10th. Emp. Lyttæ Nucha. Pulv. 8vis horis. 11th. Thoracic symptoms much the same; abdomen distended; restlessness. Mist. Assafoetida, ziv. pro Enemate. Perstet in Pulv. bis quotid. 14th. A second enema thrown up yesterday: on each occasion restlessness quieted. Hooping now frequent. 15th.-Fixed pupils and comatose aspect induce me to apply one leech to the temple. From this very free bleeding took place, with immediate convulsions, additional coma continuing till death, which occurred at noon on the 16th. POST-MORTEM.-Brain large and firm; convolutions unusually deep; no effusion in ventricles; general character rather exsanguine, but not abnormal in any other point. Greater part of both lungs noncrepitant, of a nutmeg colour, generally softer than the usual character of hepatised or carnified lung. Pleura opaque, with a remarkably soapy feel on being handled. A large white polypus on the left ventricle of the heart. No other abnormal appearance. In this case it may be conjectured, that the cerebral phenomena observed during its latter period resulted from an imperfect supply of blood, and that the abstraction of a part of this supply aggravated the fatal symptoms. The hypothesis, therefore, of cerebral congestion was erroneous. Much of the utility of blood-letting in cases of congestion is brought out by a judicious use of preparations of iron after it; and the converse is true in cases indicating the latter remedy; for it will often prove ineffectual, until the system has been moderately relieved by the lancet. In a case of acute nervous pain at the vertex of the head, in a middle-aged unmarried lady of full figure and florid countenance, but small pulse and torpid circulation, every form of tonic had been tried, with a judicious use at the same time of aperients and alteratives. I applied once several leeches to the vertex; after this, the use of tonics and antispasmodics cured her. Something, no doubt, was due in this case to the position of the leeches: she had before been depleted from the arm, and by cupping, without any benefit. I shall take leave of this interesting subject with the following extract from the posthumous work of Dr. Perry, with which my own experience coincides, in its yet more extended application to bleeding for cerebral congestion. Difference of effect between small and large bleedings in Hemiplegia.-When Dr. H., who was about 70 years of age, was seized with hemiplegia, in which he totally lost the voluntary power of his arm and leg, I ordered him to be cupped. only a few hours after the seizure. ration was performing, when only four ounces of blood This was done While the ope had flowed, the power of voluntary motion returned in his limbs; but again vanished by the time ten ounces had been taken.' The lesson, however, here conveyed must be read with caution, in regard to the inference which it may appear to warrant. * Medical Writings of the late C. H. Parry, M. D., vol. i. p. 474. CHAPTER XII. SCARLATINA MALIGNA. : AT the commencement of this record of cases, I have pointed out an expediency which attaches to such records, apart from any value that they may claim from novelty of communications ;-namely, as supplying or rather contributing to the great stock of materials from which every day's practice is drawn. Nosological descriptions supply, indeed, the points essential to the type of each disease, and would be illogical if they travelled into non-essential matter. They are, in fact, diagrams, and, as such, perform a function on the importance of which I need not expatiate no one can safely advance into practice, or even use his own experience without risk, unless thus instructed in general principles. But, after all, it is from individualised cases of his own, or others, that he immediately obtains those portraits which he must copy in his practice; and that man cæteris paribus is the best practitioner, who, having been enlightened by a just nosology, can bring to bear the largest number of remembered facts. Hence the value of a record of cases; about the novelty of which, by the way, we need not be anxious, if we give them honestly, for no two cases ever were alike. Lady H., aged 54, of a full and flaccid person, long subject to hysterical affections, was attacked by rigors, soreness of the throat, and extreme general uneasiness, on the 7th of February, 1841. She had been attended by a judicious general practitioner to the 10th, on the evening of which day I saw her with him at nine. The pulse and temperature of the skin were low; the tongue dry and brown; the tonsils of a purplish hue, slightly enlarged, with some coagulable lymph on their surfaces; the face pallid and sunken. I observed a slight redness on the arms and chest-so slight that it seems never before to have attracted attention; still its character appeared to both of us decisive on careful examination. I learnt that the bowels had been acted upon by several aperient doses, and that eight grains of calomel had been given. If we had not possessed this evidence of the presence of scarlatina, we should still at that period have considered the patient in great danger, on grounds afforded by the tongue, pulse, and temperature. Her consciousness, I should observe, was then unimpaired; but I understood that during each night she had been occasionally delirious. Sinapisms were directed by us, the decoction of cinchona, with the sesquicarbonate of ammonia, and other cordials, freely given during the night, and at an early period of the morning we had the advantage of Dr. Latham's advice in favour of this system. But the patient sunk rapidly, and the case terminated by half-past 12 P.M.; not the slightest reaction having taken place. No autopsy was permitted. On the 21st of March, more than five weeks after this event, in the same house, a son of Lady H., a fine, |