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1847]

Tanchou on the Indications for Bleeding.

279

any locality sufficiently known to pass along without difficulty. If the nature of the occupation or the degree of the myopia compels their use, their power should be much lower than that of those which are employed for seeing at a distance. Frequently we are obliged to allow concave glasses to young persons for the purpose of deciphering music or of following the demonstrations which are made upon a black ground in the schools and colleges ; but it is very important that the number of the glasses should only be such as just to allow of vision at the desired distance, and their employment should be limited to this. Far better is it, indeed to do without them, and endeavour by frequent exercise to gradually increase the range of vision. We must not attach too much faith to the alleged impossibility of seeing without glasses ; for abundant resolution and perseverance will frequently overcome every obstacle. If, during writing, the chest becomes fatigued by the bent position the state of vision obliges the young person to assume, a moveable desk may be employed, which may be raised or lowered as desired, and by increasing the visual distance a very slight determinate extent every week or fortnight, we can gradually increase the range of vision. The same contrivance may be employed for holding the music at the piano, and the injurious bending forwards thus prevented. Such means are applied with difficulty to large commercial books, and to the open books employed while learning the violin: and in these occupations, if the myopia is considerable, glasses are required. If the individuals are very young, we should postpone the period of their so employing themselves, and in the mean time exercise their eyes in such a manner as may tend to the diminution of the myopia. When this is impossible, let the glasses be as feeble as possible, and accustom the wearer at intervals to lay them aside and cast the eyes on distant objects, which will at the least have the effect of preventing the sight getting worse. These short-sighted persons must very seldom look through dioptric instruments, such as magnifying glasses, microscopes, &c.

"I may cite my own case. I was myopic from birth to a considerable degree; but I have, by my frequent exercise of the eyes, and by my care to allow myself the use of spectacles as seldom as possible, which in my youth exposed me to much privation and frequent ridicule, been enabled to render my sight twice as good as it was; for, in fact, I now read at a distance about as great again as I did twenty-five years ago.”

The myops then should exercise his faculty of exercising the eye at different distances as much as possible, or he will lose the power of doing so, and find his affection gain upon him more and more. It is especially necessary to prevent young children approaching objects too near their eyes, and not to give them too small toys which will oblige them to do so. Not only will this cause an increased myopia, but it may produce strabismus. The visual axes naturally converge when we fix our eyes upon near objects; and the more this act is repeated the more habitual does the convergence become, until it ends in becoming permanent and passing into strabismus, It is on this account that this deviation of the visual axes is so easily produced between the ages of four and six, the period at which children are generally first taught their letters; and it especially occurs when there is an inequality in the focus of the two eyes.-Annales d'Oculistique, Tom. XVII., p. 200.

رو

Practical REMARKS ON BLEEDING, AND UPON ITS UTILITY IN THE

TREATMENT OF THE DISEASES OF THE UTERUS. By M. Tanchou.

On Bleeding in General.-It is not always easy to decide upon the institution or the repetition of bloodletting, and I have long been in the habit of consulting the condition of the blood itself for clearing up any doubts. Generally it is bluck, and that colour, in conjunction with its consistence, justities its abstraction. Oftentimes, however, it is red at the commencement of the bleeding, and becomes black at the end of this. Again, it is at first black, and then becomes red; in a fourth case, the two threads of the spiral it forms may be of the two different colours, and lastly, the blood may be red from the beginning to the end of the bleeding:

Whence is this last due ? There can be no doubt that when the individual is weak, and exhausted in some gree by preceding bleedings, it arises from the rapid and freer passage of arterial blood into the venous system ; but when the patient is strong and young, the circulatory system full, and it is observed at the first bleeding, I believe it arises from the contact of the air, which, traversing the skin, acts upon the blood ; for I have made this remark especially in hot weather, when the patients have been several hours in bed, upon young subjects affected with inflammatory fever, and young healthy pregnant women-whenever, in fact, the skin is supple, elastic, and perspirable, conditions favourable to the absorption of air; or in individuals suffering from exhaustion from any cause, and in whom the organism always consequently manifests an avidity for what, ever may maintain life and recruit strength. I may remind you that the blood of infants is generally red, that of old persons black; and that the skin, under these two circumstances, is in quite opposite perspirable states.

