EPIDEMIC CONTINUED FEVER. two families; one by W. Roper, his wife, and seven children; the other by John Sparrow, his wife, and two children. From the commencement of the fever in Pegg's house, they had kept quite close, declining all communication with the infected premises, and had hitherto escaped. It struck me that if I could remove the two healthy families, and isolate them, I should, even if they did not escape, destroy the focus of contagion, and thus probably cut off the disease. I therefore waited upon the Board of Guardians, and laid the case before them. There was some difficulty upon the subject, which was, however, eventually removed. The Union Fever Hospital, which is a detached building, was given up to them, and after some persuasion, the Ropers and Sparrows departed from the “city," which they left with all the regret of long attachment, and on the 23rd of November, took up their residence in the Fever Hospital of the Union, which is about three miles from the "city." The men were allowed to go to their work as usual. I confess that I felt interested in this experiment, and made frequent enquiries after the emigrants. I had no fresh case, and "all well" was the answer week after week which I received. I began to congratulate myself that there was an end of the epidemic, but I was disappointed. Thirty-one days after their removal to the Fever Hospital, one of the sons of Roper was attacked with fever, and was followed by five other children in the course of the week; and on the 31st of December, one of the children of Sparrow, making then seven out of the thirteen. These cases fell under the care of another medical man, and all recovered. Their ages were 2, 4, 6, 7, 8, 10, 12, and they will number in my list, Cases 14 to 20, inclusive. They remained three months in the hospital. January 17th. CASE 21.-On the 17th of January, 1847, fifty-five days after the Ropers had been removed to the Hospital, Samuel Gardener, residing at the cottage marked 21 in the diagram, was attacked with fever, had it very severely, having been reduced to the very last extremity, but ultimately recovered. Samuel Gardener had worked with the Ropers daily before their removal to the Union, and this is all the connection I could trace. None of the neigbours of Gardener had the disease, and this is the last case which occurred. I have thus given a brief description of every casethe first and the last-in this, which I may fairly call a distinct (though limited,) epidemic, commencing on on the 25th of August, 1846, and ending on the 17th of January, 1847; lasting five months, arising without any traceable cause, and communicated from individual to individual, in eighteen certain and clear, and three other more doubtful, instances. It was confined to eight families, of whom it attacked in the case of 679 11 of whom all recovered 3 of whom one died 9 of whom all recovered 4 who recovered 1 " 5 who recovered 7 who recovered 1 Gardener 1 Secondly. The fact observed in all fevers, and wellestablished in regard to many other diseases,-viz., that a certain state of the system, at present unknown and undefined, is essential to the reception of this contagious principle, was well shown in the epidemic I have described. In eight families, the members of which were in daily, and some of them in hourly communication with the party infected with this highly contagious fever, twenty-seven out of forty-eight escaped. Thirdly. The interesting fact of the poison of fever remaining dormant in the system for a fortnight (Case 11,) one month (Roper and Sparrow,) or even two months, (Gardener,) causing no alteration in the health, until the state of the system was favourable to the development of fever, is clearly and unanswerably demonstrated in the facts I have related. Fourthly. The probability of contagion being effected through the medium of a third party, who himself never has fever, is strongly indicated in Case 13. I could extend these observations, but I have already occupied space enough, and I am anxious to avoid detracting from any value which may attach itself to the facts I have related, by being tempted into the fascination of theoretical speculation. One word more, however, upon the all-important subject of treatment. Several (I think about nine,) years ago, I had nearly the whole management of an epidemic similar to that which I have related, and occurring in the same parish. In this case the symp toms commenced with a type which appeared sufficiently inflammatory to warrant the abstraction of blood, which in three or four instances was done by myself, and one or two by other practitioners; but every case in which blood was taken, either generally or locally, died. In fifty-four cases there were ten deaths, or about one in five. In the epidemic I have just related, in twenty-one cases there was only one death-one in twenty-one-a difference very great. Of late years I have used the lancet very sparingly indeed in the treatment of all diseases, except those purely and acutely inflammatory; but I have never taken a drop of blood from a patient labouring under continued fever, and I have had no reason to regret the malaria of ague producing continued fever, it the omission. vanishes altogether when brought to bear upon putrid In the instances above related, I kept two indications animal excreta, and this perhaps is the most natural before me:theory we can devise to account for those cases in which no contagion can be traced. Stowmarket, November 24, 1847. 