duced in the mirror. Finally, when I requested the patient, conducting her towards it, as it were, step by step, to utter a cry, which I also succeeded in obtaining, I was convinced that the vocal cords could perform their normal function, having seen them approach and vibrate in the mirror during the emission of the sound.

I then requested the patient to read some passages from a newspaper, even at the risk of suffering pain during the reading. She accomplished this after long hesitation, but she seemed agitated and astonished to hear herself speak, and complained of acute pain during phonation.

All the exercises above enumerated had provoked, among other things, signs of pain.

To the questions which I then addressed her, she responded, briefly it is true, and, as it were, in spite of herself, but articulating very distinctly.

REMARKS.

In view of this strange fact, there was naturally presented to my mind the idea of a particular form of hypochondria, or perhaps even simulation. This was, in fact, the diagnosis to which I arrived at the time.

Not having seen the patient again, as she returned to her home the next day, I do not know what became of her; but I do not hesitate to acknowledge that my interpretation of the case has become modified since; having had occasion to observe analogous cases, much less marked it is true, but possessing absolutely the same character, and in which it has been possible to convince myself, by prolonged observations, of the reality of the symptoms complained of.

We encounter sometimes-thus far my observations have been confined to females-persons who experience, without any vocal fatigue having preceded it, an annoyance in the functions of the larynx, accompanied with great sensitiveness, and even pain more or less intense. Not only does phonation become difficult, but the closure of the glottis in the act of expectoration and in the movement of straining, is equally pain

ful.

There is neither cough, nor any particular general trouble. The laryngoscope does not portray any material lesion. The reflex sensibility of the laryngeal mucous membrane is not at all exaggerated, for I have many times carried into the interior of the larynx in these cases, a sponge moistened with a weak solution of nitrate of silver, without provoking any greater reflex movements than are produced in ordinary cases.

To analyze the nature of the class of affection to which this belongs, I am obliged, at the risk of making a rather long digression, to enter here into some other considerations, for it becomes necessary, in the first instance, to define the different varieties of sensibility of the laryngeal mucous membrane.

way," there still follows a convulsive movement of the muscles of the glottis as in the case already cited, but the phenomena are very different. Among these phenomena, the one which predominates is a violent cough, fearful, stridulous, to produce which, all the expiratory muscles contribute by reflex action; while as to the inspirations, they are difficult at the commencement, but soon become calm and normal. The cough, on the contrary, continues as long as the slightest sensibility of the laryngeal mucous membrane remains. It seems that trifling foreign contact with this laryngeal mucous membrane provokes a sensibility intended to preside over the work of expelling foreign bodies engaged in the air passages, and it is this sensibility to which the name of reflex sensibility belongs. It is hyperesthesia from a special cause, such as occurs in various affections; it then provokes cough even at the simple solicitation of atmospheric air passing through the glottis.

But we have just seen that corrosive and painful applications provoke phenomena of an entire different order. They give rise to closure of the glottis without cough. There occurs then in the muscles situated beneath the laryngeal mucous membrane just what takes place in any other organ provided with a mucous membrane, covering a muscular surface; that is to say, the local spasm corresponds to a local excitation. In this case, then, it is the general or common sensibility of the larynx which has been excited.

It is evident that the two modes of sensibility are not distinguished only by degrees of intensity, and what I have in view is to show that this distinction is real, and that it depends upon pathological facts, thoroughly de

termined.

After having shown that the cough, a convulsive movement of all the expiratory muscles, corresponds to the non-painful excitation of the reflex sensibility of the larynx, it yet remains to determine the rôle which pathology prescribes for the excitation of the common sensibility of the larynx.

I thus find myself conducted to the interpretation of the case of which I have given the history. This case which I have chosen from among several like it, but less pronounced, is, in fact, a marked example of the cessation of the functions of an organ from exaggeration of its common sensibility. There is the same condition which occurs in a painful limb, inaction. Suffering during phonation, the patient is condemned to an absolute silence, as an individual with a severe sciatica is condemned to absolute repose.

Have we here a neuralgia of the superior laryngeal nerve; or is there only a well-marked hyperesthesia of the terminal filaments of this nerve? I am not prepared to decide with certainty, but I am inclined towards the latter opinion, that is to say, a simple local hyperesthesia; the pain never occurring spontaneously, and not manifesting itself except during the various functions of the organ.

When we cauterize the mucous membrane of the larynx with a liquid corrosive substance, or still more, The subject is too new not to admit of other interwhen we touch it with a solid substance which instant-pretations; I have explained it as I have comprehended ly modifies the surface, as for example, nitrate of it; and what I desire above all, is to call to it the attensilver in crystals, we provoke a convulsive closure of tion of other observers. the glottis, manifesting itself by several successive movements of inspiration stridulous and painful; the movements of expiration remain calm and quiet. The mucous membrane of the larynx remains painful for several hours or several minutes, according to the strength of the substance employed, but it does not provoke cough.

