in Ireland, and for about three weeks he laboured under continued fever. He then began slowly to recover, but his convalescence was soon arrested by a return, in a very severe degree, of the pain in the loins.

As it was evident he was losing ground, Mr. Church, with Mr. Norman, examined the state of the back, on the 29th of May. Mr. M. referred the pain entirely to the right lumbar region, excepting that some pain extended down the right thigh. He had constant nausea, and about this time began to have vomitings. There was no disease discovered by examination of the spine, or of the abdomen, and Mr. Church and Mr. Norman were inclined to believe the disease was in the kidney, although the urine shewed no evidence of disease, excepting in excess of lithic acid, and once or twice a slight trace of blood. Alkaline medicine and sedatives afforded some slight relief, but in two or three days violent pain came on in the back, accompanied by vomiting; the pain continued for hours, and was so intense as to require large doses of opium. It was after this attack that there were traces of blood in the urine, and his medical attendants were the more impressed with the belief that the disease was in the kidney, though unable to decide on its character. For some days the pain continued in a less degree, but in the same part, and the next material circumstance was, that Mr. M., whilst sitting on the night table, became faint, almost lifeless, and without pulse at the wrist, but by being placed on the bed, and the administration of stimulants, he recovered, after some time, and became much as he had been before, excepting that his pulse became weaker, and he lost strength daily, as well as all inclination to take nourishment. He afterwards had three or four more attacks of syncope, but not to the same degree; he became exhausted, and died on the 12th of June, having vomited up a quantity of dark grumous blood for three or four days before his death.

On examination of the body the following day, there were found strong and old adhesions of the pleura in the right side, on which side he had once sustained fracture of the ribs. There were no adhesions on the left side, and the lungs on both sides were free from any trace of disease. The heart was perfectly natural; its valves and large vessels in a normal state. On opening the abdomen, the stomach was seen to occupy a large space, and the upper surface of a dark colour, from the veins being in a congested state. The stomach contained a quart of the same kind of dark grumous fluid that had been ejected previous to death. On the mucous surface of the inferior portion of the stomach was a deposit of lymph, adhering to the surface, but which could easily be scraped off. The mucous surface of that part was red and vascular, but not ulcerated. The liver and gall-bladder were perfectly natural; so also were the intestines, and the left kidney. In the situation of the right kidney was a tumour, extending into the right iliac region, formed by coagulated blood effused into the adipose substance surrounding the kidney, by which the kidney had been forced back out of its usual position, but there was no evidence of disease found in it. On opening the descending aorta, to trace from whence the hæmorrhage had taken place, about three-fourths of that vessel, a little

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above where the emulgent arteries are given off, was destroyed by ulceration, and the opening communicated with an aneurismal sac, the size of an orange, formed by condensed cellular substance, and covered by the peritoneum. The inner surface of the sac was in a great part formed by laminæ of coagulum. The coats of the artery were all destroyed at the point of ulceration, excepting the remaining three-fourths of its diameter. The ragged edges of the internal coat were everted, as is usual in aneurism. Directly below the ulcerated portion of the aorta, the area of the vessel was contracted, and nearly two-thirds of its circumference were ossified for the length of an inch. In the lower part of the aneurismal sac was a circular opening where it had given way, and through which the blood had passed into the adipose substance surrounding the kidney. The peritoneum being every where entire, no blood had got into its cavity. Bath, September 30, 1847.

HISTORY OF A CASE ILLUSTRATIVE OF SPECIMENS OF PUNCTIFORM AND TUBERCULAR MELANOSIS.

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.)

The patient from whose foot three specimens of melanosis were dissected, was a healthy-looking wellmade man, of ordinary stature, aged 45, a labourer in a mine. He was sent to me by my friend and former pupil, Dr. Paddon, under whose care he had been for several weeks, for a troublesome ulceration of the great toe. I found the under part of the toe of the left foot, presenting a large dark-coloured almost sooty mass, moist on its surface, and denuded of skin to the extent of an inch in diameter. The surrounding parts were irregularly tuberculated, soft in some places, hard in others. On the dorsum of the foot were ten melanotic deposits, varying in size from a pin's head to that of an ordinary pea; over two of the larger deposits ulceration had commenced, displaying the same dark half-fluid substance as that described to exist on the base of the toe. It will be seen by an examination of the preparation, that none of the sooty cysts extend to the cellular membrane, but that they are lodged in the true skin.

I

I advised an immediate removal of the diseased parts, and for that purpose recommended him to go to the Infirmary, where he was admitted on Oct. 30th, 1845, under the care of Mr. Bassett, who, on Nov. 4th, amputated the toe at the metatarsal articulation, and dissected out the two elliptical portions of skin here preserved. The stump healed slowly, and when he left the Infirmary on the 26th of February, 1846, which he did at his own request, there was a superficial sinus or two remaining, and the cicatrix on the dorsum had assumed a bluish appearance.

