indian army. amount of talent, or of general and professional knowledge, Without holding continually in view the various antecedent can compensate for the absence of local experience in the changes of circumstances, and of climate, specially, to which treatment of its diseases; and it is hardly necessary to say the European is exposed, during the whole period of his resi- that the same kind of experience is quite as necessary to the dence in tropical regions, and that the very converse of almost just management of their sequelae in Europe. A careful conall the moral and physical circumstances under which he had sideration of all the influential circumstances, moral and lived in hot climates obtains, on his return to his native physical, under which the European lived within the tropics, country, it is difficult, if not impossible, to obtain a just and (" Whilst he did climate there," as Shakspeare expresses it,) comprehensive view of his actual condition of health. This will go far, however, to supply the want here mentioned; and truth, which can admit of no denial, will, it is hoped, be re- it is in the hope of contributing in some degree to this end ceived, in excuse of the following details. And let no one con- that I venture to submit the following observations. The most immediate of the tropical influences on European sider these subjects tedious, or unimportant, but rather that constitutions are evidenced in the excited conditions of the the manner of their exposition is so.t The return of the tropical sojourner to the land of his nervous and vascular systems, while the most important are fathers, strange as it may seem, is not unaccompanied by those affecting the functions of the skin, liver, lungs, and serious risks to his health, and by many moral considerations kidneys; and owing to the extraordinarily high range and of a painful and distressing character. rapid changes in the temperature, humidity, and other qualiSince the day when, as a mere youth, he bade adieu to his ties of the atmosphere, all these important influences are sorrowing relatives, quitted the protection of the paternal exemplified in extreme degrees. During the Hot and Rainy Seasons, which in Bengal extend roof, and his native climate, he has undergone changes in his moral and physical nature but little considered or understood from the beginning of March to the end of October, the deterby his kinsmen and countrymen in general, amongst whom he mination of the fluids generally is to the surface, accompanied now finds himself, in middle, or more advanced life, differing by an increase of the nervous excitability and animal heat; in habits, associations, and pursuits, from those around him- by an acceleration of pulse, and a prodigious increase of the his nearest relatives departed, and he an invalid and a stranger pulmonary and cutaneous exhalations, the latter amounting, in the land of his birth. This is a great and sad revolution in in the rainy season, to an exhausting discharge, as if the very life, whether we regard it in a moral or a physical sense, and serum of the blood were exuded. At this latter season, the medical officer who has observed its causes abroad, and its through the saturation of the atmosphere, its vivifying proconsequences at home, can bear testimony to severe and com- ’, perties are diminished, while the excessive decomposition of plicated sufferings on the part of a highly intellectual portion animal and vegetable matter gives to the air in some of the of our community. I most unhealthy localities the properties of a tainted vapour The youth, on his arrival in India, is at once placed in a so- bath. The perspiration is not carried off by evaporation, ciety wherein the social affections and the domestic habits while the transudation is enormously increased-thus, heat of our native country are cherished and cultivated with a accumulates in the body, and the local action of cold produces luxuriance characteristic of the climate, and of which no other serious consequences, rendering the system susceptible of the least impression from cold, or malarious influences, with a country, perhaps, has offered so distinguished an example. At a distance of twelve thousand miles from the British strong tendency to congestion in all the abdominal organs. The excessive watery discharge from the skin during this shores, and separated for more than half our lives from all those who, in our early youth, were most cherished, it is but season must of necessity have the effect of rendering the natural that in India we should cling together the closer that venous blood unnaturally dense, and of thus causing the all feel in common-the old Indian and the new comer-the European to be more liable to congestive forms of disease. utter uncertainty of again revisiting the homes of our youth. Dr. C. J. B. Williams refers the disposition to liver complaints, Such is the state of feeling in the East; and throughout the dysentery, and cholera to the stimulating properties of the whole period of an Indian’s career, whatever his line of ser- blood, deprived, as we have seen, of more than its usual vice, he lives in a society whose generous kindness in pros- amount of water, and of less of its hydro-carbon. Such, briefly, are the hot and rainy seasons of tropical perity, and whose soothing attentions in adversity, or in sickness, are unequalled ill any other quarter of the world; and it climates, and such are some of the reasors for their proverbial unhealthiness. The mind even seems to partake Lecturer on the Principles and Practice of Physic. By Thomas Watson, in the general relaxation and lassitude, being unfitted for M.D., &c. t The ohject of these cursory remarks is, to point out the injurious revigorous or sustained efUji’ts of any kind. During the eight sults folloBVin upon exposlU"e to extremes of climate. Were it proposed, months here uuder consideration, the sleep is seriously dishere, to speak of the remedial powers of climate, I should quote largely turbed-a circumstance in itself sufficient to account for from the valuable scientific and practical work of Sir James Clark, on The Sanative Influence of Climate"-a wot deserving the careful consideraticn many of the attendant evils. of all classes of the community. The " cutaneo-hepatic sympathy" of Dr. James Johnson is r
L .