If, instead of corroding the mucous membrane of the larynx, we drop upon it (with the little laryngeal spongeholder) a simple drop of water, imitating in this manner what happens so often when we "swallow the wrong

NOTE BY THE TRANSLATOR.

I have never met a case like the above. I have seen several where the voice had been lost for a continuous series of months, in some instances more than a year, and which was restored at the first interview with the patient, by means of galvanic and other stimulus. A case of the kind was recorded by me in the first volume of THE MEDICAL RECORD, page 178, and I have since met many others, notes of which are at present being preserved in a permanent form. I have never met

INJURY OF THE HEAD-PROFUSE WA- soft parts; the other, in which it is said to be the se

Various opinions as to the source of this watery disalter-charge from the ear have been held by different observers, but they may be reduced to two classes: one, in which the fluid is said to be nothing but the serum of the blood exuding from a clot or lacerated vessel lying along the fractured bone or in the neighboring EAR-cretion from some membrane. The first of these opinions has not been borne out by subsequent investigations, and with regard to the second, the discharge in different instances has been proved to be the "cerebrospinal fluid," and the "liquor cotunnii; " while in a case reported by Mr. Henry Gray, in the Transactions of the Pathological Society of London, it was proved to have proceeded from the inflamed membrane of the middle ear, there being no fracture of the temporal bone. A case is also reported by Mr. Holmes, where, in a patient in St. George's Hospital, the discharge was due to a fracture of the lower jaw, the lower fragment having perforated the wall of the meatus auditorius. These two cases prove that we may have a copious watery discharge from the ear, without any fracture or injury about the petrous portion of the temporal bone, or any communication between the internal and middle ear.

HYPODERMIC INJECTION OF ATROPIA IN THREATENING GLAUCOMA.-Dr. Anstie (The Practitioner) believes that, in two cases, he has succeeded in preventing March 3d.-The discharge from the ear ceased en-threatening glaucoma from developing itself by a tirely during the night, and with its cessation the sense hypodermic application of atropia; at least, the most of hearing returned. From this time until her clavicle threatening symptoms were present, and rapidly subunited she was kept quiet on her back, and had no re-sided under the use of 1-60th grain injections of atropia.

ACUTE OCULAR CEDEMA. CAUSE UN

KNOWN.

By E. C. SEGUIN, M.D.,

ACTING ASSISTANT SURGEON, U.S.A.

and the absence of the usual symptoms attending inflammatory processes.

Second, the apparent hereditary character.

Third, the coincidence of the disease with a semicachectic state.

FORT CRAIG, N. Y., October 15, 1868.

ON CONSTIPATION.

CAL SOCIETY OF THE COUNTY OF NEW YORK.

By R. J. O'SULLIVAN., M.D.

B., a private in Co. B., 3d U. S. Cavalry, aged 18 years, a native of Pennsylvania, has never enjoyed good health. From the age of 15 to date of enlistment, last March, he worked in an iron mill, and was exposed to great heat and vivid light. A few years ago he had BEING THE ABSTRACT OF A PAPER READ BEFORE THE MEDIintermittent fever. Has always had a tendency to diarrhoea, and is now under treatment for an attack that threatens to become chronic. He is pale, flabby, looks old, face and forehead are much wrinkled. When a child he suffered from night-blindness. Sept 24th, he presented himself with his left eye much swollen; says that ten minutes before his eye was well. He was reading, when suddenly a severe smarting pain was felt in the inner canthus, and was at once followed by swelling. He is certain that no foreign body entered The lids are externally oedematous and nearly closed. On opening them, an almost complete chemosis is seen, the ring being imperfect at its upper outer part. There is no injection of blood-vessels and no lachrymation; pupil normal. I applied a solution of nitrate of silver(ij to j aq) freely over the chemosis, and directed a light wet compress to be applied during the evening and night. The next day the eye

the eye.

