disturbance and mis-direction of biliary secretion | other functions when checked or deficient ;—a necessary element in the digestion of certain alimentary princi-ples;-and a means of sustaining the peristaltic action of the intestines.

4. I have little to say respecting medicinal remedies, such being well known to my audience. I may remark, however, that a reliance should be placed on hygienic rather than upon pharmaceutical measures, the former alone bringing about permanent improvement. Mercurials, though giving temporary relief, ultimately act injuriously if long continued, by depressing the system. Hydrargyrum cum Creta, and Extr. Hyoscyamus, given sparingly, will unload the abdominal veins, and correct The preceding investigation will serve to direct our vitiated secretion, these being combined with, and principles of treatment, which will have reference to followed by, light vegetable tonics,—as rhubarb, hop, the functions performed by the biliary secretion in the calumba, with alkaline, carbonates, and saline aperients. economy, namely, a provision for eliminating from Drastic purgatives must be carefully shunned. The the blood effete tissues consumed in the lungs ;-agastric intestinal mucous membrane is generally very Enid vicarious of the products of respiration, or of sensitive in such cases, and will not tolerate mineral,

PERIODICAL PERPURA VICARIOUS OF THE CATAMENIA.

455

· or even the more active vegetable tonics, at first; | but merely took down her name on a piece of paper, -subsequently, however, chalybeates will produce an excellent effect, if this irritation be first subdued, and if combined with alkaline aperients. A suitable mineral water will often prove highly useful,-as the artificial Vichy, or Ems, or saline Cheltenham water, followed by a course of Tunbridge chalybeate. From the introduction of aërated chalybeate water here, at my recommendation, a most efficacious and agreeable remedy may be now had, a course of which will be attended with much benefit, if preceded by appropriate treatment.

The carbonic acid with which this aërated water is surcharged, is in itself a highly useful remedy, its reception into the stomach being followed by agreeable and exhilirating sensations. From its stimulant impression on the organic nerves, distributed over the mucous coat, it increases the secretion of gastric juice. Its effects, when received into the blood are analogous to those arising from the vegetable acids. Finally, carbonic acid evidently enhances the tonic properties of the chalybeate.

over which she performed a sort of incantation, and then pronounced the bleeding to be stopped. This the mother found on her return to be the case; but on the evening of the same day the patient was covered with medical attendant was again summoned, and at the purple spots, the largest about the size of a pea. Her end of a week the spots disappeared. She soon felt quite well again, but precisely one month from her last illness the body became again covered with a similar eruption; the spitting of blood returned with it, and the inside of her mouth, the whole surface of the tongue and palate, was covered with dark spots. The gums bled on the slightest touch, and eating and swallowing became very painful. The bleeding continued for a week, but it was a fortnight before the mouth was month, to the very day, precisely the same symptoms well and free from spots. After the lapse of another occurred; and up to the date of her admission, the bleeding from the mouth had returned, with extraor dinary precision, every month. It began on a Friday, and it last appeared on a Sunday, having varied only these three days in about a twelvemonth. She states the quantity of blood to be about the same on each occasion, and that its discharge continues one week,

In conclusion, I would just remark, that in biliary disorders, as in all others, we must seek for the patho-the mouth getting well after another week. There has logical cause, and counteract its influence, if we look for success,―n result, moreover, to be further solicited by restoring all the functions to full and barmonious

action.

been one exception to the uniformnity of these periodical symptoms. About six months ago, on the day the hæmorrhage from the mouth was expected, a sanguineous vaginal discharge occurred; this increased the next day, and lasted for a fortnight. There was no bleeding from the mouth, neither was it sore, but the spots made their appearance, although of a lighter

PERIODICAL PURPURA VICARIOUS OF THE colour, and less numerous on the body,

CATAMENIA.

By CHARLES BARHAM, M.D., Truro, Physician to the Royal Cornwall Infirmary.

(Read at the Annual Meeting of the South-Western Branch of the Provincial Medical and Surgical Association, held at Truro, July 28th, 1817.)

