No. 961.

LONDON, SATURDAY, JANUARY 29, 1842. [1841-42.

CLINICAL LECTURE,DELIVERED AT

UNIVERSITY COLLEGE HOSPITAL,BY

DR. TAYLOR,Physician to the Hospital, and Professor ofClinical Medicine in University College.

CASES OF ANEMIA.

CASE I.

AMELIA RA11’ISCAR, aged 19, was admittedSeptember 22, 1841, under Dr. Taylor ; wasoriginally a nursery-maid, but has latterlybeen a servant of all-work. She is of a sal-low complexion and melancholic tempera-ment, with black hair and eyes; themucous membranes of the mouth and lips areextremely pale. She says.that she has beengetting much paler than she was formerly,hut that she never had much colour. Shehas generally enjoyed good health untilabout two years ago, when she states thatshe suffered from giddiness and pain in theforehead; she was not able to walk up anddown stairs ; she had palpitation of the heart,and pain on both sides of the chest, andaching pain in the loins; she says that hercountenace was then very sallow. She wentto the Westminster Hospital, where, underthe use of hip-baths and medicines, she wasin the course of a month much relieved.She remained well in service for six months,but was then again taken ill; went again tothe Westminster Hospital as an out-patient,and got well in three weeks. She went toservice again, and becoming unwell, wasadmitted into this hospital, under Dr. Wil-liams, in February last. She then com-

plained of giddiness, hea.da.ch, darting painsacross the forehead, pains in the side ex-tending round to the back, palpitation of theheart increased on the slightest exertion.The urine was sufficient in quantity: shehad only menstruated twice altogether, andnot at all for six months previous to her ad-mission. The first sound of the heart wasthen short and loud, but there was no mur-

mur ; there was slight venous murmur in theneck. The sesquioxide of iron was admi-nistered, and under its use the patient gra-dually improved. She lost the sallownessof the countenance, and the lips got morecolour. She was discharged in sixteen daysconvalescent. She now returned to serviceagain. The last place she lived at previousto her coming to the hospital was a place ofall-work, where she had to work late and

keep late hours ; this she thinks broughtback her previous complaint. She left her

place, and about two months ago the giddi-ness, palpitation of the heart, and pains inthe same parts as before, began to return.These continued with varying degrees of

severity, and the patient gradually lostcolour and strength, till at length she appliedfor readmission to the hospital.

Present Symptoms.-She now complainsof pain in the forehead. When she attemptsto stand up she feels giddiness and slightloss of sight, and is obliged immediately tolie down, owing to her feeling a sensation offaintness. She says that in lying down shefeels a flush of heat over the face, and a diz-ziness in the ears, especially of the right ;the eyes feel heavy; she complains of ach-ing pains in the sides and back, which pre-vent her from remaining long in one posi-tion ; there is palpitation of the heart, whichis increased on the slightest exertion of anykind ; there is pulsation of the carotidsoccasionally visible, especially if the patienthas made any exertion, however slight; shesleeps very soundly by night, and is not dis-turbed by dreams; she sleeps also soundly inthe day, during which she is very drowsy ;pulse 80, of a jerking character; tongueclean, and very pale in colour ; appetite bad;she says that she never cared much aboutmeat at any time, and at the place whereshe last lived servant she never took anymeat, but lived chiefly on bread and butter,with a little porter ; she complains of thirstand parching of the lips, and says that aftertaking cold liquids there is slight pain in thestomach, but this does not take place aftershe takes anything hot; her bowels areopen now, and are generally very regular ;she passes her urine freely, and in sufficientquantity, it is clear, of the usual colour, and

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there is little or no sediment in it. The cata- care of Dr. Taylor. She is a servant of all-menia have been irregular since she left the work; lived last at Holloway, in a dry,hospital in February last, having appeared open, airy situation, but has been much con-only three times in seven months; at these fined, owing to her employment. She istimes, however, they were sufficient in single ; was formerly very stout, as well asquantity: she menstruated for the last time florid, but has been getting thinner, and hasten weeks ago. not had much colour for the last two or