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404 well known, and so is the theory which considers that, while eases of the air-passages, lungs, and kidneys, are of but rare respiration is less perfectly carried on, owing to the rarefaction occurrence, while, on returning to Europe, dangerous diseases of the airavicarious decarbonization of the blood is established of these organs are so liable to occur. Fever is by far the most common result of the high temby a great increase of the biliary secretion. If, as supposed by Liebig, the function of the bile is, " to support respiration perature of our hot season in the East, complicated with disproduce animal heat, by presenting carbon and hydrogen turbance of the nervous centres and occasional determination and in a very subtile form to the oxygen of arterial blood," how to the liver. This fever is generally of the continued, occagreatly must the condition of the vital functions-respiration,, sionally of the remittent form, and of an ardent character. It the generation of heat, circulation, and secretion-be influencedl demands experience and care in the treatment. Cholera is by the palpably increased secretion of bile in tropical climates,, most prevalent and fatal in the hot months of April and May. followed as that excited action of the hot and rainv season is; In the succeeding rainy months, fever assumes a remittent ten- character with diminished vital action generally, and a danby a proportionately diminished action, and dency to congestive disease in the cold season ? Indeed, we are gerous abdominal congestion. In place of the burning dry everywhere, in hot climates, thrown back on the observation1 skin and racking headach of the fever of the hot season, we of that acute and accurate pathological observer, Dr. Johni have here a moist, cool surface, indicating a want of action in Clark, that of all the viscera in the human body the liver is3 the sudatory vessel, an oppressed pulse, and a tendency to the most formidable collapse. Dysenteries as well as fevers be. the most subject to disease. The blood being less arterialized in proportion to the eleva- come more frequent, severe, and complicated, as the season adtion of temperature, it is evident that in tropical climates theO) vances; the former implicating the whole of the abdominal lungs are relieved from some of the labour performed by themi organs. The diseases peculiar to the cold season are, congestive fever, in temperate or cold regions; and thus it happens that many persons enjoy good health in hot climates, who, from tendency of the continued form; intermittents, with the sequel of tumid to pectoral disease, could not have lived in Europe; indeed, or indurated spleen or liver; insidious, subacute, hepatic inmany persons in the curable stage of consumption-that is, flammation, terminating rapidly in abscess; dysenteries, frelabouring under the preceding stage, or that of " tuberculous quently complicated with hepatic disease,-all more or less cachexia," regain their healths and survive their relatives at acute, according to individual habit, or length of service in home. Those, on the other hand, who go to India with India. Apoplexies of the most fatal form known in India softened tubercles, or even in the stage approaching it, are only occur at this season, as do the paralytic affections so commonly associated with them. Chronic eruptions, in active develophurried into their graves. During the hot and rainy seasons here referred to, the ment during the two previous seasons, are now suddenly refunction of the kidneys is always diminished, while at the pelled, followed by congestion of some of the viscera. same time the urine is surcharged with saline and other im Having exhibited, in the rapid manner here sketched, the Dresmations. diseases to which the European stranger is liable, and the unnatural and over-excited in all his functions as powerfully deteriorating influences to which, during each year European subject has hitherto been viewed, we soon find him, of residence, he is exposed in the East, we shall now suppose under the influence of the Cold Seasons, affected in a manner him, after a sojourn of from twenty-five to forty years, recompletely the reverse. The now altered balance of the cir- turned to his native country. Here he enters at once, and culation and nervous function; the entire drying up of the sur- without preparation, on a season of eight months’ cold and face, and the corresponding congestion of all the viscera; the z’ moisture, in exchange for the same period of previous excesless arterialized and viscid state of the blood; the diminution sive tropical heat and excessive moisture conjoined. I am of