However this may be, I have been led to the following practical inductions. If the blood is black during venesection we may allow it to flow, or repeat its abstraction if the symptoms indicate this; while, if it is red, we must absolutely abstain from doing so, or we shall only aggravate the symptoms for which we employ it, and increase the fever. Thus, in pneumonia the hreathing becomes more laborious, and the oppression greater, as if the pulmonary congestion increased as we diminished the general resistance by the loss of blood. So in hæmoptysis the blood in the expectorations becomes redder and more abundant ; and in metrorrhagia the flow is increased. In typhoid fever bleeding is of use when the blood is black, and constantly hurtful when it is red. The remark should not be lost sight of by those who practise bleeding coup sur coup: In all these cases the pulse is accelerated in proportion as the blood flows and the individual becomes enfeebled, the artery seeming fuller and harder, so that the most experienced may become embarrassed. In threatened miscarriage, wherein bleeding is often so necessary, if we practice it when the blood is red we inevitably induce abortion. I therefore always recommend those pupils who bleed for me to be guided in the quantity they draw by the colour of the Ruid, and they have often been in a condition to prove the correctness of the rule. It has hap, pened to me sometimes to close a vein immediately after having opened it, and to suddenly stop the flow upon this simple indication, and in all these cases I have never had cause to regret it.

When a patient is about to enter upon convalescence, the pulse often becomes full and frequent, the cheeks are flushed, the eyes sbining, and the skin hotter-in a word, there is fever; and it is not rare for the practitioner to hesitate whether he should abstract blood or content himself with dieting. I have always been safely guided by the colour of the blood. Black blood coagulates and reddens after it has left the vein; when it remains black on the surface it is diseased; and when it does not coagulate it is dead, as is seen in that flowing from old ulcers, uterine and other cancers. In the bleedings practised on young pregnant women red blood at first flows out and then black'; the former, I believe, coming from the superficial, and the latter from the deeper-seated veins. In the treatment of a disease, then, if on opening the vein the blood is black, let it flow; if it is red, be certain that the disease is vanquished, and the point of tolerance reached. Great thirst also, which almost always follows excessive bleeding, is not a symptom to be overlooked. In organic disease the blood is generally black; but it may not always be prudent to abstract it, while if it is red we shall but increase the gravity of the disease.

1847]
Pneumonia of the Aged.

281 Another remark, which I do not remember to have seen, is, that the blood in a diseased part may be different to that in the economy at large. I have seen it flow black from the general circulation, and red from leeches or cupping-glasses, and vice-versa. It is this that revealed to me the importance of bleeding in the treatment of cancer, or in tumours threatening to become cancerous; but that always in relation to the general vital powers; and in such a manner as to prevent general infection by absorption, which bleeding hinders or favours, according to the circuinstances under which it is undertaken.

M. Tanchou goes on to state, that in the inflammatory and congestive Diseases of the Uterus repeated bleeding may be very useful, as long as it is not carried to excess; and that proofs of its being so are derived from the fact of the resistance of the disease, and the signs of general enfeeblement of the economy. Most of these effects of the too-great loss of blood are familiar to our readers ; but he mentions two which are probably less so, viz. constipation and the condition of the urine. The stools are inodorous, infrequent, and lumpy, intestinal absorption having extracted all that was possible from them. The uripe is high-coloured, but without any deposit, and emits a peculiar penetrating odour when passed, which disappears on cooling. This odour is at once recognized by the experienced observer as the most infallible sign of inanition, frequently appearing before any of the others.—Gazette Medicale, No. 20.