23. Ordered by Mr. Quain to have a three years, more especially during the lastpowder consisting of a scruple of magnesia, six months. Hair dark. She has alwaysfive grains of mercury with chalk, and fif- had sufficient food, and her appetite has beenteen grains of rhubarb-powder, directly. very good. Father died about seven years

24. There is a distinct murmur with the ago, after a long illness of phthisis; motherfirst sound of the heart, extending from the living, and enjoying good health. She hasbase to the top of the sternum, and not heard lost a brother and two sisters within the lastat the apex of the heart ; bruit de diable in three years, also from phthisis. She hasthe neck heard only when she is sitting up ; seven brothers and sisters living, some ofno tenderness of the spine ; bowels open. whom have not very good health. TheTo have two drachms of the sesquioxide of patient has herself generally been weakly.iron three times a-day. She has been subject to fainting fits ever

27. The pulse is not so jerking as it was ; since she was a child. She has never hadthere appears to be alittle more colour in the rheumatism. For the last year or two shecheek ; complains still of considerable giddi- has been very unwell, having had sickness,ness ; bruit de diable is heard in the neck, pain in the head, with shortness of breathing,but ceases on moderately-firm pressure over at various times. These symptoms conti-the external jugular vein. As the bowels nued a short time, and then left her. Aboutare not sufficiently open, give her half an five weeks ago she began to feel unwell; sheounce of castor-oil. was very sick, and vomited some phlegm ;

29. The mucous membrane of the mouth she had pain in the head, with giddiness, andand lips is still very much blanched; there pain in the chest, and dypsnoea. Theseis a murmur still heard at the base of the symptoms continued much the same till lastheart; venous murmur in the neck is Saturday week, when she was again veryscarcely audible ; the medicine causes her sick. She had now more pain in the chest,slight nausea. and more difficulty of breathing. Cough

Oct. 1. Much the same. now attacked her, and this was violent.4. There is a venous murmur in the neek, There was much tenderness, or rather a feel-

stopped by pressure over the external jugu- ing of soreness, on the anterior surface oflar vein. The patient is stronger, and the the chest; this extended, she states, equallygiddiness less. over the whole anterior surface of the chest.

6. There is a murmur heard in the neck ; She continued much the same until her ad-that with the heart is still heard, but less. mission into the hospital.To have three drachms of the sesquioxide of Present Symptoms.—There is now con-

iron for a dose. siderable coldness of the surface, especially8. The murmur at the base of the heart is of the feet, which, she says, are always

diminished very considerably ; there is still cold ; the face, lips, mucous membrane ofa distinct continuous murmur in the neck ; mouth, and also the general surface of thecountenance has obviously regained much body, are pale, almost bloodless, presenting,colour. in a marked degree, the character of ane-

11. There is not now any giddiness; mia; she says that she sometimes sleepscountenance has more colour; there is still a very well at night, but at other times is notmurmur at the base of the heart. able to sleep at all ; there is some spinal

13. The murmur at the base of the heart tenderness in the middle of the dorsal region,still continues, but is diminishing, as also more on the left side than on the right;that in the neck: she has menstruated when this part is pressed upon a pain shootsagain. thence to the left side of the chest, no pain

18. There is no pain in the head, but it unless the part is pressed upon ; there isfeels heavy, and the breath is short; the giddiness on making any exertion; when shevenous murmur cannot be heard in the takes a deep breath she feels pain in theneck. chest, which is of an aching character, this

20. Complains of pain in the head. To pain is more on the right side, she feels ahave five grains of blue pill at bedtime. sensation of weight there ; she has cough,

22. The pain in the head is relieved. which is worse at night, and occasionally25. Discharged cured. prevents her sleeping; there is a murmur at

