Sir-Should you think the following cases worthy of an insertion in the "Intelligencer," they are at your service. Yours, respectfully, JOHN J. SINNICKSON. ART. I.-ADHESION OF THE PLACENTA, PUERPERAL PERITONITIS, &c. In this case, as no notes were taken at the time, I am under the necessity of stating the facts from my recollection of them. About the 15th of December, 1835, I was called to visit Mrs. D.; upon my arrival I was informed by the midwife that it was a case of twins, she having delivered her of the first child near twenty-four hours previous: the labour being easy and the vertex presenting. Experiencing great difficulty in bringing forth the second, the patient becoming exhausted, and the pains gradually ceasing, the friends became alarmed, and I was sent for. Mrs. D.'s consent being obtained through the midwife for me to take charge of her, I made an examination, and found the vertex presenting; by using frictions over the abdomen the pains were increased and the labour soon over. I then retired, in order that she might obtain an interval of rest prior to the coming away of the placenta. After the lapse of an hour the midwife informed me that the placenta had not advanced, and the pains were very severe. I introduced my hand as far as was practicable, during the intermission of the pain, but the uterus being in such an irritable condition, and so much pain arising therefrom, I was obliged to desist. After some time the pains entirely ceased, and a gentle tension upon the umbilical cord convinced me that the placenta still remained within the uterus. After having recourse to every means within my knowledge without any benefit, I made use of the ergot of rye in every form, both in small and large doses; this increased the pain, but the placenta still remained. I then became convinced that it was adherent to the uterus, and the only resort I knew of, was tearing it away; this I made an effort to do, but so great was the pain, that it was abandoned, and the assistance and counsel of my esteemed friend, Dr. Leggett, solicited. When the doctor arrived I communicated to him all that I had done; he requested another trial with the ergot, but no advantage was derived from it; he then undertook to separate the adhesion, but the same difficulty prohibited him as happened to myself. What was to be done? We concluded to yield it to nature and combat any untoward symptoms that might superOn the morning of the second day she was seized with rigours and all the usual symptoms of puerperal peritonitis, she was bled copiously, and the most active treatment resorted to, to overcome the disease; the fœtor arising from the sloughing placenta was so insupportable that it was impossible to remain in the room for any length of time with her; medicated injections were used to counteract it, but every thing that we could do vene. availed naught, and she died on the morning of the ninth day, after the delivery of her last child. In concluding this I would remark that the second child in a day or two after its birth assumed a purple hue, and presented the symptoms of cyanosis, caused, as was presumed, by the foramen ovale remaining unclosed: it survived only seven days. I think this case interesting, although death took place; is it not uncommon in a twin case for both presentations to be the vertex, and cannot this be one of self-evolution? I have since been informed that injections of cold water into the vein of the umbilical cord have proved beneficial. Upon what principle does it prove so? I know not in what manner it has a tendency to destroy the adhesion. Retention of the Placenta for four days and a half.-Mrs. S. was confined with her first child on the 1st of January last, and towards midnight delivered by an old negro woman who officiated as midwife. On the following morning her friends became alarmed in consequence of the placenta being retained. A messenger was despatched in haste after Dr. Smith, he being the nearest physician; upon his arrival, and ascertaining the nature of the case, he bled her very freely, but without any benefit. Dr. Stewart was then requested to visit her; upon making an examination he found the os tincæ firmly contracted; venesection was repeated, and the ergot administered in the usual doses, without producing the slightest pain. On the morning of the 4th, through the request of Dr. Stewart, I accompanied him to her residence; we found upon examining over the surface of the abdomen, the uterus firmly contracted, no pain or tenderness upon pressure, pulse soft, full, and rather frequent, skin moist, &c. Having some fresh ergot with me, we concluded to use it with the warm hip bath still not the least pain was produced, nor did the contraction of the uterine fibre relax. Having exhausted our knowledge, and every remedy that we could command failing us, we left her with that regret which every physician must experience in a greater or less degree when he abandons his patient in such a condition, leaving the case as a last resource to the effort of nature. Expecting to hear of her death, we were agreeably disappointed upon receiving the intelligence that the placenta came away entire about ten o'clock on the morning of the 6th; she rapidly recovered. Since this case, I have seen in your publication, the "Intelligencer," the recommendation of injecting the decoction of poppy heads into the vein of the umbilical cord, as having proved very efficacious. JOHN J. SINNICKSON. Professor R. Dunglison. ART. II.-LOCAL APPLICATION OF IODINE IN HERPES CIRCINATUS. Dear Sir. For the last twelve years I have used the alcoholic tincture of iodine as a local application in those troublesome cases of herpes circinatus or ring worm so common in our southern country, with the happiest effect. Indeed I do not recollect any case in which it has been used without a radical cure. As I believe it is not generally known to our medical public, not having seen it recommended by any author in similar cases, you may confer a favour on some of the readers of your valuable periodical by inserting this notice. Ararat, Montgomery Co. Ala. April 8th, 1839. Yours, truly, G. BILLINGSLEA. ART. III.