of the thorax, by attending to the appearances exhibited by the urine. When a purulent fluid is present, there is usually more or less of evening hectic; and it is found that the discharge of such a fluid with the urine generally occurs during the night. The irritation of the urinary passages from the elimination of pus by the kidneys is sometimes very considerable, and may even induce slight Nephritis. In a few cases of pleural effusion, we have seen a decidedly purulent discharge from the bowels; but this is much less frequent than from the kidneys.

In reference to the use of Digitalis, our author remarks that its effects require to be very attentively watched, especially in old people; for in them it is apt to induce not only an alarming weakness, but a positive wasting and marasmus-probably by its acting injuriously upon the nervous system and the organs of digestion. The cautious physician, therefore, will never omit diligently to ascertain the state of these parts, during, and for some time after, the administration of this potent medicine. The preparation, which Dr. S. considers one of the best, is the acetum digitalis; the exclusion of which from the late edition of the Prussian Pharmacopoeia, he very much regrets.

When all, or nearly all, the pleural effusion in the present case was absorbed, the patient began to complain of pain in the intercostal space between the eighth and ninth ribs on the right side. That the albuminous or fibrinous contents of the effusion-and these are often in the state of coagula or large flocculi-may act in some degree as foreign bodies, when all the fluid portion has been drawn off or absorbed, is not at all improbable; and perhaps such was the case in the present instance. However this may be, it will always be prudent to arrest at once the very earliest symptoms of a serous inflammation; for it is truly remarkable with what quickness (in the case of the Peritoneum still more so than in that of the Pleura) the disease spreads. Accordingly, a small quantity of blood was taken from the seat of the pain by cupping, and the use of the Digitalis and Nitre was resumed, until all the symptoms of uneasiness were removed. The patient eventually was restored to health.

In the next case, the Pleuritic Effusion (the presence of which had been quite overlooked by the medical man who first saw the patient) was on the left side, and to such an extent that the Heart was pushed considerably over to the right side, so that it was felt to beat behind and at the right edge of the sternum. The usual subjective and objective symptoms were tolerably well-marked. The diaphragm was considerably pushed down, so that the epigastric region was more prominent than in health, and pressure there occasioned a sense of oppression and distress.

Nearly the same remedies were used in this, as in the preceding, case. As there was reason to believe that there was still some degree of inflammatory congestion in the lower lobe of the left lung, a small quantity of blood was taken by cupping. The following mixture was prescribed :— B. Infus. herb. Digitalis (gr. xij.) živ.

Nitri depurati,

Kali acetic. aa Zij.

Syrupi Mannæ, 3j. M.

A table-spoonful to be taken every two hours: Selzer water for common drink. The left side was ordered to be rubbed with an ointment composed of mercurial ointment, hydriodate of potash, and digitalis.

Two or three days subsequently, the bronchitic symptoms being aggravated, the patient was bled from the arm to a small extent and with decided relief. An attack, having somewhat of the character of delirium tremens, supervened, and necessarily rendered the prognosis rather more unfavourable. It became, therefore, very seriously the question whether we should continue to trust to the action of the remedies in use for the removal of the water, or have recourse at once to paracentesis for its evacuation. The results of Dr. Skoda's experience in this operation have been so very unpromising* (two-thirds of his patients died and generally too in consequence of a fresh accession of the Pleuritic disease), that there is certainly not much encouragement for its performance. Fortunately, it was deemed wise in our case to defer having recourse to it; for the thoracic symptoms began speedily to subside under the operation of the remedies employed. On the whole, Dr. Schoenlein seems to be anything but favourable to the operation of Paracentesis in cases of pleuritic effusion, more especially when there is reason to believe that flocculi of coagulable lymph are present, or floating about in the effused fluid; for, in his opinion, the presence of these flocculi not unfrequently excites inflammation of the pleura, after the serum has been drawn off by puncture. It may, indeed, be objected that the same thing must take place whether the fluid part of the effusion be removed by absorption or by paracentesis; but to this it may be answered that, in consequence of the slow and gradual removal of the fluid in the former case, the contact of the flocculi with the surface of the diseased pleura can never excite so much irritation as when the water has been suddenly drawn off all at once by operation. Moreover, it seems not at all improbable that they may undergo a partial dissolution and absorption, just as we observe to take place with the coagula of blood in the Brain in certain cases of Apoplexy.

The progress of this case was, on the whole, in spite of several unpleasant occurrences, pretty favourable. The quantity of the effusion gradually diminished under the use of the mixture (a drachm of the Muriate of Ammonia had subsequently been added to it), so that the heart began to resume its natural position on the left side. The patient left the hospital, before he was completely cured: the level of the effusion however had already sunk below the left nipple.