____ the base of the heart, with the first sound, of

CASE II a loud and rough character ; bruit de diable.

also in the neck; pulse jerking, 85; thereRebecca Hazelgrove, aged 21, was admit- is no expectoration with the cough; tongue

ted Tuesday, November 9, 1841, under the very pale, especially at the edges, the sur-

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face, however, is clean, and not furred ; 8. Discharged cured ; the murmur as loudthe breath has’!rather a foetid smell, and she at the base of the heart as on admission ;complains of a nasty taste in the mouth; she anemia quite gone ; patient much stronger.feels pain at the epigastrium after eating; ____

this pain, which is of a burning character, CASE IIIextends up the throat; appetite has always

.

been good, and she has had sufficient food ; Rosa Hambrook, aged 24, was admittedbowels open once a-day ; urine plentiful, of November 30,1841, under Dr. Taylor ; ofthe natural colour, specific gravity 1.028, moderate conformation, with dark hair ; hasrendered of a deeper colour by nitric acid, been getting thinner lately, and has beenand slightly effervesces with it, it is not losing colour gradually for the last six

precipitated by heat ; the catamenia are months. She states that she never had muchnot regular, they appeared this week, and colour; she is a nursemaid, and single; haswere small in quantity ; they appeared not had to work very hard ; always has hadabout a month previous to this, but before plenty of food, and has lived moderately ;.that time they did not appear for three she lived in a dry, airy situation, and wasmonths, and then were scanty; she states in the habit of going out with the children;that they first appeared when she was four- generally enjoyed good health until aboutteen years of age, and that they have never four years ago, when the menses began tobeen regular. To have the following :- be irregular ; after this she suffered fromThree grains of iodide of iron in an ounce pain in the head, loss of appetite, sickness,and a half of camphor mixture, three times and pain in the side. Two dozen leechesa-day. Full diet, and half a pint of porter were applied to the head ; she did not thendaily, lose much colour, but spat up blood in small

12. She states that the stomach swells quantity, and suffered from night-sweats;after meals, and did so before she came into she was ill about a month, during whichthe hospital, for a week or two, and this time she was in the Middlesex Hospital.whatever she ate ; murmur at the base of the She was discharged relieved of all but pain inheart still heard, the head; for this she attended as an out-

15. Complains of headach ; bowels not patient for three weeks, and was then well.confined ; pain at the stomach remains as She remained well for about two years frombefore; has had a cough since three days this time, when the same symptoms recurredbefore her admission; some sonorous rhon- with increased severity, and she lost muchchus heard behind on the right side ; appe- more colour. She was again in the Middlesextite good ; not gained much colour yet. In- Hospital for five weeks, and as an out-patientcrease the iodide to four grains. afterwards, when she was again relieved, and

,, , , , i i remained well for three months: she then17. Sonorous rhonchus heard under the suffered from another attack, in which the

right clavicle. Increase the iodide to five pain in the head was more severe ; she wasgrains. blistered, and had medicine administered to19. More colour; pain in the head better; her, under which treatment she got some-

less giddiness ; no pain in the side ; back what better, and returned to her situation.rather tender; murmur at the base of the She has suffered from her present attackheart not so loud as formerly ; bruit de ever since July last. The first symptomsdiable still very distinct; bowels open. were weakness, pain in the head, night-

22. Venous murmur in the neck ; loud sweats, shooting pain down the right side ofmurmur at the base of the heart; pain in the face, slight cough, great pain in thethe back, especially at the lower part ; sensa- limbs and chest on using any exertion, astion of weight at the epigastrium. To have walking up stairs, or lifting anything at allthe compound camphor liniment applied heavy. Some medicines were administered,twice a-day to the dorsal region. but with no marked benefit, and she applied

