332 the rule, and practitioners will be very much disappointed if they expect it to be uniformly successful. I have just received a letter from the country evidencing how useless it and all other remedies have hitherto proved in controlling the more severe paroxysms; still the cotyledon is a remedy which does undoubtedly occasionally effect a cure, and especially in the milder forms of epilepsy. -, aged twenty-two, tall, muscular, and well-formed, was seized with a rigor, followed by the usual

more »

... ymptoms of inflammatory fever. Temperature high; skin moist; face covered with profuse perspiration; pulse quick, firm, and full; thirst; irritability of the stomach; excessive headache, with a tendency to sopor; coughed up a little sputa, rusty, or rather streaked with blood. Had been bled from the arm to about twelve ounces by Mr. -, who also had prescribed a purgative and a diaphoretic mixture. Such were the circumstances of this case previously to my visit, which took place about eight hours from the period of attack. Upon examining the patient I found the above symptoms present in an aggravated form, the headache being intense; respiration much hurried; slight cough; vomiting; chest clear on percussion anteriorly, with rather puerile respiration; laterally, and between the shoulders, percussion and stethoscope discovered nothing further than a louder breathing than natural. Abdomen free from pain; in fine, no particular pain otherwise than that of the head; no wandering of the mind. The purgative had acted; the venesection was repeated: the diaphoretic continued ; calomel every six hours; hair off, and cold to the scalp. Second day.-Nine A.M.: No abatement of symptoms; headache increasing; respiration quicker, every second or third expiration being accompanied by hiccup. Four ounces of blood was taken from the temporal artery to relieve the headache, and Dr. S-, who was requested to see the patient at ten P.M. of the same day, diagnosed abscess of the liver, and drew attention to a bruit with the first sound of the heart, which he attributed to the loss of blood. The mercurial and antiphlogistic treatment was relinquished, and a sustaining line adopted. A blister was applied over the right hypochondriac and the epigastric regions. The case progressed, daily getting worse; stomach rejecting everything; hiccup accompanying every respiration; intellect perfectly clear; no sleep. The entire waist against the diaphragm was surrounded by a belt of blisters, and about three days before death it was again ineffectually attempted to bring the system under the influence of mercury. The patient died about fourteen or fifteen days from the commencement of the attack, the hiccup persisting to the last, and pus was supposed to have been seen in the dejections, but which I believe to have been fallacious. The patient throughout could not lie in the horizontal position. L-, aged twenty-one, stature five feet four inches, muscular, lathy, well made; seen three days after seizure; pulse 112, firm; respiration much hurried, and entire inability to rest in the horizontal position; no cough; temperature moderately increased; tongue moist, coated; thirst; excessive vomiting, and constant harassing hiccup; no yellowish tinge of skin or conjunctivæ; no headache; anxiety of mind; chest clear on percussion anteriorly, also posteriorly on the left side, but in the right, internal to and below the scapula, extending a few inches towards the sub-mammary region, there was dulness; a rubbing sound and very indistinct respiratory murmur immediately above; the breathing was much increased. The fullest inspiration caused no pain further than by aggravating the hiccup, yet by digging the fingers into the intercostae a severe lancinating pain was produced over that part. The bowels previously opened by domestic medicine. Treatment : bloodletting, repeatedly blistering the part; the entire chest rubbed every three or four hours with oil of turpentine, and the system brought under the influence of mercury, which was effected principally by inunction, as the stomach rejected everything. The hiccup persisted for seventeen days, gra dually giving way as the salivation advanced, and pari passu with the chest symptoms. Cured. C, aged fifty-six, a thin, delicate man, a blacksmith, but had relinquished his trade lately; had been suffering from constant hiccup for upwards of eight days previously to my visit, and for which he had had almost every variety of anti-spasmodic, &c. Symptoms : The right, pleura and lung affected as the cover and rest on the diaphragm above the liver; pain of right side and shoulder, extending to the ear; dulness and absence of respiratory murmur; embarrassect cough; hiccup preceded each expiration, even during the short snatches of sleep he occasionally had. Treatment similar as in the last. The hiccup persisted for twenty-six days. Cured. D-, aged forty, a strong, robust farmer. Had been for a, few days under the treatment of my friend Mr. C-. His only symptoms were those of a very partial pleurisy of the right side, attended with hiccup; no cough; pulse almost natural; stomach retained food pretty well. A small bleeding ; blistering; calomel and opium night and morning, which effected a cure in a few days, without producing salivation. I fancy that cupping with a blister might have been equal to the removal of this slight attack. The hiccup from the first continued for about twelve days. The chest symptoms that presented themselves after the second day are not given in the first case, as they were ew-bodied in a letter to Dr. S-, and no other memoranda being kept; besides there was a difference of opinion in the cases. However, I have but slight hesitation in asserting that they bore a marked relation to those of the three following, and to. L me at least clearly pointed to chest disease. L Barnet. Herts. fph 1854. Two Cases of Vesico-Vaginal Fistula. (Under the care of Mr. LANE and Mr. I. B. BROWN.) Nulla est alia pro certo noscendi via, nisi quam plurimas et BMrBotum et dissectionum historias, tam aliorum proprias, collectas habere et inter se comparare.—MORGAGNI. De Sed. et Caus. Morb. lib. 14. Procemium. THE operation for vesico-vaginal fistula is one of those which entail upon the surgeon a serious amount of anxiety and trouble, and which, despite of manual skill and surgical experience, very often baffles the best directed efforts. Nor is the latter circumstance calculated to cause surprise when the numerous difficulties to be overcome are for a moment con'sidered. And yet instruments and apparatuses intended to facilitate the operation have been carried to great perfection, chloroform allows an indefinite time for its performance, and the subjects operated upon are generally in a fair state of & p o u n d ; health. Much will of course depend on the size of the opening establishing a communication between the bladder and vagina; for when the aperture is small there is much likelihood that the actual cautery will excite sufficient inflammation, and lead to eventual cicatrization ; but when the rent is large and high up there is much difficulty in reaching the spot, in applying the sutures, and preventing the pressure of the urine from destroying the adhesions on the point of forming. Incisions made on either side of the opening to be closed are very likely to counteract the lateral traction which so often prevents union, but these incisions are unfortunately pretty often found of no avail. A mode of proceeding which we have, however, not seen adopted in the different operations of this kind which we have witnessed, is the detaching of a piece of tissue in the immediate neighbourhood of the rent, and the causing it to glide towards the aperture to be closed. This is Jobert de Lamballe's . method by glissenaeiit. In fact, this latter manner of proceed-; ing is not unfrequently followed by success in operations upon chinks of the hard palate, when the thick textures lining the , bones are sufficiently detached from the latter to meet in the r median line by lateral pressure. AVe have seen Mr. Avery, of Charing-cross Hospital, resort to this method in several