1st. To obviate the effects of local congestion, of what I believe to be in fever altered blood; which effects, again, I believe we see in or about the capillary system, or ulceration of Peyer's glands, &c,; and, 2nd. To prevent my patients from dying by asthenia; to keep them, in fact, alive. The first indication I attempted to fulfil by the use of the Pulvis Soda Comp, of Guy's Hospital, a most useful medicine in these cases. It is composed of carbonate of soda, compound chalk powder, and calomel; sixteen grains contain one grain of calomel. Of this I gave from five to twelve grains every four hours, with or without a solution of the carbonates of soda and ammonia. The second indication I endeavoured to fulfil by the administration of port-wine, with or without brandy, in large quantities. In the cases I have detailed I had frequently abdominal and thoracic complications; in one case (11,) there was decided pneumonia, but I did not on this account omit the wine, though I pushed on the mercury. I was equally regardless of delirium, which is, probably, always an effect of innervation in these cases, or of dry tongue. Whenever I found unequivocal indications of debility, as evidenced by a quick, thready, irritable pulse; trembling; sordes about the mouth and teeth, &c., I invariably gave wine. The result of the cases I have related fully bears out the propriety of the practice. Had I been able to get more wine down the throat of poor Ann Threadgill, (No. 10,) I believe that I should have had no fatal case to record. SHORT NOTES OF THE OPINIONS AND (Continued from page 654.) When chancre is associated with phymosis, it sometimes ulcerates backwards as far as the arch of the pubes; at others it penetrates laterally into the canal of the urethra, causing the urine to communicate with the sore, and producing excruciating pain. So long as the urine is imperfectly discharged, the ulceration of the integuments will continue to extend, and the pus and urine pass out together through one or more openings. Sometimes in complete phymosis, ulceration takes place through the prepuce at the point where the corpora cavernosa join the glans, and the urine, having no other outlet, will be forced upwards at a right angle with the urethra, producing the greatest possible annoyance to the patient. If the chancre, having perforated the urethra, has formed a sinus, making its way towards the scrotum, the urine will escape into the cellular membrane, and produce great pain and inflammation, and in a few instances affect the testicle. When the sinus is narrow, and the aperture small, the inflammation will extend, and form a small hard tumour near the ossa pubis, the superincumbent integuments not always being involved, In these cases the urine will be expelled by squirts; and if the tumour be neglected, the sinus will proceed downwards in the course of the urethra, and produce fistula in perinæo. In another instance, when the glans has been destroyed, the ulceration will extend along the corpus spongiosum, and cause the greater part of it to slough away, whilst the The doctrine of contagion in fever is all-important in these days of sanitary reform; every addition to our knowledge, therefore, upon the subject, is valuable. Dr. Watson, in his usual masterly manner, has brought much evidence and reasoning to bear upon the subject. He believes that malaria or miasmata produce a disease which is not contagious, and that continued fever, and the exanthemata are never caused by malaria, but are invariably produced by contagion,-integuments may remain unaffected; but the sound ¿.e., by an animal poison arising in the individual, and propagated from one person to another, either by actual contact, or by exhalations from the lungs or surface of the body. But this argument, it is clear, must in itself extend to animal excretions, and what is skin will so contract upon the space left by the sloughing of the urethra, that the urine will be expelled in a stream not larger than a hair, and a bulbous enlargement will be found behind the point of contraction, by every effort to discharge it. There is undoubtedly true of the body, may thus, mutatis generally at the same time thickening and induration of mutandis, be equally applicable to the dunghill or the the prepace, with a contraction of its aperture. Should neglected privy. Dr. Watson says, having established the ulceration include the common integuments, these, the proof of contagion, it is difficult to imagine any: other way of propagation. Granting that the diffi-and the urine will be discharged through a small as well as the corpus spongiosum, will be destroyed, culty is great as a mere mental effort, with respect to Lectures, Vol. I., "Malaria ;" and Vol. II., "Continued fever." aperture near the pubes, at the anterior part of the scrotum, whilst the corpora cavernosa might probably remain entire. NOTES ON SYPHILITIC DISEASE. Chancres in the female are usually situated on the inner surface of the labia, on the nymphæ, or the ves tibulum, more rarely on the præputium clitoridis and margin of the meatus urinæ. Those on the outer surface of the labia have generally a crust formed upon them in consequence of their exposed situation. They are seldom, if ever, seen primarily in the vagina. In sixty-three women, thirty had primary sores on the inner surface of the labia; twenty-seven on the vestibulum; one on the anterior perinæum; and five on the nymphæ and præputium. 681 discharged from such sore shall not always produce other soressui generis. When more chancres than one appear at the same time, they probably arise from the same source simultaneously, and it is certain that more than one may appear. This, however, is an exception to the rule. Treatment of Gangrenous Syphilitic Sores.