24. The countenance to-day rather flushed; and was admitted to this hospital at thefeels some tightness of the chest ; giddiness above date. ,-.,,.,

less. ’ b Present tS’)/Mp)hMKS.ŁGeneral surface of

26. There is pain in the right side under body cold ; feet feel cold ; she does not per-26. There and the right back a little lower spire at all, but occasionally has shivering;the mamma and the right back , a lIttle lower comp la’ III S 0 f pal On’ In the right side, and dI’ffi -down; the mucous membrane of the mouth culty of of pain in the right side, and dififi-much less pale; she is stronger, and feels countenance is pale on using any exertion ;less giddy. A mustard plaster to be applied countenance is pale owing to pain doestwo the dorsal spine. not sleep well at night, owing to pain in theto the dorsal spine. head, but she does not dream ; some pain in

29. Better. the right side of the upper dorsal spine ; onDec. 3. Complains of pain in the head, pressing on the right scapula, she complains

which is hot; appetite gone ; thirst; no of pain shooting through to the anterior sur-shiverings ; bowels open. Omit the iodide face of the chest; there is shortness of breath-of iron. ing, but no pain with it, and no cough ; pain

6. Much improved. on pressure under both clavicles ; ztongue

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pale, and covered with a white fur; mucous 22. Discharged, to make room for a pa-membrane of the mouth pale generally; tient with an acute disease ; she has regainedsome pain in the stomach, which is worse much of her colour and strength, eats well,after eating, but is relieved by taking any and is free from pain in the head or giddi-hot fluid, as tea; bowels have been confined ness.

for a day or two; urine passed freely, and in Clinical Re2narks.sufficient quantity, specific gravity 1.014, Clinical Remarks.

very pale, slightly sedimentary, and re- Symptoms and Diag-nosis.-These cases

mained clear on the application of nitric acid illustrate very well the ordinary course ofand heat; catamenia have only appeared anemia ; the general aspect of the disease isonce during the last six months, and even so characteristic, that it can never be mistakenthen very small in quantity ; before this she by the least practised eye, and yet the localhad been regular, with the exception of the symptoms which always accompany it nottimes when she was ill. To have three unfrequently cause it to be mistaken for in-

grains of calomel at bedtime, and a dose of ilammatory or structural diseases, and leadpurgative medicine in the morning. to a most injurious kind of practice. In each

Dec. 1. Complains most of pain in the of these cases there was the peculiar, almostright side; she never had giddiness: pain semi-transpareut, paleness of the counte-

and superficial tenderness in the abdomen ; iia-ice2the blanched condition of the surface

some weakness in the leg ; there is a loud generally, but especially marked in the mu-bellows-murmur with the first sound at the cous membrane of the lips, mouth, andbase of the heart; bruit de diable also heard tongue, in the conjunctiva, and the hands andin the neck; murmur of first sound of the fingers. There were also extremelanguor andheart less distinct at the apex, the murmur

coldness of the extremities, arising from theheard loud, prolonged, and rough. To be deficient quantity and impoverished qualityplaced on full diet, and to take three grains of the blood. Ramscar presented the pale,of iodide of iron three times a-day. greenish-yellow tint which distinguishes

3. Complains of bad appetite, but has less chlorosis, but her case differed in no otherpain in the head. important respect from the others; most of

6. Headach no better; there is no giddi- the usual local symptoms were present asness ; she feels faint; she has,violent beat- well as the general ones. In all of them the

ing in the head, which, with the pain, is head suffered. There was severe pain of a worse when she sits up; she sleeps badly, on violent throbbing character, and attended

account of the pain in the head ; she has no with considerable giddiness ; the pain waspain in her side ; pulse not very frequent nor least when the head was supported on a

sharp ; the second sound of the heart is not moderate-sized pillow, and was increased

perfectly healthy ; bowels open. when it was placed very low, or the patient8. Feels stronger; has no pain in the sat upright. of bloodhead, and less giddiness ; her appetite is still In headach from determination of blood,bad. Increase the dose of the iodide of iron the pam is usually easier in the erect pos-to four grains ture, audit has seldom so much of the vio-