As illustrative of the general question of Pleuritic effusion, and of the propriety of not hastily having recourse to a surgical operation for its withdrawing, the following very interesting Report deserves a place here.

Phthisis-Rupture of a Vomica-Effusion of Gas and Air into the Pleura— Paracentesis Thoracis-long survival of the patient.

"The displacement of the heart, Ectopia Cordis, from the effusion of fluid into the left sac of the pleura, was very conspicuous in a case of Hydro-pneumothorax-the result of a phthisical cavern in the upper lobe of the left lung becoming suddenly ruptured-which once occurred in Dr. Schoenlein's practice. The heart was found beating at the right side of the sternum; and, according to the patient's statement, this had taken place in the night, immediately after a

* Oester. Med. Jahrbucher. Januar-Juli, 1841.

severe fit of coughing. The place of the rupture was probably closed, for a time at least, by a false membrane. There was but little fever present, and the dyspnoea was so inconsiderable that it was deemed prudent to delay the performance of paracentesis for some time, and to try the effects of remedies in causing the absorption of the effused gaseous and purulent matters. Accordingly, the infus. Digitalis was prescribed, and the affected side was diligently rubbed with an ointment, composed of ung. mercurial. Zij., ung, kali hydrojod. 3j., and ung. Digital. 3j. At first, the use of these means seemed to be attended with benefit; but this was only temporary. A decided fulness, amounting almost to a pointing, became perceptible in the ninth intercostal space on the left side. Here, therefore, an incision was made into the cavity of the pleura; between six and seven quarts of purulent matter flowed out. The immediate effects of the operation were satisfactory; for the dyspnoea and oppression were very much relieved. It seemed however that the rupture in the lung again opened shortly afterwards, as a fresh accumulation of pus took place in the pleural cavity: and the wound was therefore kept open, to permit the free exit of whatever was effused. As might be expected, the patient gradually became worse and worse. He survived however for six months after the bursting of the vomica, and for nearly two after the performance of the operation. On dissection, the left lung was found much shrivelled and contracted; on its under surface there was a rupture, so that a free communication was established between one of the bronchi and the cavity of the pleura, which still contained an admixture of gaseous and purulent matters the right lung was full of tubercles."

Here we must close for the present our analysis of this truly valuable work we shall probably resume it in our next Number, as there still remains more than a half of its contents unnoticed.

THE TRANSACTIONS OF THE PROVINCIAL MEDICAL AND SURGICAL ASSOCIATION. Vol. XIII. 1845. 8vo. pp. 417.

THE present volume of these "Transactions" is not equal, in the interest and importance of its contents, to some of its predecessors, although much superior to them in all that relates to the "getting up." There are five communications.-1. A Retrospective Address, by Dr. Cowan, upon the Progress of Practical Medicine. 2. A Retrospect of Anatomy and Physiology for 1843-4, by Dr. Budd, of Bristol. 3. A Paper upon Inflammation of the Retina, by Dr. Hocken. 4. An Essay upon Inversion of the Uterus, by Mr. Crosse, of Norwich; and 5. A Case of Malformation of the Urinary Organs, by Mr. Giles of Stourbridge.

The two Retrospects are ably written, especially that by Dr. Budd; but treating of by-gone things, most of which have already come under our review, they demand no detailed notice at our hands. There are, however, some of the introductory and incidental observations which we are desirous of placing before our readers.

The following passages exhibit Dr. Cowan's view of the present position of medical science.

"The science of medicine may be said to be now emerging out of infancy into manhood, to be gathering up the copious generalisations of the past, and submitting them to the ordeal of inductive examination, to be testing hypothetical

assertion in the stern crucible of experiment and observation, and to be giving to language an accuracy and a limitation of which before it was insusceptible. We are, in fact, engaged in reducing an art into a science, and are arrived at the period of maximum difficulty and toil. The elements in our hands are fashioning and shaping for future forms; but, though we can vision the dim outline of a higher and nobler erection, there is yet too much movement and bustle for accurate measurement of what we are accomplishing; things new and old are strangely commingled, and impediments arise from the very number and zeal of the artificers. There never was a period of such sudden excitement, such extensive and simultaneous activity. The unexampled development of the contributory sciences has furnished fresh and unexpected instrumentality for pathological inquiry, and compelled renewed investigation in accordance with the nature of the means now in our possession."