On her admittance she made no complaint; the functions generally were healthily performed, and ber condition merely indicated a degree of anæmia. The tongue was very pale and flabby; both its upper and under surfaces, together with the gums and inside of the cheeks, presented the same exsanguineous

appearance.

The return of bleeding from the mouth was expected on the 22nd, and on that day the tongue had lost its pasty appearance, and had become redder, and more natural. She complained of violent pain across the

loins.

On the 25th she awoke with a nasty taste in her mouth, and the saliva was tinged with blood. She also noticed spots over the cliest and arms. These had increased in number and size at the time of the

Ann Teague, aged 17, was admitted into the Cornwall Infirmary under my care, November 12th, 1846. She is rather tall, well formed, with dark hair and eyes, and a pale exsanguine countenance. She has always had sufficient food and clothing, and has been only employed in household work. Her father and mother are living, and she has six brothers, and one sister, five years old. They are all in good health. With the exception of the ordinary diseases of childhood, which she passed through very favourably, she had no illness, but always considered herself well and strong till about two years ago; she was then seized suddenly with a severe pain. in the right side, just below the ribs. She was attended by a medical man, and in about a month the pain left her. About two months after this she expectorated, without cough, some dark-coloured blood, and fancied it came from the throat. The bleeding recurred for a few days only, and was not attended by pain in the side. About three months later her nose bled profusely, she thinks more than a quart, and she was so * much weakened as to be confined to her bed. The mother was alarmed, and resorted to a celebrated charmer.' The old woman did not visit the daughter, | ones appearing on the tongue, and the mouth becoming

visit, (9 a.m.,) and the sputa then consisted entirely of dark blood. This formed a coagulum, if the mouth was not frequently cleared, on the upper surface of the tongue, and when this was scraped off numerous red papillae were seen with bleeding points. The gums bled freely, but nothing abnormal was observable on the inside of the cheeks, or on the lower surface of the tongue, nor was the mouth sore.

On the 26th the lips were red, and some spots appeared on the lower. On the following day the spots were seen on the inside of the cheeks, fresh and larger

very sore. The severe pain in the back passed off at this time.

New and larger spots were noticed on the 28th, whilst the old ones had faded; they were confined to the upper part of the body on this occasion. No further bleeding occurred, so that it had lasted during four days. Three or four days later little trace remained of the purpura; the tongue and mouth had become pale, and the general health as good as before the attack; so it continued till the next period arrived for this disturbance of the system.

December 24th. The lumbar pain was less on this Occasion; the purpura more severe; the tongue presenting a larger bleeding surface; the elevations on the under lip amounting to bullæ, and the spots extending over the whole body, diminishing in size from above downwards, so that on the feet they were miliary. Her ordinary state of health was recovered within ten days, and she was then discharged at her own request.

A case of hæmorrhage from superficial vessels, vica" rious of the menses, occurs to my recollection, which was under my care as an out-patient at the Infirmary, about eight years ago. The patient was a girl about 20, who had an ulcer below the knee, from which a copious sanguineous exudation took place for some days monthly. The catamenia which had been for a considerable time suspended, did not return during several months, when she continued under my observation, and the ulcer remained unhealed. I speak of this case entirely from memory.

Another out-patient still under treatment, presents an affection of some superficial vessels of the left mamma of an analogous description, though less strongly marked with the evidence of substitution for the uterine discharge. She is a girl 20 years old, of robust form, though short, with fully developed mammæ. Menstruation is stated to have been regular and free in quantity, from the age of 16 to 18. It then was suddenly suspended, and has remained so, with the exception of a very transient appearance about ten days ago. She received a blow from a man's fist on the left breast, a twelvemonth since, and it then exhibited decided marks of the contusion; but they disappeared speedily, and it was not till six months after the bruise that they seemed, as it were, renewed on the same spot, and they have now for the last half-year alternately become vivid and receded, at no very regular intervals,-sometimes once, sometimes twice or more, in the week, varying from the appearance of purpura to that of ecchymosis. The part concerned is painful when the spots are high-coloured..