10. Head less painful; there is moreco- lent throbbing, knocking character which islour in the face ; she feels giddy ; she sleeps

common in anemia. In Hambrook s case

better at night; feels stronger, and has more the pain was limited to the right side of theappetite ; there is no cough nor night-sweats; head, and was accompanied with consider-

there is sonorous rhonchus on the right side able tenderness : both these characters are

anteriorly ; there is pain and superficial ten- frequent in the headach of anemia, and are

derness of the left side ; less tenderness of common to this disease and to rheumatism,the spine, and none under the clavicles ; but the general symptoms and history atthere is a loud, rough murmur with the first once distinguish the two ; the tenderness ofsound of the heart, and the second is less the scalp is one of a series of neuralgic af-clear than natural; the murmur is loudest fections, of constant occurrence in cases of

between the second and third ribs. anemia. the cases there were numerous local13. Feels stronger ; appetite quite good ; In all the cases there were numerous local13. Feels stronger; appetite quite good ; symptoms referrible to the circulatory system.there is more colour in the cheeks. In- All had palpitation increased on exertion, or

crease iodide of iron to six-grain doses. by allY mental emotion ; but the beat of the15. Is much better ; feels stronger, and heart was different from that of hypertrophy ;

has more colour. it was a quick, smart stroke, without any17. Has some headach, particularly across real increase in the force of the impulse, or

the forehead ; has pain and tenderness on in the extent over which it could be felt. In

pressure in her left side ; her appetite is not hypertrophy each beat of the heart is com-

quite so good to-day; bowels rather con- monly slower, stronger, and of a more

fined. Ten grains of extract of colocynth heaving character, and it can be felt over aoccasionally, larger space than usual; palpitation, too, is

20. Better to-day ; there is no headach, a much less urgent symptom in most of thesenor giddiness ; countenance improved. cases, than in the functional disorder occur-

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ring in anemia and hysteria. In each of the case in vain during several years, andthree cases there was a loud, prolonged, and amongst some hundreds of cases in whichmore or less rough bellows-murmur syn- murmurs existed in the heart.chronous with the systole of the heart, The mode in which the bellows-murmur ismost distinct about the third or fourth costal produced in anemia, is still a matter of uncer-cartilages, and audible in the arteries of the tainty. Experiments appear to show thatneck. In addition to this bellows-murmur, thin iiuids are more readily thrown into vi-which has an interrupted character, there bation than thicker ones; the increasedwas heard in each case at the sides of the quickness of each beat of the heart in anemianeck (more especially at the right side) ; would also favour the production of theseanother murmur of a humming or roaring de- vibrations by any mechanical obstacle to thescription continuous, not interrupted, but in- current of the blood ; neither of these causescreasing in intensity at each systole of the acting singly could produce it, otherwise itheart. This has been called by Bouillaud would be of common occurrence in hysteria"bruit de diable," from its resemblance to without anemia (which it certainly is not),the sound produced by a toy of that name ; or it would occur in all cases of anemia,and in this country it is very often termed a which is not found to be the fact. It mayvenous murmur,from its supposed seat in the possibly turn out that it occurs only inveins of the neck. those cases in which there is some slight dis-