Some months afterwards he again fell under the care of Dr. Paddon, as surgeon of the mine, who cut out

the diseased parts a second time, but ulceration re-commenced, and the glands in the groin have enlarged, ulcerated, and discharged large quantities of black fungoid matter. I am uncertain if the poor man is yet living, but the last report which reached me of him stated, that he was gradually sinking under his accumulated miseries.

I should add, that the diseased toe was found to consist of a mixture of melanotic and fungoid matter, and that the softening rad extended to the bone, destroying the articular cartilages.

was raised in the semi-erect position, thus favouring the return of blood from the head. I then, as she was now somewhat tranquil, opened a vein in the arm by a large orifice, and at once abstracted no less than thirtyfive ounces of blood. The pulse before bleeding was full and bounding, and increased in frequency. On introducing the hand the os-uteri was fully dilated, and the membranes entire. Snow being on the ground, this was constantly applied to the head, and a thorough perflation of fresh air emitted through the apartment. Appearing now somewhat easier, the breathing being

CASES FROM PRIVATE PRACTICE.

By JOHN RICHARD WARDELL, M.D., Edin.; Late President of the Royal Physical and Hunterian Medical Societies, Assistant Pathologist in the Royal Infirmary, Edinburgh, &c. &c.

(Continued from page 574.)

CASE. III.

PUERPERAL CONVULSIONS. February 2nd, 1847. Summoned in great haste at two o'clock this morning to see Ann W, residing at a village two miles distant, who was reported to be in labour under the charge of a midwife, and very dangerously ill; indeed so precarious was her condition, according to the messenger, when he was despatched, that he thought it highly probable she was not then alive. On arrival I found the patient to be a stout, muscular, short-necked, young woman, apparently three or four and twenty years of age, lying on a bed in a state of unconsciousness. Her mouth and lips were besmeared with blood, and her looks seemed vacant and unnatural. It was stated that she had had lingering pains during the previous day and night, and that up to an hour before she was suddenly struck down in the first fit, she had not given any manifestations of any particular symptoms; she then com plained of headache, which became more violent, and speaking of this a few moments before she fell down, she described it as being so intense that she felt as if her head were 66 opening and shutting." Two hours before this occurrence the pains were strong and much more powerful than they had been; they then almost entirely ceased. She had had four fits before my arrival, and during the intermissions she was scarcely, or not at all, conscious of what was passing around, or of her own condition, and tossed about the bed in a furious manner. Immediately after I had entered the room another paroxysm came on; the eyes became everted, the countenance greatly congested, the hands powerfully clinched, and the whole frame convulsively shook in the most alarming degree, whilst the foaming at the mouth, stertorous breathing, etc., added to the grave character of the scene. Her agitation and continuous efforts to throw herself off the bed were so strong that it was with difficulty that she could by two or three persons be restrained. The features quickly became darker, and the attack continued for a considerable period. After the fit had terminated the body

on delivery. The hand was carefully introduced, and the child turned and born in from twelve to fifteen minutes. Thirty drops of laudanum were then given, and the head ordered to be shaved immediately. She continued in a tolerable state of composure for four hours, at intervals having a short sleep, during which she would murmur in a low muttering delirium, and on suddenly awaking would distressingly mourn, roll her eyes, and speak in a quick incoherent manner, frequently changing her position in bed, and strenuously endeavouring to get up.

7 a.m. Another violent paroxysm came on characterized by the same symptoms as the former. On the termination of the fit the following treatment was pursued :

Venesection to twelve ounces. R. Calomel., gr. viij. ; Pulv. Opii, gr. ij. Sit pulvis statim sumendus. Empl. Lytte nucha. Sinapismi cruribus et spinæ lumborun. Hirudines xii. temporibus. Enema Terebinth. in Decoct. Amyl. Oiss., statim injiciend. Snow continued to the head.

4 p.m. No return of fits since this morning at seven o'clock; tossed about for a short time, when she became quiet, and slept three hours; on awaking appeared to be partially sensible; skin moist; pulse 90; injection came away mixed with a copious quantity of fæculent matter; tongue swollen, and somewhat besmeared with blood.*

R. Tinct. Opii, gtt. xxx.; Aquæ, oz. iss. Sit haustus hora somni sumendus.

3rd. No return of fits; slept pretty well during the night; bowels opened; tongue moist; skin rather hot, and complains of headache; is quite sensible; pulse 86; blister rose well; has some pain in the inferior abdominal region; answers questions more coherently, but is not quite sensible.

R. Pulv. Jalap. Co., scr. ij.; Syr. Rhead, dr. ij.; Sp. Ammon. Co., dr. ss.; Aquæ, dr. x. Sit haustus

statim sumendus.