-When a syphilitic sore is gangrenous, the first object is to check the gangrene, and promote a separation of the slough, before any attempt is made to treat it as a specific case; it will therefore be best to poultice the part, and give bark, acids, &c. If the sore be out of sight, a decoction of poppies should be injected to wash out the sordes. Opium must be given, but it will not be advisable to give much wine. In seven or eight days In many cases the primary sore is solitary, but three or four are oftener found in women than in men. This may arise from delay in procuring advice; for where early application is made, there is seldom found more than one. Considerable pain, inflammation, and tume-probably the slough will separate; and it will be faction of the labia frequently attend these ulcers, which enlarge and become very fœtid. Large sores on these parts often become sloughy and gangrenous, and it is not uncommon for the whole of the external parts, with part of the vagina, to slough away; indeed it sometimes happens that the body of the uterus is exposed, and the rectum lies loose in the ulcer. As a result of these deplorable cases, the cavity of the vagina will be sometimes almost obliterated, and only a space left just large enough to permit the exit of the urine. The lowest class of prostitutes are most subjected to these severe ravages, from their inattention, intemperance, poor diet, and frequent exposure to the inclemencies of the weather. Independently of the magnitude of syphilitic sores, a sore of a peculiar kind is sometimes formed at the lower and external parts of the labium, or on the anterior perinæum. This kind of sore frequently sloughs, and spreads towards the anus, having hard, 'but not thick, edges, and the discharge from it approaches the nature of sanies. The patient is very weak and irritable, and the sore is aggravated by the use of mercury, and often becomes gangrenous. It is probable this species of ulcer is caused by the syphilitic matter coming in contact with an abraded surface, or a pustule. It is a sign of a broken down constitution, and often proves fatal. Sometimes a troublesome discharge from the vagina remains, after syphilitic sores on the labia and nymphæ have yielded to mercury, which cannot easily be restrained by ordinary means; and sometimes it is almost impossible to remove the indurated swelling that is caused by them. If it be on the nymphæ or clitoris, excision may be employed, but such a practice is justifiable only when it impedes locomotion, or interferes with the functions of the rectum or bladder. It is singular that the venereal virus seldom produces more than one or two primary sores, although so large a surface is exposed to infection; and if exposure to infection produces disease in so limited an extent, we are not to be surprised that the matter judicious to wait till the granulutions are rising, and the venereal action becomes evident, before mercury is given. After the complete separation of the slough, the syphilitic action is characterized by a foul appearance of the sore, and by its elevated edges. It ought now to be treated as syphilitic, and the bark, &c. should be discontinued. Although this may be considered as a general rule, it has nevertheless its exceptions. Sometimes, notwithstanding the use of bark, opium, and good living, the gangrene spreads, the pain becomes more severe, and the patient's health declines. In such a case the syphilitic virus is to be considered the immediate cause of the mortification, and mercury is to be given freely with the other remedies, which will frequently be attended with success. [When extensive gangrene has taken place, and is rapidly increasing, the case is attended with the deepest anxiety, both to the patient and surgeon; and it is not at all times easy to decide what treatment ought to be adopted, whether to give mercury freely, or none at all. I venture to make the following brief remarks on this interesting point :— 1st. If the gangrene has taken place under the use of mercury, its immediate discontinuance, and the use of tonics, with a generous diet, are clearly indicated. 2nd. If previously to infection there existed a delicate, weak, or cachectic condition of the constitution, even if no mercury had been used, the case should be treated with tonics, especially the iodide of potassium, opium, and a generous diet. But 3rd. If the primary sore quickly followed exposure, spread rapidly, with pain and inflammation, and soon became gangrenous, and if the general health had been previously unimpaired, then the destruction of the parts may be fairly referred to the intensity of the virus, and the free use of mercury at once employed.] Where there is a sloughing sore with phymosis, and hæmorrhage takes place, if the prepuce cannot be retracted, it must be divided, although in such a state of the parts such a step is most undesirable. If the 1 bleeding be not very considerable, other means may be previously tried, such as the injection of warm porter or wine between the prepuce and glans. The hæmorrhage generally springs from the glans penis, and although its texture, even in a healthy state, is scarcely fit for the needle, and of course is much less so in a state of disease; it will be, nevertheless, right, if prófuse bleeding continue, to make the attempt to stop it by such means, taking care to include a portion of the surrounding parts in the ligature. If this method should not succeed, the bleeding vessel may be compressed by the hand of an assistant as long as it may be necessary, with a bit of sponge or puff-ball, or a little bag, containing some powdered sulphate of copper; and should these means fail, turpentine, boiled over a candle in a spoon, may be poured upon the part from which the blood issues; or the