The bellows-murmur occurs very fre- ease of the valves at the same time. An at-

quently in anemia, without any concomitant tentive examination during several years ofdisease of the valves ; and in these cases, as the hearts of persons dying of all diseases,in very many others, it was impossible to say had satisfied the lecturer that a very smallat the outset whether there was in addition proportion only are quite free from morbidany valvular disease or not: as Dr. Hope structural changes in the valves; many ofhas pointed out, it is only one kind of mur- these are too slight to give rise to any physi-mur from diseased valves that can be con- cal sign in the ordinary condition of the pa-founded with that produced by anemia, viz., tient, but might, perhaps, become the sourcea murmur synchronous with the first sound, of sonorous vibrations in the blood, whenand occurring at the base of the heart. If aided by the thin condition of that fluid andthe murmur were synchronous with the se- the quickened beat of the heart occurring incond sound at the base alone, or occurred at anemia.the apex alone with the first sound, it would In one of these three cases the murmurimply the existence of regurgitation through ceased as the anemia disappeared underthe aortic valves in the one case, and the treatment, and therefore depended upon themitral in the other, and, of course, the anemia. In the other two it was littlesimultaneous existence of disease in these abated when the anemia had diminished orvalves permitting regurgitation. The occur- ceased, and was probably, therefore, to berence of a murmur with the second sound at ascribed to valvular disease. This is oftenthe apex alone might be possible in anemia the only means of diagnosis we possess.without valvular disease, but the lecturer The bruit de diable is of much more con-had never met with it or heard of it. stant occurrence in anemia than the bellows-

The quality of the sound might sometimes murmur, but the mechanism of its productiondistinguish the murmur of anemia from that is, at least, equally obscure. In each ofof valvular disease, but generally it could these cases it ceased (as it generally does)not be depended on. In anemia the murmur when the jugular vein was compressed, andhas usually a soft character, but might pos- for this reason it is supposed to have its seatsess a considerable degree of roughness. The in this vein.lecturer had observed a rough or rasping It is said that it may always be producedmurmur in a patient affected with anemia, in health by compressing the jugular vein soand who died of disease of the brain. On as to diminish its calibre, without obliteratingexamination no disease whatever was found its cavity. The lecturer had often made thisin the valves of the heart. In some cases, experiment, but hitherto without success.

however, of valvular disease, the murmur In strongly-marked anemia it certainly oc-

was rougher than he had ever found it in curs without the application of any externalsimple anemia. Of all the causes of mur- pressure, and in some cases a distinct vibra-murs in the heart, disease of the valves and tory tremor is readily perceived by the fingeranemia are infinitely the most frequent: placed as lightly as possible at the root

hysteria is commonly enumerated amongst of the neck ; the sound is continuous, proba-such causes, but the lecturer was satisfied bly, because the current of the venous bloodthat most of the cases of murmur ascribed to is continuous, and its increase with each sys-hysteria were really duc to anemia existing tole of the heart is supposed to depend on theat the same time. The production of a mur- compression of the jugular vein by the pulsa-mur in hysteria without anemia, and where tions of the carotid artery.there was proof of the absence of valvular The pulse in each case had a rather quickdisease, if it ever occurred at all, must be jerking beat, and the pulsation of the carotidinfinitely rare. He had sought for such a arteries was more visible than in health:

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this character of the pulse has been noticedin a former lecture, as occurring in a stillhigher degree in regurgitant disease of theaortic valves; it is known as the haemor-rhagic pulse, because it occurs after largelosses of blood, whether accidental or other-wise. In all these cases its cause appears tobe the same; namely, a more than usuallyempty condition, and consequently dimi-nished tension of the arteries. In these cir-cumstances they are more dilated by eachjet of blood from the heart, and the impulseof each jet being less modified by the elas-ticity of the arteries, is transmitted to theirsmaller branches with more abruptness. Withother symptoms of more or less disorder ofthe stomach, there was in all pain at theepigastrium, possessing the distinctive charac- ters of gastrodynia, namely, it was relieved !by swallowing hot drinks, and increased by!cold ones. ’

In each, likewise, there was a pain in theside, increased on exertion, and also on pres-sure ; merely pinching the skin causednearly as much suffering as firmer pressure,and the pain was therefore neuralgic. Therewas, at the same time, tenderness on superfi-cial pressure of the corresponding side of thevertebral column in the dorsal region. Theseare leading characters of the morbid condi-tion denominated spinal irritation; a conditioncommonly supervening in those disposed tosuffer from it, in all circumstances in whiciithe strength of the individual is reduced, andof almost constant occurrence, to a greater orless amount, in anemia. In one patient(Hambrook) there was an additional symp-tom, namely, weakness of the left leg. Themenses were very irregular in each of thecases ; they appeared at long intervals, werescantv in nnantitv-and nale in colour.