-PHILADELPHIA HOSPITAL, (BLOCKLEY). Case of Meningitis. Reported by Dr. A. M. VEDDER, Senior Resident Physician. Hannah Murray, (black), ætatis 40; entered Black Women's Medical Ward June 22d, 1838. Patient is nurse of the incurable ward; is married; has been subject to a slight cough for a long time. She has had several attacks of neuralgia, which were always relieved by sinapisms or cups to the spine. Four weeks before her entrance she had some difficulty in walking. About June 10th was taken with neuralgic pains, which were treated in the usual manner; some relief followed. June 14th, complained of pains in her limbs: it was then observed that she tottered in her walk; during this time she had cephalalgia and loss of appetite; failure of memory. No convulsions; no hallucinations; no vomiting. Was able to walk on the 21st with great difficulty, however. On the morning of the 22d, Dr. Taylor, who had charge of the ward, was sent for, and found her in a comatose state. was then transferred to the hospital, having refused to go previously. Present State, June 22d, P. M. Small frame, well formed, muscular. Decubitus dorsal. Comatose; opens her eyes when aroused; eyes are protruding, shining, rolling about; a vacant stare when open, with an expression of surprise. Conjunctiva scarcely injected; pupils contracted to a mere point. Dilatation of nostrils on inspiration. Breathing laboured, stertorous. Resists attempts to open her mouth. Tongue cannot be seen; seems to hear when spoken to. Pulse 108. Skin cool, perspiring. When touched she starts, cries oh! with an expression of agony. She When attempts are made to flex the arms, there is a sort of involuntary resistance; if the arm be raised gently it can be flexed and extended, if done slowly and gently. Expression cerebral; spasmodic twitching of the muscles of the face at times. Cannot swallow. R. Prescription. The head to be shaved, and ice applied. Sinapisms to the extremities. Cucurbitulæ cruenta, (ad f. 3 viii.), ad nucham. Magnes. sulphat., fol. sennæ āā 3i. Infunde in aquæ bullientis Oi. Adhibeatur formå enematis. June 23d, P. M. Stupor continues: slight distortion of mouth; pupils small, not dilatable. When spoken to opens her eyes. Lies with her mouth open. Respiration laboured, 36; moaning almost constantly. Does not move her limbs or change her position in any way; cannot swallow. Same expression of pain on being touched, or when attempts are made to move her limbs. Arms partially flexed; lower extremities extended. No urinary discharge since entrance; percussion, however, is gaseous in the hypogastric region. Four stools from the enema; she seemed less stupid this morning. Pulse 114. Skin cool, moist. Head rather warmer than body. Moaning continues. No convulsive movements of extremities. No subsultus tendinum. Occasional twitching of the eyelids. Repetantur cucurbitulæ cruentæ nuchæ et enema infusi fol. sennæ et magnes. sulph. Continuetur applicatio glacies ad caput. This morning an enema of oleum terebinth. was administered without effect. Died at 12 o'clock P. M. June 23d. A few minutes before 12, had a convulsion, with constant twitching of the muscles of the face, rolling of the eyes and twitching of the lids. Necroscopy thirty hours after death. Exterior not emaciated; lower extremities very rigid, upper not so. The great cavity of the arachnoid contains about f. 3 ii. of light straw coloured serum; that portion of the membrane covering the posterior part of both hemispheres is opaque. The right portion is a little rough to the touch; these portions of the membrane, as well as that dipping into the great fissure are decidedly injected. The membrane can be raised without tearing the substance of the brain beneath; the tissue of the brain is rather pale and of good consistence throughout. The lining membrane of both ventricles is pale; they contain about a drachm of reddish coloured serum. Plexus choroides a little deeper coloured than usual. Fornix of good consistence. Arachnoid covering the medulla oblongata extending to the spinal marrow is intensely injected of a bright red colour, and contrasts strongly with surrounding membrane; that portion covering the cerebellum a little more injected than the average. The tissue of the cerebellum is firm. Corpora striata present the usual appearances. Chest.-No effusion into either pleura. Both lungs are of a dark colour externally; much congested, the right particularly. After a simple incision, an abundant dark coloured fluid runs out. A few nuclei of tubercles are found in the right lung. No cavity. Heart, rather large, flaccid. Semilunar and auriculo-ventricular valves are normal. No other part was examined. A. M. VEDDer. ART. IV.