[The author, in detailing his practice still farther, recommends general bleeding in uterine affections to a far greater extent than would be countenanced in this country, and seems to much fear discontinuing it otherwise than gradually. He cautions his readers, however, against the abuse of the lancet, and not without reason, for he says, “We have seen women who have been bled 80, 95, 100 times, or even more, in one or two years !” Shade of Guy Patin arise, and tese tify that thy descendants are no degenerate phlebotomists! We have quoted the paper however on account of M. Tanchou's remarks on the indications derivable from the colour of the blood while flowing, which are new to us, and are so opposed to what is generally accepted, as to require confirmation.—Rev.]

The PNEUMONIA OF OLD PERSONS.

Op ten cases we observed at Salpétrière, seven were well-marked, and three doubtful. The term doubtful pneumonia may surprise some readers accustomed to meet with the well-known signs of the disease. But if we waited for the usual train of symptoms met with in the adult before we commenced treating pneumonia in the aged, we should often begin to act only when art had become powerless. For physicians accustomed to the aged, and who know how frequently in them it is latent, it suffices to observe malaise, fever, accelerated respiration, and a dry tongue, to direct their attention to pneumonia, especially in winter or spring-time. If we find in books that the pneumonia of the aged is more commonly than that of the adult preceded by precursory symptoms, and that it seldom shows itself in old persons suddenly, this is because too frequently the period of the commencement of pneumonia has been dated only from the appearance of stethoscopic signs. The earliest of these, and often the only one throughout the disease, is the feebleness of the respiration, or sometimes its complete absence over a certain extent. This sign, joined to bronchophony, constitutes for the experienced observer a certain indication of the presence of the disease.

The digestive and cerebral functions are much oftener disordered in the aged than in the adult. A dryness of the tongue, which alone may lead us to fear a pneumonia, is complicated with a yellow or brownish coating, bilious vomiting,

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and even delirium. An icteric colour of the face has not excited sufficient attention, notwithstanding its so constant co-existence with pneumonia of the apex.

Most practitioners are very circumspect in bleeding in these cases; but their fears are based upon no sound appreciation of facts. We see old pneumonic persons bled two or three times without any ill-effect, the blood retaining its normal characters and the characteristic buffing. M. Fauvel, after having bled the patient once, twice, and even three times, according to their strength and the amount of fever, and generally after having on the first day given antimony as an injection, administers from five to twelve of the following powders: --Calomel 8 grs., Opium 2 grs., Tartar emetic, 1 gr. Mix for eight Powders. Salivation does not generally take place until the 3rd or 4th day; but as soon as that is perceived, the patient's condition ameliorates; but the powders are continued until resolution has commenced. He formerly gave tartar-emetic in large doses; but was obliged to renounce it in consequence of the inflammations of the throat and bowels it gave rise to. It is to be observed, that in individuals who have long lost their teeth, salivation does not take place, or only with great difficulty, the gums remaining unaffected amidet the general buccal inflammation. In some of these patients an intestinal tlux, coincident with the resolution of the pneumonia, is substituted for the salivation.-L'Union Medicale, No. 39.

ANESTHESIA IN SATURNINE AFFECTIONS.

M. Beau has remarked that all the subjects suffering from saturnine affections, manifest more or less insensibility of surface. We do not allude to that saturnine anesthesia described by authors, when it exists in a marked degree, and which is not seen above six or eight times in a hundred cases. M. Beau declares, and he has shewn us several cases now in his wards, that whatever may be the saturnine affection under which the patient is labouring, severe or slight, there is always insensibility of the skin, in some regions oftener than in others, and in proportion to the intensity of the saturnine disease. We saw him prick the skin of the arms and hands of several of these patients without their feeling any notable pain; so that lead may be stated to blunt sensibility. The fact is a new and important one; for it may aid in the diagnosis of some doubtful cases. -Gazette des Hôpitaux, No. 54.

ALUM AS AN EMTEIC IN CROUP.