the biliary, and the enormous increase of the renal secre- here speaking of the English season, from the beginning of tions ; the oppressed state of the cerebral, thoracic, and ab- October to the end of May. This is a great revolution in dominal functions, leading to the most formidable and com- climate, and it at once induces a corresponding physiological plicated diseases, and to the suppression of chronic eruptions change in the system, stamping the individual with a peculiar in a previous state of development : all render the cold season of physical character. The exhalent organs of the skin, which Bengal the reverse of healthy, except to those of sound con- for so long a succession of years had been called into the most stitution, or the newly-arrived European, or such as have not violent action, now become sealed, as if with a coating of suffered from the previous unhealthy seasons. varnish ; from the extreme of transudation he comes at once The fevers of this season, unlike those of the hot weather under the rigour and vicissitude of an English winter, to conand rains, approach gradually, insidiously, but not less dan- striction and dryness of the entire surface of the body. The gerously, than those more ardent and concentrated types of result of such changes it is easy to perceive. From the previous extensive, equable, and sometimes violent, fever last named. It will be seen that congestion has repeatedly been mentioned as participating in the most dange- determination to the surface of the body, he is suddenly subrous of our diseases. That climate has a principal share in jected to an opposite action-an extreme dryness of the surproducing this unfavourable state there can be no doubt; but face, amounting, occasionally, to a furfuraceous desquamation admitting this, we must consider also that the absence of all of the cuticle, and at other times to a miliary eruption, acexhilarating exercise of mind and body, with their animating, companied by determination of the entire mass of the blood varied, and healthful influences, on all the functions, predis- inwards; a loaded condition of the great venous trunks of the poses much, when aided by a too full and stimulatng diet, to abdominal, thoracic, and cerebral cavities, with diminished this end; unhappily, too, the European resident in tropical power in the heart and arteries. climates has no sufficient remedy against the evils of this This is by far the most common result of exposure to the double inaction, except moderation in diet, which many will cold of an European winter and spring; but we occasionally not adopt; for during the hot and rainy seasons, the amount find its opposite-a relaxation of the surface, inducing a. of exercise necessary to health in temperate regions would copious and clammy sweat on the least exertion, accompanied here be impossible, and would be hurtful if even possible. by extreme languor of the circulation, with cold, damp extreThose who would preserve their health, therefore, must be mities. This state, which is confined to persons of leucotemperate-use such bodily exercise, as each season admits of, phlegmatic habit, is only to be removed by a complete restoand relieve their minds from the monotony of routine official ration to health. The nervous function, highly exalted during residence in duty by the inexhaustible resources of European literature, science, and elegant accomplishments. It is only thus that the East,becomes now proportionately obtundd and depressed. health, happiness, and reputation can be insured under theThese are great changes, and it is next to impossible that any accumulated disadvantages of our position in India, where man shall go through them with impunity; indeed, the first too commonly the whole time is given up to business. inspection of the Indian, on his return home, proves that he I shall now enumerate the disease peculiar to each season, has been subjected to changes foreign to his original nature. premising that it is to a long continuance of exposure to the He has now to undergo others which, through long acquired various causes stated, more than to their intensity, that w(habit, have become almost as foreign to him. must refer the greater portion of the injurious influences o:f most prevalent, under Passive congestion is the condition tropical climate on European constitutions. just stated; and no matter what his preIt has been seen that in hot climates the lungs are relieve< 1 vious disease in India, the morbid condition now superadded of a portion of carbonic acid through the inereased activity o t proves a serious difficulty to the invalid. If the patient sufthe cutaneous exhalations, while the kidneys and mucou s fered from tropical dysentery, his distresses are greatly aggrasurfaces are alike relieved of uric acid, urea, salts, and wate}’. vated during the long English winter and spring. The sufferers This state of activity, which holds, during eight months 4)f from fever, hepatic or splenic disease, are similarly distressed every year will explain how it is that in such climates di.,by severe abdominal congestion; and if the tendency, through
