has not seen?) the agony and distress occasioned by severe and repeated headache, but must rejoice in having the power of affording relief in so prompt and simple a manner.

II.

Acute Laryngitis treated by Injections into the Larynx and Trachea. By W. H. SHERWOOD, M.D., Unionville, Ohio.

[New York Medical Journal, June, 1868.]

As no case treated in this manner has yet been made public, I will describe the present one as minutely as possible, hoping that success in this instance may lead to a new form of treatment of diseases of the air passages.

The patient, Mr. H. W., is unmarried, æt. 26, five feet eight inches in height, of slender stature, light brown hair, blue eyes, and fair complexion; his pulse 110, blue tinge around the gum, scantiness of hair on the chest, finger nails incurvated. I saw him for the first time Feb. 20th, 1868. His head was thrown back, and he was suffering from extreme dyspnoea, and inability to articulate above a whisper, and difficult deglutition. After ascertaining the history of the case I learned he had had several attacks of hæmoptysis, with a cough attended with purulent expectoration. Notwithstanding he was somewhat emaciated, there were no marked hectic symptoms. Over the left subclavian region pectoriloquy was perfectly distinct, with amphoric respiration; his right lung seemed quite free from any tubercular deposit.

Seeing him in this painful condition, and thinking that the ordinary remedies at least were unsatisfactory in their effects, I resolved to employ a method which I had dwelt upon for some time past, namely, to apply an astringent solution directly to the inflamed membrane. On account of the apparent uncertainty of introducing a solution through the rima glottidis, as recommended by BRETONNEAU, TROUSSEAU, and by American surgeons such as HORACE GREEN and J. WARREN, I determined to inject the larynx by piercing the cricothyroid membrane by the point of the hypodermic syringe, which operation I performed after previously rendering the parts insensible by means of rhigolene passed through an atomizer. After passing the longest tube of the hypodermic syringe without difficulty into the larynx, half way between the upper border of the thyroid and the lower edge of the cricoid cartilage, and exactly in the mesial line, my assistant, Dr. M. P. BRAINARD, filled the hypodermic syringe, holding one-fourth of an ounce, with a solution of nitrate of silver containing five grains to the ounce. The tube was then screwed onto the syringe and the solution thrown into the larynx. duced not so much strangling as is witnessed after the introduction of the sponge by the mouth, and was shortly followed by coughing, with expectoration, and marked relief. I prescribed three drops of veratrum viride, to be taken once in six hours, and ten grains Dover's powder at bed time. Upon seeing him the next day, the dyspnoea and difficulty of deglutition had nearly ceased, and he was quite cheerful. I directed him

This pro

to take one tablespoonful of cod-liver oil three times a day, and made an issue under the left clavicle.

I then determined to treat the existing tuberculosis by means of injection. On April 21, 1868, at 2 P. M., assisted by Dr. M. P. BRAINARD, I injected the lungs by piercing the trachea between the cricoid cartilage and the isthmus of the thyroid gland, and injected a solution composed of ten grains of argentum nitras to the ounce. I found that this produced no dyspnoea, but was followed by some cough and expectoration. He was ordered to continue his constitutional remedies as before. When I again saw him, he was somewhat improved, cough less harassing, pulse less frequent, and felt a little stronger; consequently, on April 27, I injected as before, with similar results.

As the patient will continue under my treatment, I will take notes and publish them hereafter; but I consider this sufficient to demonstrate that medicines can be injected into the larynx and lungs through the trachea with impunity. This method saves the uncertainty and danger of inserting a tube or sponge into the rima glottidis, and is simple and painless in its performance. For the treatment of laryngitis in my hands it has proved successful; and its trial in diseases of the air passages is urged.

12. Syphilitic Ulceration of the Throat treated with Sulphurous Acid. By H. S. PURDON, M.D., Physician to the Belfast Dispensary for Diseases of the Skin, etc.

[British Medical Journal, May 9, 1868.]