I am indebted for the foregoing particulars to the minute and faithful record of the case drawn up by Mr. Gorringe, the Assistant House-Surgeon of the Infirmary. It would be useless to eater into the details of treatment. Mild alteratives, and chalybeate tonics were chiefly used during the intervals, and derivative emmenagogues at the monthly period. In the second attack a few leeches were applied near the vulva, and the bleeding was profuse and with some difficulty stopped. Electro-magnetism was tried, but was only once submitted to, as it caused considerable pain and more alarm. These and the other means used, produced no distinct modification of the symp-There has not been very much constitutional disturbtoms, and the opportunity for treatment was unsatisfactorily curtailed.

Since she left the Infirmary, six months ago, our art has not I believe been much in requisition, but nature has been effecting important changes in the direction of the erethism of the minute blood-vessels. Mr. Nankivell, of St. Columb, the able surgeon who has been her ordinary attendant, has kindly enabled me to bring down the history of the patient to the present date, confirming at the same time the state. ments made by herself. Writing on the 13th, instant, he says-

t

"St. Columb, July, 13, 1847.

"My dear Dr. Barham, "I have to-day seen Ann Teague; she looks worse than she ever did; is quite blanched. The uterus has in an abnormal measure parted the catamenia. Three months since she menstruated, and it continued for a week, being accompanied throughout with profuse bleeding from the nose, but not from the gums. Twice since then she has had hæmorrhagia (without epistaxis,) continuing for a fortnight. A week since she was again taken unwell, and fears that it will continue several days longer. There are about a dozen spots of purpura on the neck. You are aware, I think, that she menstruated once when 16 years old, and never since until recently, except vicariously. She thinks that since that time she has had the hæmorrhage from the gums about twelve times. She tells me that she passes many coagula. There is no leucorrhoea."

ance, a painful fulness towards the left inguinal region being the chief amenorrheal symptom, besides someof the ordinary results of plethora ad nolem.

CASE OF SIMPLE FRACTURE AND DISLOCA-
TION OF THE GREATER PORTION OF THE
RIGHT ASTRAGALUS, FORWARDS AND
OUTWARDS.

By EDWARD JOHN SPRY, Surgeon to the Royal
Cornwall Infirmary.

(Read at the Annual Meeting of the South Western Branch
of the Provincial Medical and Surgical Association, held
at Truro, July 16, 1847.)

Thomas Rogers, a tall, muscular, and robust miner, aged 42, was brought to the Infirmary on the 24th of September, 1846, and was admitted under the care of Mr. Bull. From the statement made by the patient, it appeared that whilst at work in the morning of the day preceding, at Poldin Mine, in Gwennap, he had slipt from the end of a scaffold, about fire or six feet high, and had fallen perpendicularly to the ground, the hollow of his right foot coming in contact with a large projecting stone, which caused him to be thrown on his right side. On attempting to stand, he found that he could place no weight on the injured foot, that it was distorted, and very painful. The surgeons of the mine were promptly on the spot, and endeavoured to restore the displaced parts, but without:

FRACTURE AND DISLOCATION OF THE RIGHT ASTRAGALUS.

success, and on the following day they sent him to the Infirmary, where be arrived about nine in the evening. The limb was then examined by Mr. Gorringe, our assistant surgeon, acting for Mr. Bull, and by my colleague, Mr. Bassett, who persevered for a considerable time in their attempts to reduce the dislocation with the aid of the pulleys, but with no better result than attended the former efforts.

The next morning, being at the Infirmary, I was requested to examine the limb, and ascertained its condition to be as follows:

457

the case to the natural efforts, as it was clear that the integuments must slough, and that in due time the bone might be separated.

To favour these efforts, the limb was placed on an inclined plane; fomentations were diligently applied, an anodyne was given, and he passed a good night. The pulse on the morning of the 26th being only 93; but little constitutional disturbance was excited. On the 29th the pulse was still 93; he felt easy, and the swelling gradually subsided. Vesications formed over the projecting bone.