Causes.-The causes of anemia are not

commonly very obvious; it is intimately con-nected with retention or suppression of themenses. We should expect, a priori, thatthe imperfect menstruation is the conse-

quence of the anemia. When the blood ispoor in quality and deficient in quantity, itseems reasonable to expect that the varioussecretions from it should be deficient too ;especially a secretion like the menses, pos-sessing several of the’ characters of theblood itself : but observation shows, that ina great proportion of cases the defective men-struation precedes, instead of following’, thedevelopment of the anemia-this was thecase in all the instances under consideration.Anemia seems to occur in persons of habi-tually delicate health. None of these patientshad ever been strong; two of them neverhad much colour, and one had been alwayssubject to fainting fits.The disease may sometimes be traced to a

want of suliicient food, or an inability to eatit. This may have been a principal cause inRamscar, whose appetite had always beenbad, and who had always a distaste for ani-

mal food ; Hazelgrove, however, was alwaysable to eat, and always had enough food ofgood quality ; and in Hambrook the loss ofappetite followed the anemia, and did notprecede it.The patients were all servants, their occu-

pations were not sedentary, and they werenot confined in a close, impure air; one ofthem was living in an open part of Padding-ton, and going out daily with children, anda second lived at Holloway.The patients were all near the age at

which the disease is most commonly seen ;namely, at or near the age of puberty. It iscomparatively rare in females more advancedin life, except as a consequence of loss ofblood ; and is almost unknown amongst men,except when arising from the last cause,from wasting disease, or starvation. It

seems, therefore, to be intimately connectedwith the more delicate constitution offemales, and especially with the develop-ment of the menstrual function, since it isseen chiefly about that period of life.

Treatment.—The medicinal treatment ofanemia is very simple, and very certain inits results, but the disease is very liable torelapse. In many cases the circumstances

producing it, whether they consist in theconstitution or mode of living of the patient,cannot be removed. Each of these patientshad suffered from it for several years, and intwo of them the attack was the third theyhad experienced within that time.

General experience has established thesuperiority of steel to every other remedy;and it was given to each of these patients,but not in the same form. Ramscar tookthe sesquioxide of iron in doses of twodrachms, three times a-day. This is the

preparation in which the lecturer places thegreatest confidence, perhaps because he hasseen it more extensively used than any other.It was given in twice its weight of treacle,which in general prevents the steel from

constipating. He had seen a vast numberof cases treated in this wav. and with uni-form success. Some persons thought it wasuseless to give so large a quantity—thatmuch of the remedy was wasted. Whetherthat was the case or not he could not say;he gave that dose because he knew it would

answer, and he did not know whether asmaller one would do or not. The patientwas allowed the full diet of the hospital, andhalf a pint of porter daily. She still, how-ever, retained her indifference to meat, andasked for fish instead, which was allowedher. Under this treatment the patient’scolour soon began to return, her strength toimprove, and the other symptoms to dis-appear ; and at the end of a month she wasdischarged quite well. She had plenty ofcolour, and had acquired both flesh and

strength ; the headach, palpitation, and

pains in the side had ceased, and the bel-

607

lows-murmur and the bruit de diable couldno longer be heard,The sesquioxide of iron, although almost

always to be depended upon, is not a veryagreeable preparation, and in private prac-tice it is difficult to induce patients to takeit; occasionally the quantity overloads thestomach, and some patients cannot take it intreacle. For these reasons the lecturer wasdesirous of ascertaining whether other andmore agreeable preparations were equallyefficacious. He had given the tincture of themuriate in a large number of cases, andoften with very good effects ; but it had notappeared to him so generally to be dependedupon as the sesquioxide, and not unfrequentlyit had disappointed him altogether.He had not had much personal experience