Dr. Meigs, relating some cases of true croup, takes the opportunity of confirming the accuracy of the account furnished by his father long ago of the great value of alum as an emetic in this disanse. A teaspoonful given in honey, treacle, or other vehicle, acts more speedily and certainly than any other substance, and that without inducing prostration of the system. It is rarely necessary to repeat it.— American Journal of the Medical Sciences, No. 26.

COD-LIVER OIL.

M. Bretonneau states that he has observed effects just as markedly beneficial to result from the use of the common whale oil as from the cod-liver oil : an important fact, seeing the great expensiveness and the frequent adulteration of the latter.

1847]

Bibliographical Record.

283

Gray's SUPPLEMENT to the PHARMACOPÆIA ; being a concise but comprehensive Dispensatory and Manual of Facts and Formulæ. Entirely re-written, re-arranged, and considerably enlarged. By Theophilus Redwood, Professor of Pharmacy to the Pharmaceutical Society of Great Britain. Octavo, pp. 1118. London, 1847.

Mr. Redwood has added a great deal of interesting and very useful information to this new edition of a well-known work. The introductory chapters, containing a chronological history of Pharmacopeias and Dispensatories, an account of weights and measures, description of the methods of taking specific gravities, tables of thermometrical equivalents, &c., a pharmaceutical calendar, and various other matters, have been carefuily and correctly prepared. We observe some omissions in the more strictly pharmaceutic department, that Mr. R. will do well to supply in his next edition. For example, we happened to look into the work for the composition of Ruspini's styptic, but found no notice of it. Such well-known formulæ, too, as vinum ferri, vinum antimonii, ought surely to have had a place,

The addition of some toxicological tables also would be of service. To find room for these and various other matters unnoticed, much of the chapter on Animals might be left out without any detriment to the usefulness of the work.

BIBLIOGRAPHICAL RECORD.

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1. The American Journal of Insanity. Edited by the Officers of the New York State Lunatic Asylum, Utica. Parts I. and II. Vol. III. 8vo, pp. 192. Utica, 1846.

2. Statistics of the Royal Infirmary of Glas. gow. Third Series. For 1846. By R. S. Orr, M.D. 8vo, pp. 36.

3. Thoughts on the Nature and Treatment of several severe Diseases of the Human Body. By Edward J. Seymour, M.D. Two Vols. Vol. I. Sto, pp. 264. London, 1817.

4. The Transactions of the Provincial, Medi. cal, and Surgical Association. Instituted 1832. Vol. III. New Series. 8vo, pp. 437. London, 1847.

5. Remarks on the Diet of Children, and on the Distinctions between the Digestive Powers of the Infant and the Adult. By G. T. Gream. Svo, pp. 201, London, 1847.

6. The Cyclopædia of Anatomy and Physiology. Edited by Robert B. Todd, M.D. Part 28. London, 1847. 7. Erect Vision from an Inverted Image. By B. F. Joslin, M.D. From the New York Journal of Medicine for November.

8. A Treatise on Fractures in the Vicinity of Joints, and on certain Forms of Accidental and Congenital Dislocations. By R. N. Smith, M.D. 8vo, pp. 325. Dublin, 1847.

9. Inhalation of Ether. By J. Mason Warren, M.D. 8vo, pp. 18. London, 1847.

10. The Surgeon's Vade Mecum. By Robert Druitt. Fourth Edition, 156 Wood-engravings. 8vo, pp. 640. London, 1847.

11. The Construction and Government of Lunatic Asylums and Hospitals for the Insane, By John Conolly, M.D. With Plans. Svo, pp. 191. London, 1847.

12. A Case of Large Secondary Prostatic Cal. culus removed by Perinæal Incision. From the " Transactions of the Association. Vol. III. New Series. By T. Herbert Barker, M.B. 8vo, pp. 12. London, 1847.

13. Observations on the Connexion between Fever and Famine in Ireland and elsewhere. By Henry Kennedy, A.B., &c. 8vo, pp. 50. Dublin, 1847.

A very able pamphlet, well deserving of atten. tive perusal.

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