Mr. Robert W., æt. 30 years, consulted me on August 17th, 1867, for a hard chancre of a few days' duration, situated at the corona glandis, which I touched with strong nitric acid, and prescribed “black-wash” as a local application, with the green iodide of mercury internally. Under this treatment, he was apparently cured, and I lost sight of him till the following November. I may mention he told me that about four years previously he contracted a chancre, which was quickly followed by a bubo. The medical man he then consulted prescribed "Plummer's pill," which occasioned profuse salivation. I again saw him in November, and found that he was laboring under a syphilitic affection of the throat, both tonsils and part of the pharynx being covered with an ash-colored slough; he experienced great difficulty in swallowing, appetite bad, passed sleepless nights, and was extremely anxious about his present state of health; no cutaneous eruption visible. For upwards of eight weeks various remedies were tried; viz., iodide of potassium, in ten grain doses three times a day, the bichloride and biniodide of mercury, gargles of chlorate of potash and alum, and solution of the nitrate of silver, twenty grains to the ounce, with opium at night to procure sleep. This treatment only checked the spread of the disease, which remained in statu quo till the middle of January, when I happened to see recorded in the Lancet, for October, 1867, a case, in which a patient of the London Hospital was treated for syphilitic ulceration of the throat by the application of sulphurous acid spray. I thought Mr. W.'s case likely to benefit by the

same treatment, and commenced using the spray to the affected part three times daily on January 25th inst. At first I applied it for a short time only, but, finding that it gave no pain, the end of the instrument was brought nearly in contact with the part affected, and the application of the spray continued for several minutes each time. On Saturday, February 15th, the throat was perfectly well, and there has not been any return of the disease since.

I have at the present time under treatment a gentleman suffering from a syphilitic affection of the tongue, in which I am applying the sulphurous acid spray with the best results.

13.

Treatment of Disease of the Mitral Valve. By Dr. J. ANDREW. (St. Bartholomew's Hospital Reports, vol. II. London. 1867.)

[Amer. Journal of the Medical Sciences, July 1868, p. 220.]

In the treatment of mitral incompetence there are three principal indications, to the more or less complete fulfilling of which our success will be proportioned.

I. To diminish, as far as possible, the sum total of the blood in the body; for a heart which is unable to transmit a certain quantity of fluid in a given time may suffer little or no embarrassment when called upon to deal with a smaller quantity only. This is best accomplished by a diet nutritious but restricted, especially in respect of the quantity of fluid which is taken. This restricted diet is further advantageous by diminishing the risk of over-distension of the stomach and the consequent mechanical interference with the cardiac and respiratory movements.

2. To maintain the nutrition of the heart and its muscular power; for by doing so we shall obviate to some extent hypertrophy and dilatation with their attendant evils. The continued use of some preparation of iron-the tinct. ferri perchloridi is, I believe, the best-will be of the most essential service; but if the iron can not be borne, quinine or the mineral acids must be substituted for it.

3. To diminish the frequency and energy of the heart's action. When regurgitation takes place through the mitral orifice, the more numerous and forcible the pulsations of the left ventricle the greater will be the distension of the left auricle and the congestion of the lungs. The patient must religiously avoid all excitement, fatigue, or muscular effort; but the benefits of rest will be greatly increased by the use of digitalis in doses regulated by its effect on the pulse. With proper care it may be employed continuously for long periods without any untoward symptoms being produced by it. A belladonna plaster on the cardiac region sometimes appears useful.

By this line of treatment we may often do a great deal more than merely palliate the symptoms of heart disease produced by mitral incompetence. But if it is to be effective it must be persevered in for months, and even years, and, above all, must not be lightly exchanged for measures intended to relieve such symptoms as dyspnea and anasarca. There is no other

class of cases in which the temptation to employ means which yield immediate relief is greater, none in which such temporary expedients inflict more permanent harm. If the nutrition of the heart be once impaired, it is too often impossible to redress the injury thus sustained. Of this a sufficient proof is afforded by the numerous cases in which valvular disease exists for many years without causing any serious annoyance, until on the occurrence of some debilitating disease or of profuse hæmorrhage, distressing and fatal symptoms are at once developed.