actual cautery, all other remedies proving of no avail, may be applied. In order to make use of these more severe methods, the prepuce of course will have been divided. At first it is best to make the division by a single longitudinal incision, in order to liberate the parts, and to finish the operation after the sloughing process shall have ceased. If mercury be found to aggravate the local disease, it must be discontinued, for it will be better that the system should continue under the influence of the syphilitic poison, than that the organs of generation be destroyed, and the general health impaired, by means of mercury. Treatment of Primary Syphilitic Sores in Women.When chancres are accompanied by much pain and inflammation, they may be washed with a lotion of calomel and lime-water, or with the Aqua Phagedænica of the old Pharmacopoeia. [Aqua Phagedænica is commonly called the "yellow wash," made by mixing two grains of the bichloride of mercury with a fluid ounce of lime-water.] By these means they will generally be found to heal rapidly; but if the sores be very large, they may be dressed with the mercurial cerate. Where the inflammation and tumefaction of the labia and nymphæ are so great as to confine the patient to her bed, poultices, as well as the dressings above-mentioned, are to be applied; and if gangrene has taken place, the stale-beer poultice may be used, together with the internal use of bark, mineral acids, &c. As the result of syphilitic sores, there will some times be considerable enlargement and induration of the nymphæ; and if this state of the parts should not have been reduced by a full mercurial conrse, by poultices, the vapour of hot vinegar-and-water, or spirit of wine, nymphotomy may be performed. The operation may be done in the following manner: Let the incision be commenced with the scalpel at the superior part of the nymphæ, and carried downwards till within a quarter of an inch from the bottom, at which point it should be terminated laterally. By this method the principal artery of the nymphæ will be avoided; but when there is much enlargement, it will be sometimes necessary to secure the bleeding vessels. The subsequent dressing may consist of dry lint, a pledget of lint, and a T bandage. The patient is to be kept low and an opiate administered. After twentyfour hours a poultice may be applied. The sore will usually heal in about ten or fourteen days. Excision may be also adopted, if the præputium clitoridis is very much enlarged and indurated; but such a mode of treatment is seldom necessary. There is no specific mode of treating the sphacelating constitutional scre above mentioned; there is generally quick and feeble pulse, but the patient does not suffer in any very great degree. Bark and mineral acids, with a nutritious diet, is the most suitable treatment; and the best local applications will be those that give the least pain; a solution of the nitrate of silver will be attended with advantage. (To be continued.) STRANGULATED HERNIA ON ITS PROPER FOOTING. TO THE EDITOR OF THE PROVINCIAL MEDICAL AND SURGICAL JOURNAL. SIR, I have written often on this subject, in expectation that my views would prevail generally; in this I am disappointed, therefore wish to explain still further, aware that human suffering and life are involved in the discussion. The theory and practice adopted generally, as appears by the writing and teaching of eminent men during the last century to the present day, are, that strangulation consists in displacement of the hernia, and that replacement is the remedy. The protruded part is represented as if bound by a cord, and the practice is to push it back until returned into the abdomen, to press it towards the aperture, sometimes to grasp it with the hands; also to try with the fingers of one hand at the top, to get in a small portion, whilst with the other to raise from the bottom by various movements, and return the remainder. It is a common practice to knead it as flour is worked into dough; in most cases many hands are thus employed. One treatise, which is valued, advises perseverance for an hour in these attempts. I have always considered the theory and practice as here laid down, erroneous. When we reflect that the part is very often protruded, among the working classes, and remains so many days, it is evident that situation outeide is not the cause, and consequently, to return it is not the remedy. With respect to the practice, it is outraging every sound principle to grasp an inflamed and inflated intestine, and to push it back forcibly against a stiff tendinous border, which binds it as stated. The aperture had been always filled up by the spermatic process, the hernia being added and unable to expand, the intestinal tube is closed up unavoidably in the ring. Surely the attendant irritation forbids such attempts as to press portion by portion; also as ON STRANGULATED HERNIA. 