After alluding to the effect which recent chemical and microscopic research, and the revived attention to humoral physiology and pathology have had in indicating the defects of our already acquired information, and in at once extending our sphere of acquirement and the number of our resources, Dr. Cowan continues :

"Another most striking feature of our present condition is the unexampled facility afforded by the press for the expression and diffusion of thought. Every idea now finds an easy channel for utterance; in our periodicals and other publications encouragement is given for the most fleeting expression of opinion; and investigations, whether trivial or important, are equally honoured by publicity. The necessary consequence has been, that evil has been mingled with the good; our literature has become most inconvenient from its bulk, full of crudities and endless repetitions, heterogeneous and fragmentary in character. The student is wearied and confused by the very extent of the surface, the exercise of thought is impeded by so continued a draught upon his powers of acquisition, and what s original and vigorous in the mind is too often repressed or entombed. The natural tendency upon an ambitious spirit, if not of the highest and most comprehensive order, is to over-stimulate and exhaust its energies in the mere effort to acquire, to consume beyond the power of digestion, and either to rest with shvish dependence upon the dogmas of others, or escaping from what is felt impessible to reconcile, to pursue the path of ignorant self-reliance, reckless of all authority and experience.

"We are kept in a constant state of expectancy and interrogation: doubt pervades every thing, and truths which ages have confirmed are exposed to assailants of every form and dimension, boldly requestioned and challenged by the experimenter of a day. Our periodical literature, and more formal treatises, inconveniently and undesirably multiplied, teem with detail and assertions of the most superficial and contradictory character; yet all, as in olden times, based upon fats, and raised to a higher nominal authority, because supposed to be founded upon a purer indicative philosophy."

That the great facilities, and even inducements, which the numberless medcal periodicals now offer for whosoever is willing to appear in their colunns (whether in the shape of an original article, a case with endless observations, observations without any case, or in the hundred ways in which their voluminous pages are now filled), are attended with considerable evils, there can be, we suppose, no doubt. In this way, the superficial and incompetent are placed in an unduly prominent position, a feverish anxiety for premature publicity is engendered, and even the really competent ae deterred from bestowing that thought, care, and re-examination of

their productions, which would be considered but due were they destined to appear in a less fleeting medium. But, on the other hand, we must not forget that, without such facilities, many really valuable communications would have never seen the light, and that they form an excellent means for the wide diffusion of the knowledge of the improvements in the more practical portions of our art. We may observe, en passant, that the truth enounced by the Reporter in a subsequent part of his address-“ A much smaller number of medical periodicals, if truthfully and energetically conducted, might be most advantageously substituted for their, at present, most inconvenient multiplication"-does not appear with the best grace when addressed to the proprietors of one of the youngest of the family— whose pages, too, have been subsequently opened for the reception of articles in defence of the ultra-pretensions of Mesmerism.

Notwithstanding the, in some respects, chaotic state of our accumulating materials, Dr. Cowan justly observes, that our condition upon the whole is one of progress.

"While making these remarks, we are not overlooking the far more gratifying and unquestionable consideration, that medicine, both as a science and an art, is really advancing; that the labours of a few master-spirits, particularly during the past half-century, have astonishingly extended our knowledge of the nature and seat of disease; that we are in the possession of a discriminating power in diagnosis and treatment, to which our predecessors were strangers; and that, provided as we are with new instruments of research, and furnished with additional therapeutic resources, we may yet calculate upon much increase beyond what has already been attained. But, still, it is no less true that we have our disadvantages, and there are clouds which bedim the horizon of our future prospects.

"We are too apt to forget that the great work we are now engaged in is rather that of explanation or development, than of discovery; the clearer illus tration of what is old more than the revealing of what is new; reducing into accuracy of classification and expression what was before only general and vague, and demonstrating the soundness, not the absurdity, of many of the ideas and conclusions of our predecessors. We must not estimate our present progress by mere numbers, opportunity, or zeal, nor suppose that the multitude will ever be directly instrumental in the extrication of truth. No: this holy and glorious mission will ever be the privilege of the gifted and laborious few, and its acconplishment be impeded rather than advanced by the undue multiplication of labourers. However excellent the system we adopt, however perfect the schene of our enquiries, the true value of results must ever chiefly depend upon the power and qualifications of the observer. Few, very few, possess these to he requisite extent, and hence we are daily overwhelmed with materials too incomplete and amorphous ever to become the foundation of scientific induction."

There are some useful observations also upon the inefficiency of the numerical method as applied to practical medicine. The ever-changing and complex character of the phenomena of disease render resort to it impossible or unsafe.

"Though strongly advocating the utmost possible extension of numerial research, substituting as it does the accurate for what is vague, and regarding its varied and extensive applications at the present moment as among the distinctive peculiarities of our times, we yet feel that in the practice of medicine is uses are limited, and that there are evils as well as benefits resulting from its undue application. Not only is it incapable of preserving us from mistakes as egregious as any which have been fostered under the less definite sanction of experience,