R. Liq. Ammon. Acet., oz. iss. ; Spr. Æth. Nitr., oz. ss.; Mist. Camph., oz. iv. Sit mist. Capt., oz. j., quarta quaque hora.

4th. Does not feel quite so well to-day as yesterday; head aches, and complains of severe pain in

Of course the requisite precautions were taken immediately on my arrival to prevent injury being done to this organ during the fits. The midwife who had been in attendance had omitted this, and indeed so ignorant was she of the nature of the affection, that she stretched the patient on the floor, expecting it was simple syncope. It is high time these incompetent practitioners had their func tions suspended.

abdomen; countenance of a yellowish tinge; pulse 84; skin moist, and has sweated a good deal. Bowels well opened by draught; no lochial discharge; tongue moist and on the whole is going on favourably. Intellectual faculties much more natural.

5th. Had a better night, having slept for some hours consecutively; tongue moist, and skin not at all dry; pulse 88, tolerably soft; complains of less pain in head; no uneasiness on pressure over abdomen. R. Infus. Calumb. Ten., oz. viij.; Sol. Morph. Mur., dr. j. Sit mist. Capt., oz. j. ter die.

7th. To-day, at 1 p.m., was hastily sent for, another fit having come on. On my arrival the paroxysm had terminated, and she was then sensible. From the accounts of the attendant, this attack bad been of a milder character. Reported to have complained of some headache yesterday; bowels open; tongue moist; skin rather hot but not dry, and still complains of pain in the head. Venesection to six ounces, which induced syncope.

R. Pulv. Opii, gr. ij.; Calomel., gr. vj. Sit pulv. statim sumend. Sinapimi cruribus. Mistura omittatur. Ol. Ricini post horam.

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of mortality with the present notions of the affection, and the ratio of deaths that now occur, under different pathological views and a more fearless mode of treatment, we are impressed with the complacent reflection that the progress of science, and the valuable truths arrived at by careful observation, have in this complaint been followed with the most valuable results, and that

such have tended to the prolongation of human

existence.

Puerperal convulsions usually occur during one or other of the stages of labour, or immediately after parturition. They may also come on at any period during the latter half of pregnancy; such, however, is far more rare than the former. The most frequent of all times is undoubtedly a little before the termination of the first stage, when the os uteri is becoming fully dilated. This affection may also take place at any peri lod within the first twenty days after labour, but such is more uncommon, for after the uterus has expelled its contents, and so long a time as ten days or a fortnight elapsed since delivery, the supervention of the convul

of this person it is seen that the first fit came on

10th. Continues much the same, but does not sleep very well and complains of some beating at the heart. Mist. cum Infus. Calumb. sumatur.

14th. Says she cannot sleep, and for some days has not slept three hours consecutively. Has pain over the os frontis, which is described as a dull headache. Action of heart on application of the stethoscope is excited, but no bruit can be heard. Pulse 80, of tolerable strength.

R. Tinct. Digitalis, gtt. xl.; Sol. Morph. Mur., dr, iss. ; Aquæ, oz. iv. Sit mist. Capt. quartem partam omni nocte

15th. Slept well last night. In all respects improving. 17th. Rapidly improves. 24th. Convalescent.

REMARKS.

There is not an affection more alarming, nor one in which promptness and energy are more imperatively demanded, than an attack of- puerperal convulsions. Procrastination in our measures, and an imbecile line of treatment, are often attended with disastrous results; whilst a ready decision, and the bold employment of those means which, with the well informed, have now become indisputably established, can in a great majority of cases avert a mortal termination. Before this disease was so well understood as it now is, not more than one half or one third recovered. In the seventeenth and eighteenth centuries, it was regarded by the physicians of those times as a well-nigh always fatal disease. Hunter, Jacobs, and others affirmed that more than fifty per cent. invariably died, indeed, they considered it as one of the most fatal of complaints. Comparing such statements and the degree

and it is also worthy of remark, that five days after her delivery another fit came on, althorch there was no return of the paroxysms from the period of parturition to that time. With regard to the dilatation of the uterine orifice, I am aware some authors have affirmed that a fit will supervene when scarcely any signs of labour are present, and in a few minutes after such fit, not only will the parts have become sufficiently dilated, but the child be immediately born, owing to the morbid excess of muscular action. Such statements may be regarded as an exaggeration rather than as a simple declaration of facts, for it will generally, if not always, be observed, that where the fœtus is so precipitably expelled, the os had some time before been gradually becoming patulous.

It may here, too, be mentioned, that the affection is much more common in primiparous females, than in women who have previously borne children. Ann W. had never before been confined. In four cases which I have known, three were in the first confinement. Collins, in an account of thirty cases, says that twenty-nine were first births; and of thirty-six by Merriman, twentyeight were first births. We can readily conceive that the first time nature accomplishes this process, her efforts will have a more severe effect upon the animal economy than when the parts have been previously distended, the impression made upon the nervous system give rise to greater excitation, and the mental disturbance which ranks amongst the acknowledged causes exert a more powerful influence upon the body.