October 2nd. From this time the sloughing process proceeded, which extended over the outer "ankle;

by suitable diet and medicine. On the 6th the bone was partially uncovered; and on the 20th it was found to be so loose that Mr. Gorringe had no difficulty in detaching it after dividing only a little ligamentous tissue. A large cavity was of course left exposed, in which could be seen the concave articulating surface of the tibia. Soine hæmorrhage ensued, which was readily suppressed by applying a pledget of lint and a roller.

The foot was extended, the toes turned inwards, and the outer edge of the foot downwards, the foot being twisted inwards. There was considerable swell-pulse 76. The patient's strength was duly supported ing of the soft parts, but the skin was not broken. The inner malleolus was deeply buried in the angle of adduction of the foot, and could only be felt with much difficulty, whilst the outer malleolus was remarkably prominent; and just below, and a little in front of it, there was a large projecting bony surface, immoveable, covered only by the skin, and a light effusion of serum in the cellular tissue. The foot, could be brought into a straight line with the tibia, and could be flexed to some extent without much effort; but immediately that the hand was removed, the parts resumed their former relative positions, and the patient had no control whatever over the limb. A slight crepitus could be felt on rotating the foot, when it was brought into the position last described, which had induced the impression that the inner malleolus had given way, and that the whole of the foot had been dislocated outwards. After a careful examination, I felt satisfied that there was no fracture of either malleolus; the partial mobility of the foot rendered it improbable that it was entirely dislocated; the well defined outline of the projecting bone suggested that it was some portion of the plantar arch, and that from its size and situation, it could be no other than the astragalus, but having never before seen an accident of this nature, I arrived at this conclusion with some diffidence, although there was no resisting the anatomical evidence thus supplied.

My colleagues concurring in these views, it was agreed that one attempt more should be made to restore the displaced bone, and that as the patient was very muscular and strong, he should be prepared for the process by a large bleeding, and by being kept fully under the action of the tartarized antimony for two or three hours. This was done, and the pulleys were again used most perseveringly, pressure being at the same time made on the projecting bone, but after continuing extension to the utmost degree that would be justifiable, the man being in the most favourable state for overcoming mere muscular resistance, we were satisfied that it was perfectly useless to go any farther. On removing the apparatus it was observed that the pressure on the outer surface of the foot had produced complete absorption of the effused fluid, and that the bone was only covered by the skin, which a mere touch with the knife would have divided; but as the attachments of the bone were uncertain, and it could not be ascertained at this time that it had been broken, it was thought best to leave the future management of

The portion of bone removed proved to be the large convex articulating surface of the astragalus, broken off from the head of the bone, obliquely through its neck. It will be seen that the inner corner of the trochlea is carried away, showing pretty clearly that the foot must have been partially extended at the moment the shock was communicated to the limb, when, by the perpendicular and sudden descent of the patient, the whole weight of the body was received. On the upper and half-exposed surface of the astragalus, the anterior edge of the tibia acting like a chisel in cleaving the fracture, the foot being at the time prevented from yielding to the blow by being wedged up firmly with the projecting stone which occupied the plantar arch before described.

22nd. There is a great discharge from the cavity; the finger was carefully introduced, to ascertain if the other portion of bone was sufficiently loose to take away, but although its rough surface could be easily felt, it was too firm to remove, and it was considered best to make no further attempt to do so. This examination afforded an opportunity of verifying the opinion before given that the inner malleolus was quite sound.

24th. An abscess which had formed on the inner surface of the foot near the ankle was opened to-day, which gave him great relief. His strength was now so much reduced from the excessive discharge, that it was necessary to increase his allowance of porter to a quart daily, with four ounces of wine.

27th. This appeared to be the critical period in the history of the case. The discharge was excessive, his weakness was extreme, and it was much feared that amputation would be immediately required; but from this time the symptoms became more favourable, granulations appeared in the cavity and over the outer ankle, where the skin had given way. By gradually and carefully following out the principle of supporting his constitutional power, he had so far recovered on the 18th November as to be able to raise his leg a little