DR. O'SULLIVAN introduced the subject by a reference to the classes among which constipation is most generally prevalent. "I would," he remarked, "in the first place consider the subject, where constipation is due to simple inaction, unconnected with obstruction; and also where it is unattended by the constitutional symptoms which exist in a more advanced stage, that is, where the secretions are diseased, or where it assumes the form of dyspepsia. Secondly, I should consider the subject of constipation arising from spasmodic contractions of the abdominal muscles, among which may be classed those forms dependent respectively on socalled lead-colic and hysterical spasm. These two divisions I will endeavor to illustrate by cases occurring within the past few months in my own practice. Before doing so, however, I will allude to another class of Second attack, Oct. 3d, at 1 P. M. I had occasion cases, of which constipation, colic, and spasm of the abto see a wounded man in my hospital, and asked sev-dominal muscles are prominent symptoms. The diseral questions of B., who was watching him. His eyes ease in question, according to Dr. Claiborne's nomenwere then in a normal state. Hardly had I returned clature, is Colica Bacchanaliana, or drunkard's colic (vide certainly not more than five minutes American Medical Monthly, Sept., 1858). to my room later than B. came to me hurriedly with his right eye much swollen. He had experienced the same smarting, and the appearance of the eye was precisely similar to that of the left eye ten days previously. was no sign of inflammation. At 2 P. M., a complete and heavy ring of swelling surrounded and nearly buried the cornea. I pursued the same plan of treatment as before, and in twenty-four hours all was

was about normal.

well.

There

Patient states that he had his first attack of this curious affection in 1860, while at work in a field. Since, he has had from two to six attacks each year. This year he was affected once in April and once in July, besides the two attacks detailed above. He feels certain that in all instances the symptoms and appearances have been the same; and often the disease subsided spontaneously. Once, in 1860, both eyes were

affected at one time.

His mother and sister "have always had weak eyes," and have suffered from repeated similar attacks of oedema of the eyes. His father has excellent sight, though he has worked for many years in the iron mill. Oct. 14th. Vision tested with Sneller's type* :

With No. 3......V....

With No. 12.....V....

Inches.

43

-11-6

The term colic may, without any undue philological violence, be made to refer to the colon as its probable seat, and I desire to caution my hearers that I have used the word symptom, as being antagonistic to cause, since no physician is expected to limit his investigations to the mere symptomatology of any disease. To determine the true seat of the malady, a brief allusion to general principles is necessary. There are certain local circumstances which, when carefully considered, may present sufficient evidence of what should constitute a disease. These symptoms may point to a morbus or a morbiculus; hence the drunkard's colic, the morbiculus, may be the indicator of the morbus, or primary disease, located in the liver. A patient affected with this colic, usually has a weak pulse, a skin cold and clammy, and an excited brain, with the well-marked evidence of long-continued irritation. A cursory examination, or perhaps the voluntary statement of friends, will inform you that the bowels are constipated; you may be told that they are very bad, a phrase intended to convey the meaning that a diarrhoea is present, which in many

the

cases is unfounded in fact. Percussion of the abdomen will discover well-marked tympanitic resonance on one side, and dulness on the other; both of which conditions are rather positive evidence of a loaded colon. In the treatment, a prominent indication is, to remove spasm; which is best accomplished by the relief of Slight myopia. the pain and the removal of the constipation. Opium in some form is demanded. The patient, having taken it on former occasions, is aware that it will relieve, or at least mitigate, his sufferings, and will therefore insist upon getting it. If he be "an old toper" (as he is apt to be) he will whisper to you in a confidential way (implying much more by the spasmodic contractions of the facial muscles than mere words could do) for the bottle, you know-referring to some former prescription which you may have given him, containing opium;

Irides are pale gray: pupils habitually a trifle dilated; urine contains no albumen; heart healthy. Patient suffers much from epistaxis, in summer mostly.

There are three main points of interest in this case. First, the extremely sudden formation of the oedema

*This calculation is made upon the rough basis of 18 in. English to 1 ft. Paris measure.

and which doubtless he has had often "renewed" from the label on the bottle, by the accommodating apothecary, without your authority or written order. Such a patient will sometimes require large, repeated doses to give him the desired relief, and not unfrequently it will be pushed almost to narcotism without producing the desired effect. How frequently does it happen during the hot sweltering days of summer, when we are called to these cases, to find that doctor succeeds doctor, each giving his dose of opium, without at all subduing the spasm. The patient consequently loses faith in the doctors, as well as in medicine, and at last falls a ready prey to despondency. Why should this be the case? I answer that it is in some measure due to the unphilosophical mode of prescribing-too common, I regret to say, amongst many of our brethren, whose usual practice it is, not to overtask their brain by reflecting too deeply on the indications which may be present in such a case, preferring to use a routine prescription, and let it hit the mark or not, kill the patient or cure him, as the case may be.