-ON DISEASE OF THE VERTEBRÆ. BY SIR B. C. BRODIE.' In There is a joint between every two vertebral bodies, with the intervention only of a piece of cartilage between them. If, in a case of diseased vertebræ, you dissect the parts in the early stage of the complaint, you will sometimes find the bones more vascular than natural. After this a cheesy deposit takes place, and the vascularity of the part diminishes. At other times you will find that the vertebræ are abnormally light, soft, and spongy in texture, admitting of being easily cut through with a knife; and again, in other cases, you may find them unusually hard and heavy in texture, as bones frequently are in chronic inflammation, before ulceration sets in. Diseases of the vertebræ sometimes commence in the intervertebral substance. the healthy state there is, in the centre of the cartilage, an elastic, soft, gelatinous substance. This sometimes becomes brown and brittle, and seems divided into fragmentary lamellæ, and loses its connecting adhesions above and below. In this manner caries will sometimes commence in several parts of the vertebral column at once. In other cases the ulceration begins at the anterior or lateral surfaces of the vertebræ, but most frequently its first effects are seen at that part where the vertebral bodies are connected to the cartilage above and below. When ulceration once commences, it spreads very rapidly, and may continue for some time before suppuration comes on. This may occur when, as yet, there is but little destruction of the bones from ulceration, or the contrary; or the vascularity of the bones may diminish and they may die, but not exfoliate to any great extent. Ulceration may go on in the bodies of the vertebræ, as in other joints, for a long time without suppuration coming on; but sooner or later abscesses will form on the surface of the carious bone. Sometimes suppuration begins with but little destruction of the vertebral bodies, and but a very small quantity of pus may be secreted. Sometimes, also, suppuration will not commence until ulceration has proceeded to a very great length. When the bodies of the vertebræ die they exfoliate as in scrofulous cases, their vascularity becoming diminished, and the sequestrum is thrown off, but not to any very great extent. The vertebræ are sometimes extensively implicated, and many surfaces of bone are affected, whilst, in other cases, the reverse of this obtains. When an abscess forms it points 1 Lancet, March 16, 1839, p. 897. sooner or later to the surface, according to its situation. Sometimes, however, it makes its way inwards into the cavity of the theca vertebralis. I remember one case in which the cervical vertebra were affected, and the whole cavity of the theca was filled with pus. Caries sometimes occurs in the joints, between the articulating processes, and this is more frequently met with than is generally supposed. This most commontly occurs in the cervical vertebræ, and the destruction of parts is, in these cases, greater than where the disease is confined originally to the bodies of the vertebræ, Where caries affects the bodies of the vertebræ you do not notice, at first, any alteration in the figure of the spine; and this alteration, when it occurs, is marked by an angular curve, greater or lesser, according to the situation of the original disease. In the lumbar vertebræ the disease may go on for a long time before any alteration is observed in the shape of the spinal column, because their spinous processes are short and stand directly out. The same may also be said of the cervical vertebræ. But, in the dorsal vertebræ, the bodies of the bones are small, compared to those of the loins; their spinous processes are long and point downwards. Angular curvature, then, only occurs in the advanced stages of carious disease of the vertebræ. Sometimes it shows itself suddenly, in the course of a month, perhaps, in cases where matter forms suddenly, and as suddenly discharges itself. Angular curvature differs in different cases; sometimes there is a double angle, one below the other. If the curvature be slight there is but little alteration of position in the internal viscera; if the curvature be great, the course of the aorta is altered, and I have dissected cases after death in which the aorta made two or three turns. Sometimes, in these cases, the sternum and ribs project more than is natural, the heart appears displaced, and the lungs seem compressed and diminished in size. I shall now give you a general account of this disease of the vertebræ as it is developed in its symptoms. The pain is sometimes very obscure and trifling in the early stage, and it may gradually increase to very great severity, or it may remain very trifling in degree throughout the entire case; or it may, on the contrary, be very severe from the first day to the last. Í have known cases in which the curvature has been very great and the patient has suffered no pain whatever; whilst I have known others in which the curvature was much less, and the slightest motion gave the patient intense pain, and pressure caused very great agony. Here, then, are two extreme cases; but between these there are many degrees of variation and change. In scrofulous caries of the spinal bones there is, generally, but little pain suffered, whilst in simple inflammation, followed by ulceration, the pain is generally very severe. This disease of the vertebræ begins sometimes very insidiously, and can be traced to no original source or cause. It will sometimes follow an attack of fever, and caries, with all its symptoms, becomes soon set up. There are other diseases of bones which frequently show themselves after an attack of fever. Sometimes this occurs in persons of truly scrofulous habit; sometimes in those who possess the healthiest constitutions. Pain comes on first, and suppuration and abscess soon follow. In some cases, however, a long time elapses before any change in the shape of the spinal column occurs, or abscess presents itself. I know of a case in which abscess only showed itself ten years after the irruption of the original disease; and I know of another in which the disease had existed twenty-one years before any abscess presented. An abscess, therefore, may be pent up for a very long time. It is very strange, however, that it may exist for this length of time without the constitution suffering from its irritation. Well, then, either sooner or later, the abscess bursts. When this occurs in young persons they may recover, the cavity may become filled up, and anchylosis may take place between the vertebræ. Generally, however, the. reverse of this presents itself, and the patient dies. Hectic fever shows |