14.

The Auscultation of the Oesophagus as a Diagnostic Means in its Diseases. By Dr. W. HAMBURGER, Bohemia.

[Med. Jahrbücher, Vienna, 'xv, Heft 2, 1868.]

The author refers to the obscurity of the diagnosis of œsophageal affections, which he likens to the condition of the diagnosis of thoracic diseases previous to the introduction of physical exploration. The diseases of the esophagus are so barren of symptoms, our present means for their diagnosis are so insufficient, that the necessity of augmenting these resources is obvious. The sensibility of the esophagus, excepting its most superior portion, is very small; it is supplied with few sensory nerves and few vessels. It is clear that its abnormities must produce but few external evidences. There are really but two symptoms likely to betray the presence of œsophageal diseases; viz., pain and dysphagia,―i. c., altered sensibility or altered function; and even these are little calculated to give much information. Pain is not often present in disease of the sophagus; even cancer is here frequently painless. The seat of pain, moreover, it is mostly impossible to state with accuracy. And, on the other hand, pain and other abnormal sensations are often referred to the gullet, when the latter is perfectly normal. Difficulty of swallowing is not any more reliable as a diagnostic symptom. Above all, it must be remembered, that in nine cases out of ten, this phenomenon is not a symptom of affections of the œsophagus, but of other more or less distant organs. Of these may be mentioned inflammations of the tonsils, nutritive lesions of the thyroid, retropharyngeal abscess, ancurisms of the aorta, pericardial exudations and cardiac hypertrophy, tubercular infiltrations about the bifurcation of the trachea, etc. Cancer of the lungs and pleura often cause dysphagia. The same symptom is caused by alterations in the nerve centres, by specific irritants of the nervous system (e. g., the hydrophobic virus), etc. On

the other hand, in some organic affections, as dilatation, of the œsophagus, dysphagia may be entirely absent.

The only means left, then, when these symptoms prove unreliable, for the exploration of the œsophagus, is the œsophageal sound. This the author calls, not a two-edged, but a manyedged sword; it is capable of doing great mischief, while it is insufficient in many affections, and in others capable of leading into error. Nevertheless, the author concedes that the instrument is indispensable; but it is only by means of auscultation that it is robbed of its dangers and made available for diagnostic and therapeutic purposes.—

Every solid or fluid morsel in being swallowed produces a certain sound (noise, murmur, Geräusch,) which may be detected by applying the stethoscope or ear close upon the denuded body. The cervical portion of the œsophagus is examined on the left side of the neck, the thoracic portion to the left of the vertebral column, while the patient is directed to swallow a spoonful of water; the latter is preferable to solid morsels for purposes of experiment; the quantity must amount to at least a tablespoonful to make the noise produced sufficiently distinct. The œsophagus should be auscultated in its entire length, from the level of the hyoid bone to opposite the Sth dorsal vertebra. By a little practice it is easy to become so familiar with what is perceptible by the senses in the act of deglutition, that deviations. from the normal are easily detected.

In health.-I. Applying the stethoscope near the hyoid bone in health, (auscultation of the pharynx), a loud sounding gurgle is heard, with the sensation as if the mouthful of water was forcibly thrown into the ear of the observer. This sound is produced by the sudden compression of air and water in the pharyngeal space-hence its metallic ring and sonorous character. It becomes less audible and fainter, the farther down the neck we apply the stethoscope.

II. In auscultating the œsophagus from the level of the cricoid cartilage to the 8th dorsal vertebra, we may hear during deglutition how a small, but firm spindle-shaped body is firmly enclosed by the œsophagus and rapidly pushed downward with a sound. The author explains: (1.) The morsel (meaning the quantity of water propelled by a single act of swallowing) is compressed by the circular contraction of the esophagus into one compact body.