consequent
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405
plethora or other cause, be towards the cerebral cavity, position of the child. Dr. Smythe, of Lambeth, who kindly apoplexy is produced by exposure, or the absence of care, attended at my request, now arrived. Both feet,inone arm, the the pelvic during the season of cold and damp in Europe. When the fold of the funis, were at this time impacted liver becomes the seat of congestion, this morbid condition brim, the head doubled on the neck anteriorly, the breech
may be confined to the venous trunks, or to the whole secreting resting on the promontory of the sacrum. A full dose of parenchyma; or it may extend to both. In either case it is a laudanum was administered to the patient, and she was allowed to rest. Unsuccessful efforts were made to return the serious state of disease. I have seen many persons also, whose relatives at home arm, and traction was again employed, but uselessly. Another were weak-chested and consumptive, become subject to severe opiate draught was then given, and the use of the forceps .chest diseases from the same cause. In short, if the sufferings suggested to bring down the breech; but at that moment all were great, under the long continued exposure to the tropical difficulty vanished, and the child was brought into the world, at half-past heats, they are neither small nor unimportant under its oppo- dead, with the funis four times round its site in Europe-especially under exposure to damp cold, five o’clock. The expulsive pains had not been strong; the which exercises a peculiarly baneful influence. My experience placenta was removed by the hand, and external pressure Jiere in the last nine years would lead me to conclude that, if secured a safe and quick contraction of the womb. Renzarks.-Had there been continued expulsive pains for there really be any such immunity from cold during the first year of residence in England, as we hear spoken of so generally any length of time, and no assistance near, it is possible that in India, it is enjoyed only by the healthy and the robust. this woman might not have been delivered except by a more Numberless examples have satisfied me as to the truth of this dangerous alternative than that of turning; but we may often observation. A dry, or even frosty, cold is well borne, com- see a beautiful and conservative provision of nature, when, paratively, even by the enfeebled tropical invalid; but the the uterus failing to overcome the unseen difficulty and expel damp cold produces sensations of indescribable distress and the fcetus, the pains are less and less frequent, and sometimes depression in persons possessed of consid rable powers of re- entirely cease. It will also be observed that the fortunate sistance. Many invalids, again, in England in an period for turning had passed before my arrival. Several enfeebled state, seek what they call " the bracing air" of doses of calomel and opium were administered during the folBrighton and other such places during the winter and spring lowing three days, and the woman was spared a second danger months, in forgetfulness, or in ignorance, that, without a pre- by escaping peritonaeal inflammation. And this leads me to relate a case of that disease, which vious restoration of health, this said bracing is impossible of attainment. Many valuable lives are annually sacrificed in recently occurred in the person of a woman who watched her this vain endeavour. sister in the agony of labour, and being pregnant, was immeMore unfounded still is the prevalent notion amongst inex- diately seized herself. After delivery, no untoward symptom perienced and thoughtless lay persons, that on returning to arose until the fourth day, when a circumscribed abdominal England from hot climates they are to take leave of all their pain and tenderness were complained of, and rapidly increased. ailments, at the same time that they need take no care what- The lochial discharge was suppressed; the milk was not enThis is only another out of many tirely lost, but the headach was intense. The patient, already - ever as to their habits. .examples of the facility with which the mass of men receive emaciated, had paroxysms of severe pain; the countenance It is but the " they