Now, what are the broad, palpable indications in such a case as I am relating? Why, use that remedy which will soonest reach and relieve the engorged capillaries of the portal system; and I know of no remedy under the circumstances that will fulfil this indication equal to calomel, of course in cathartic dosés, since the susceptibility of these old stagers to the action of mercury in small, repeated doses, is always to be considered. But where there did exist a decided susceptibility to the effects of mercury, even in cathartic doses, podophyllin, with the extract of conium (the latter as a corrigent), may be conveniently substituted. Should the alternative present itself of prescribing calomel, or dosing the patient with opium to any extent, regardless of the probabilities of its proper absorption or the existence of a local impediment, I would deem it more practical to prescribe the former remedy than the latter, especially in the commencement of the disease. After giving a dose of calomel, should it not have the desired effect as soon as expected, I would use injections, and externally chloroform. The portal circulation being relieved of its engorgement, and the loaded colon of its impaction, the patient will generally rest comfortably the better, perhaps, on account of a hop pillow, which I generally suggest in these cases. All these means failing to compass sleep, I would then resort to an opiate, with a reasonable expectation of success, since the purgative has prepared the way for its more ready absorption.

taken a warm bath, and had recourse to repeated injections, without relieving the obstinate constipation; he had also been pretty freely dosed with opium, without any appreciable effect. The condition of the poor fellow at the time was truly pitiable-tossing about the bed, screaming at a furious rate. In a word, every feature of the case was serious, and a fatal result seemed inevitable. The mother, a French woman, with all the demonstrativeness of her race, ran around the room wringing her hands and begging me to save her son. The young wife, with a babe a few months old, quietly, but none the less earnestly, joined in the appeal to my sympathy. I at once resorted to the external application of chloroform, a remedy which had served me most happily on former occasions. This afforded a little relief. I could, I fancied, feel the hardened muscles relax. The immediate effects, however, having passed away, the contractions of the muscles were apparently as hard as ever. I then exhibited it internally, combined with ammonia, tincture of opium, etc., when the hardened muscles relaxed, and the spasm departed. The irritation of the stomach was subdued to such an extent that a little nourishment was ordered. The injections then being repeated, a copious action immediately followed. Suffice to say, that the patient's recovery was very rapid-a slight aperient and tonic for a few days, comprising all the treatment before he was able to resume his work. The point of special interest in this case is, the effect of chloroform in gastric irritability, which in this instance was extreme, and extended over a period of several hours. Its efficacy in lead-colic is a well-established clinical fact, and on this account I relied confidently on the relief which followed its administration. But I deem it worthy of record that here it also promptly relieved the irritation of the stomach.

The second case was that of a young lady, who consulted me, last August, regarding a constipation which had extended over a period of two years. Drastic medicines had been used in almost every possible combination, with but temporary relief, and the usual sequel of impaired intestinal tonicity. Before the interview, however, her guardian and relative, a distinguished gentleman in one of the Eastern States, con-` sulted me relative to her general health, stating that she had had no motion of the bowels for a fortnight, while irritability of the stomach had existed to such a degree that for several days previous she had been unable to retain even a mouthful of food. He also stated that several of the most distinguished physicians Desiring to be as practical as possible, I shall call in the Eastern States, after a fair trial, had utterly your attention to only two cases, which I have selected failed to master her case. This consultation with myas typical of their class. The first was a case of lead- self took place about a week after her return from colic. The patient, my immediate neighbor, a house- Europe, whither she had been sent for the combined painter, twenty-eight years of age, informed me that benefits of a sea-voyage and change of air, but only to he was attacked with pain and uneasiness of the be disappointed. Whilst abroad our patient consulted bowels shortly after engaging in his daily labor early an eminent Baronet, who gravely gave out that the in the day. Referring all his trouble to an habitual pain, debility, etc., were due to "weakness of the constipation, he determined "to fight it out, without spine, consequent upon the out-growing of her knocking off," as he had done on many previous occa- strength," and contented himself with the local apsions. The pain and uneasiness of the bowels increased, plication of tincture of iodine. I named the following however, to such an extent that necessity conquered afternoon for a personal interview. I was then not a his will, and compelled him to call in medical aid soon little surprised at her appearance. Her countenance after reaching his home. When I saw him at 4 P.M., was full and of a ruddy hue, showing no deficiency in which was on the 12th of last July, he was suffering the red globules of the blood; nor any marked defifrom a violent pain in the bowels, accompanied with a ciency of adipose tissue. Her figure was large for her spasm of the abdominal muscles, so terrible that they age-which was but seventeen. She was in brief a were twisted up in knots "as large as your fist," if 1 girl in years-a full-grown woman in development. In may be pardoned the use of an expressive, though not addition to all this, she possessed a rare intelligence, classical phrase. The contortions, in fact, resembled and exhibited a rare candor in her answers, admirable to the eye hour-glass contractions. He also had vom-in one so young. In reply to my queries regarding ting and a very slow pulse. Before my visit he had the menstrual function, she stated that she suffered