683 This is enough. the gaseous nature of the fluid struggling for vent. This is the only handling I use, and it has always succeeded when resorted to in the first instance. Water, ice, &c., have often failed when accompanied by the taxis in the usual way, which is a certain counteractive of all means. It is quite clear that after the sensibility has been lessened, gentle pressure is safe, whilst during the interim it is not so. In failure of these means I operate, making a small incision in the tendon to allow the gut to expand where it is closed; having no view to returning the hernia during the tumefaction, I gently endeavour to remove the contents, assured that this is a sine qua non. knealing to get up a part. The neck formed by the hernia as if solid, is immovably fixed, so as to present to a discerning eye, insuperable objections to all manipulations at this stage; the too narrow space wedging together what had presented two tubes, now inseparable, on account of the resisting ring. Cases of success have sometimes occurred during the movements stated, and also when none had been resorted to; these have happened when the symptoms were mild and gentleness had been attended to. The removal of strangulation where no effort had been made, strongly encourages forbearance as to haudling; the spontaneous removal is in coincidence with our views of all inflammation of the viscera. The fact that any for- A case in extremis occurred at a London Hospital, midable ailment, for which much force had been the after failure of the usual means. The patient, rather usual remedy with eminent men, shall he remedied undressed, was carried across the yard to the room for without any other means in lieu of it, is most instruc-operating, on a cold day. The strangulation vanished tive. The surgeon who practices kneading must forget | in transitu, which was discovered on exposure on the the firm state already observed upon, and that the integuments alone can be moved, which latter yielding, imparts the feel that deceives: it is quite incompatible with the corded state allowed by all, that movements of any kind could be effected. Surely the spermatic cord and enclosed intestine are by far too much for the space, and too sensitive not to suffer severe injury through such practice; fortunately the integuments interfere, and are protective in some measure. operating table. This was witnessed by Mr. Lawrence, junior, a student of high character. It calls to my recollection two cases in which I could not attend at the time, but had instructed the messengers to treat the cases as already detailed. On my arrival after half an hour, I was informed that a shivering fit had seized them, and the strangulation vanished suddenly. In the course of thirty years I have treated two or three on an average annually, and when in the early Presuming that the reasoning advanced, shews suffi-stage, successfully. ciently that return of the hernia into the cavity is not the suitable remedy, and also that the treatment at the beginning is injurious in every case, ultimate measures of improvement are to be considered. In December, 1829, I met two well-qualified surgeons prepared to operate promptly, because the touch gave excessive pain; on my applying cold water for about a dozen minutes, the sensibility was so far abated, that I applied my hand outside the folds of wet linen, gave no pain, and removed the contents in the presence of the gentlemen who had decided that the knife was the only remedy. The first feature strangulation presents is a swollen intestine, ex situ, painful in the extreme at the aperture where it is obstructed as to its passage inside and outside; it is also impervious here, impeding the circulation of its contents, which being acrid in a high degree, I was present at the operation, by an experienced irritate and distend. It is clear that impervious-surgeon, who, before and during the process, and twice ness at this precise spot must be removed, so that the contents may circulate as in health. This is the remedy in my view, which is supported powerfully by the occurrence of a gurgling noise always accompanying the removal of strangulation; this noise arises from the air rushing through and opening the intestine at the desired spot, leaving it free, and the bulk disap. pearing. The celebrated Pott remarked this noise, but drew no inference from it; had he dwelt on the occurrence as it invited, a rational practice would have been settled on ere this, instead of the farrago which bas so long darkened our course. In the opinion that the last points to which I have adverted furnish a clue to success, I shall describe my practice so as to carry out my views. I avoid the taxis or touching the part, and place the patient in a cool situa. tion, often on the floor, the trunk being bent by raising the head and knees; wetted cloths are kept on the part, the cold being renewed every five minutes. The air is admitted by open doors and windows, which often causes a rigor and sudden disappearance of the hernia; if not, I apply my hands to the sides near to the upper part, and gently press them towards each other to lessen the area; thus a stream of the contents is impelled towards the impervious tube, where it dissevers the closed coats. incising the tendons, failed to return the inflated hernia; he raised himself on his toes, and drove the part before him. In another case I interfered, and advised a trial to reduce the size, (pending the operation,) which was declined, and the usual practice persevered in. Both cases proved fatal. Instances of the like description are recorded, in which dissection shewed the part impervious, where the gut and tendon had been in contact. A case is reported in the London Medical Repository for November, 1825, in which the operation had been performed, and gut returned, but was followed by intense pain, and death. Dissection, shewed the part that had been fixed within the aperture during strangulation impervious and solid, for one inch and a half in length. The operation was perfomed by Dr. Bishop, of Thornley, Northamptonshire, who took the portion to London, where Brodie, Cooper, and others saw it with great surprise, but observed that Mr. Geoghegan had anticipated such an affection, in an essay on hernia, but produced no post-mortem facts in proof of his statement.* In conclusion, I beg to call the attention more closely • Surely success must ever prevent an opportunity of producing a post mortem fact, |