of the iodide, which had been introducedinto practice by Dr. A. T. Thomson, andwas now largely used, and he determined tomake trial of it in the case of Hazelgrove.The result had been very gratifying to him.He found a very speedy amendment in allthe symptoms, which progressed steadily,until the patient was quite well. The dura-tion of the treatment was about a month,the same as in the first case. The remedywas given in three-grain doses, three timesa-day, and increased to four or tive grains.It was not found necessary to exceed thelatter quantity.The result of this case induced him to give

the iodide to the third patient, and in hercase it had been equally successful. Shewas made an out-patient before she waswell, in order to make room for a moreacute case, but the amendment had been asrapid as in the first case, and the patientwould, probably, be cured in about the sametime.In both these cases, as he had mentioned

before, the morbid sound in the heart per-sisted as the anemia disappeared, and onthis ground it was probable that it dependedon structural disease of the aortic valves.

CASES OF

STRANGULATED HERNIA.

By ARTHUR SEALY LAWRENCE, Esq.,Surgeon, Clifton.

IT is generally acknowledged that in stran-gulated hernia, the surgeon should first ofall make use of those means which are bestcalculated to obviate the necessity of havingrecourse to an operation for its relief ; andwhich operation should not be delayed toolong, after giving a suflicient trial to what-ever is deemed most advisable in any parti-cular case.One of the latest proposals for the reduc-

tion of hernia, is that recommended by Dr.J. O’Beirne, of Dublin, which consists in

introducing a long tube up the intestine, torelieve the bowel from flatulent distention,and thereby rendering the reduction more

easy; and he states " that no medical man canhenceforth be considered justified in proceed-ing to an operation for strangulated intesti-nal hernia, without having previously givena full and fair trial to the mode of treatmentin question.’ And Mr. W. H. Maunder, ofCollumpton, in Devonshire, in THE LANCETof Feb. 1, 1840, p. 693, in a letter to Dr.O’Beirne, relates a case in which he intro-duced the tube of a stomach-pnmp to thedistance of twenty-six inches, and thus freedhis patient from flatus, and an operation wasprevented. Now, without speaking dispa-ragingly of the competency of any one in par-ticular, I believe the generality of practitio-ners, unaccustomed to such a procedure,would find that the introduction of a tube ofthis length could not be accomplished with-out much difficulty, and considerable risk ofinjuring the intestines. The rectum is butnine inches in length (according to ErasmusWilson’s Anatomy), and the stomach-tube,as described by Mr. Maunder, must in thatcase have been passed up the colon seven-teen inches above that! At all events, underany circumstances it is desirable to endea-vour to supersede the necessity of forcing atube of such a length up the bowels ; and Ihave the satisfaction of knowing, that fornearly four years before Mr. Maunder’s casewas published, I was successful in relievinga strangulated intestine that had resistedevery other means usually tried previous toan operation, together with the taxis, by dis-tending the bowels with a large injection oftepid fluid, together with cold water in abladder applied externally to the groin ;which in this instance, and another also, hadthe effect of withdrawing the protruded partof the intestine from strangulation.The principle upon which I applied cold

externally, was to condense the flatus in theintestine, and to produce a constringingeffect on the integuments ; while, by simul-taneously distending the bowel internallywith a large injection, the intestine in bothcases became freed from the constriction,and was afterwards easily returned into theabdomen.

I now proceed to give the particulars.

CASE I.-On the 7th of November, 1836,at seven, a.m., I was called to attend onMrs. M., aged 28, and found her affectedwith pain and tension of the abdomen, witha hernial protrusion in the right groin, whichhad taken place on the day previously, andas the symptoms became more alarming Iwas sent for. She had been subject to in-guinal hernia, and the bowels had beenopened before the strangulation ; but Mrs.M. could not now return the protruded partas usual, which was very painful. Therewas an anxious expression of countenance,