say it" was extremely distressed; the vomiting frequent; pulse 120. mere opinions as established facts. of the Spaniards, and that is enough for the unreflecting many. Calomel with opium were given, a blister applied to the "A moderate acquaintance with mankind," says Dr. James epigastric region, and rectified ether taken in effervescing Johnson, " is sufficient to stamp the truth of the remark, that draughts. The tenderness of the abdomen was excessive, but experience seldom instructs the mass." This is quite as true the fear of being touched or pressed was not confined to this as the observation of the older doctor of the same name, the part; in fact, there were symptoms of an hysteric character, moralist and lexicographer-viz., that there are some men who but most assuredly the danger was imminent. The opinion of In nothing are both re- Dr. Tyler Smith was obtained, who expressed to me his belief are incapable of acquiring experience. marks so just as in all that popularly relates to health, whe- that she would ultimately do well. A few leeches were ordered to be placed below the navel, the calomel continued, ther private or public. and the etherial mixture. The breasts were drawn, and the (To be continued.) bowels relieved by an enema of castor oil. After the subsidence of the inflammation, the patient was seized with painful diarrhoea and tenesmus, and this being relieved by reOBSERVATIONS IN MIDWIFERY. medies, she slowly recovered. 2Pema!?’-.ņThis mixed form of peritonitis is not frequent, BY W. MUTRIE FAIRBROTHER, M.D. and general depletion is borne with less than in any other variety of this disease. It is a great question how much Complicated Presentation;and a case of Peritonitis. policy is shown by resorting in the other puerperal forms of PRESENTATIONS of a mixed character, involving serious diffi- this fearful malady to prompt and extreme bloodletting. ’The - culty and danger, occasionally occur to those engaged in sequel of many recorded and related cases treated thus is not obstetric practice; while some which would otherwise present very satisfactory. no serious obstacles to the safe delivery of the parturient London-road, Southwark. woman become complicated by interference, being too long delayed. The following case contains some peculiarities worthy of notice :-REPORT OF A CASE OF COMPOUND FRACTURE Mary F-, aged twenty-six, having had previously five OF THE CRANIUM, AND HERNIA CEREBRI. natural labours, was attended by a midwife in this her last, —RECOVERY. who requested me to visit her patient at half-past twelve A.M., March 4th. I found the woman suffering but little from BY ROBERT W. CRIGHTON, M.D. Edin., L.R.C.S.E., uterine pains, which had been severe; the waters had broken DEMONSTRATOR OF ANATOMY IN THE MEDICAL SCHOOL, SURGEONS’ HALL, one hour before; pulse 100; countenance rather anxious, with EDINBURGH. slight shivering at intervals. Upon making a vaginal examiON the 4th of September last, I was called, at midday, to nation, one arm was discovered low down, the shoulder above J. C-,aged thirty, a saw-miller, of regular habits. it, and the other hand could be felt plainly; a coil of the visit funis had also prolapsed. The bowels having been lately , About an hour previously, while engaged at his occupation, relieved, the bladder was emptied by the catheter, and my he had been struck on the forehead by a piece of wood, right hand introduced into the uterine cavity, with a view to several feet in length, projecting from the circular saw while determine more accurately the position of the child. The in full motion, by which he was instantly prostrated. The head was felt lodging against the pubis symphysis, lightly hsemorrhage was reported by those who carried him from the grasped by that part of the uterus which surrounded it; so spot where the accident occurred as having been very profuse, that only at intervals could the hand be passed towards the and on first seeing him I found it had been to such an extent fundus, in order to bring down a foot and turn the child. The as to soak through the bed on which he was lying. umbilical cord, which was very long, gave some inconvenience He was then almost pulseless, and in a state of deep coma. by its position. A foot was brought down as far as prac- The wound inflicted on the forehead was somewhat oblique, ticable, and secured by tape, and now there was slight hmmor- extending from a short distance below the left parietal rhage. The other foot was found with some trouble, and con- eminence to a little beyond and above the same prominence siderable traction employed without materially altering the on the right. The lower part, for fully half an inch, was oc-
neck,
arriving