Pathologists have found it difficult to determine which are really the remote and which are the proximate causes; indeed, on this head there exist much

ambiguity and difference of opinion. Amongst the remote causes, however, with those who endeavour to define certain conditions as such, irritation transmitted to the great nervous centres by means of the afferent spinal nerves, especially those proper to the uterus, which, from their morbid excitation produce the sequent train of phenomena at the base of the brain and in the spinal cord, may be enumerated as importantly entering into the causation. Irritation in any portion of the alimentary canal, particularly in its gastric course, preternatural vascularity in the colon, a diseased state of the liver, of the bladder, etc., have been considered as likely to induce the affection. There can be little doubt that a previously confined and irregular state of the bowels, the accumulation of scyballous and acrid matters, &c., will act as powerful predisponents. Morbid conditions existing in the nervous centres themselves, as well as from states operating upon the extremities of the incident nerves, might also be mentioned. There can be no doubt whatever that mental discomposure acts very importantly in the induction of the convulsive paroxysms. An anxious and depressed state of mind always exerts a deleterious influence upon the body, and renders the nervous system morbidly excitable, and where such obtains to a considerable extent, or has been long continued, it may readily be imagined that such would be apt to induce the results considered. In four cases which I have known, in three there was much mental disquietude. One was the lady of an officer in the army, whose husband died very suddenly about the period of her full time of pregnancy; labour came on, accompanied with very violent convulsions. The two others were unmarried females, and had both, for some time before, been very despondent. It has been stated by eminent obstetricians, whose experience in this disease is more ample, that it occurs far more frequently in illegitimate births than in the confinements of married women,—an assertion which is very likely to be correct, owing to the acute sense of shame in the former, the censure of their friends, and other gloomy reflections which have often considerable effect. The state of the air by some, especially the older physicians, has been deemed an essential element entering into the causation of puerperal convulsions. There can be little doubt that they are more common in summer than in winter, and when the air is surcharged with electricity; yet they are much more dependent upon more potent causes, and may occur at any season of the year, and under every variety of temperature. This case it is seen was in the month of February, and I well recollect it was a keen frosty night. Dr. Ramsbotham says that the affection is most usual when there is thunder in the air,-an assertion highly probable, and in this respect being analogous to what we know with regard to apoplexy, to which disease puerperal convulsions are very nearly allied.

Puerperal convulsions appear to be proximately caused by two distinct and opposite conditions of the vascular system,-viz., an over-distension, and a too great emptiness of the blood-vessels, because we know that the cerebral vessels being over-loaded in a patient of plethoric diathesis, by producing pressure on the brain, will give rise to the paroxysms; and also when there is sudden and considerable loss of blood, as in uterine hæmorrhage, because convulsions often precede the fatal issue, and they have been experimentally produced in the lower animals by sudden and copious venesection.

ensue.

It is more difficult to account for their occurrence when exsanguination, than when plethora, is regarded as the cause. The manner in which the result is produced may probably be owing to the equilibrium of the circulation being lost by a sudden effusion of the vital fluid, when the walls of the vessels have not sufficiently accommodated themselves to the decreased volume of blood traversing their cavities; hence their propulsive power would become in some measure impaired, and thus congestion and pressure We know that the heart requires an exact volume of blood to be transmitted through its cavities during each systolic and diastolic action, and unless such volume be normal, its action will become altered, and this change of function of course exerts a commensurate effect throughout the vascular system, When therefore the column of blood is considerably decreased, the orgau is not stimulated to its ordinary degree of contractile power, the vis a tergo is diminished, the propulsive functions of the larger vessels are also impaired, and congestion at the vascular extremities is thus engendered, whilst the whole system partakes of the debilitated condition, and thus superadds to the first cause.

There are two descriptions of patients, whose conformations are exactly opposed to one another, with wh whom the disease appears chiefly to prevail-the muscular, short-necked, apoplectic-looking person; and the thin, slender, nervous female, of highly-excitable temperament and hysterically inclined. Mr. Cole, of this place, not very long ago attended a young person of this description, who had the convulsions in the most alarming manner. These being admitted as the most correct views of the radical pathology,-viz., that pressure, however remotely induced, is produced in the nervous centres, yet post-mortem investigations have not satisfactorily elucidated such conclusions, because autopsies have been made where the patient has died of puerperal convulsions, and no organic changes have been observed to follow, or in any degree account for death, just as in cases of apoplexy, termed nervous or simple apoplexy. It seems rational to suppose that radical organic changes do exist in all cases, but in particular instances they are certainly so occ ilt, as iù the present state of our knowledge to elude detection.