interpellation. His vacuum drum had long sounded, because it was empty but now that it is riddled and tattered, let him stand by it like a good soldier, and we shall give him fair battle on any point of our argument he may choose to impugn as the weakest. We never counted any thing on the Hallerian computation, farther than as a shrewd guess at the greatest effect of the atmospheric pressure and we did not even number it among the other four heads of arguments which we consider as irrefragable proofs of the insignificance of the latter. Dr. Barry, equally, by his silence, seems to consider them as unanswerable. Should he change his mind, however, he will find us quite ready to discuss the question with him in a proper manner, for we love physiological investigation, when the object of the controversy is neither gain, nor the glory of victory, but a genuine search after truth. In short, we say that atmospheric pressure is almost nullity, and sheer nonsense.-Let the Doctor disprove our position. We are, &c.

The Reviewer of Dr. Barry, in the 5th Number of the Edinburgh Journal

of Medical Science.

III.

Case of Dropsy of the Pericardium, in which the Operation of Tapping was performed. By Mr. JOWETT.*

Nottingham, March, 7th, 1827.

MY DEAR SIR.-You have probably learnt, from the newspaper paragraph, or the Lancet of last week, into which it is copied, that I have ventured to perform the operation of puncturing the pericardium, in a case of effusion arising from pericarditis. Under the impression that

a sketch of the case would form an acceptable communication for your valuable Journal, I forward the following particulars. It may first be necessary for me to premise, that, in consequence of several examples of latent pericarditis, as well as several instances of adhesion of the pericardium to the heart, having fallen under my observation in the early part of my pathological researches, my attention had

In a letter to the Editor.

been particularly directed to the detection of that insidious and not unfrequent disease. When Collin's excellent little work, "Des diverses Methodes d'Exploration de la Poitrine," appeared, I hoped to have found a valuable stethoscopic indication in the "bruit analogue, ou craquement du cuir neuf," which he mentions as a probable sign of the first stages of pericarditis. The year 1825, however, passed without my being able to verify that writer's statements in a single instance; and as Laennec has not even alluded to the phenomenon in the late edition of his work, it may be presumed, at first sight, that the hints which Collin threw out have not been substantiated by subsequent observations.

In the course of last winter, two fatal examples of copious effusion into the pericardium, from inflammation, fell under my observation, and, from them, I acquired some valuable data, as to the extent to which the membrane may be distended, and the indications of auscultation and percussion; and I also satisfied myself, that, where there is copious effusion into the pericardium, the bag may be punctured anteriorly without danger to the heart, as that organ, under such circumstances, is pushed upwards and backwards, towards the root of the bronchia.

Last spring, I met with several cases of acute pericarditis, denoted by general symptoms, and in which I also observed, for the first time, a peculiar rustling kind of noise, seeming to accompany and to be caused by the auricle's action, though not exactly synchronous with it; which these and subsequent observations lead me to regard as a pathognomonic sign of a layer of coagulable lymph effused upon the pericardium and heart. This phenomenon is always the most distinct in the superior part of the præcordial region, the cartilages of the third and fourth ribs being the situation where it is generally the strongest: though it appears to occur during the action of the auricles, it does not accompany it exactly, but seems rather to arise from the general action of the organ: it is irregular; varies much in degree and character at different times; and sometimes disappears altogether for intervals of various duration. It approaches the nearest to the rushing noise of diseased valves, but an experienced ear readily distinguishes the latter by its regular uni

form character, and by its duration according exactly with the systole of one or both of the heart's cavities, whilst the former is various and irregular—indeed, the term rustling, which I have employed, gives a better idea of the noise than any other word. The noise of muscular action, respecting which Laennec says so much in his second edition, is so obviously different, that no accurate ear can be at any loss, after having once heard both the phenomena.

Last June, a case of acute pericarditis pame under my care, in which the accumulation of fluid interrupted the heart's action so materially, that I expected the issue to prove fatal, unless it were evacuated by the operation. I at that time inserted the following observations in my note book.

"June 14th, 8 4. M. I attribute the interruption of the heart's action to the fluid filling the pericardium; and from a careful examination by the stethoscope, percussion, &c. I think the pericardium might be cautiously punctured with a trocar between the 6th and 7th left cartilages, without wounding the heart, and the fluid be abstracted. At the same time, I consider that, in the present stage of our knowledge, the operation would only be justifiable under desperate circumstances, and, when it is clear that death must ensue without it, and I have mentioned it to the friends as a measure it might be right to try, as giving a chance of life, when no other chance remained. Should the case become desperate, I think I should do it, if he consented.

"In the performance of the operation, I think two things are essentially necessary to be guarded against. (1st.) Not to wound the heart, and (2) not to admit air into the pericardium.

"1. Aninstrument introduced between the cartilages into the pericardium, in the natural state, where there is no fluid, would be almost certain to wound the heart, as it is in immediate contact with it. When, however, there is considerable effusion into the pericardium, I have observed that the heart is pushed backwards, and also upwards, towards the root of the bronchia, whilst the inferior anterior part of the bag is occupied by the fluid;-consequently, a trocar might be introduced with safety.

"I consider it essentially necessary to

prevent the admission of air into the pericardium for these reasons. 1st. To admit air instead of fluid, would only be to substitute one cause of obstruction to the heart's action for another. 2nd. That from facts I have collected, in cases where paracentesis thoracis was resorted to, I. am satisfied that the admission of air occasions the decomposition of the fluid left in the cavity, (and it is impossible to remove it entirely) which then becomes putrid and acrid, and excites fresh inflammation; and thereby destroys the chance of success, if the case be urgent previously. I think the syringe-pump, adapted to a trocar, would effectually prevent the admission of air."

I have been thus particular in stating these circumstances, in order to shew that I had fully weighed and resolved upon the propriety of the operation, long be fore I had occasion to resort to it. I will only add, before I proceed to the case, that the patient whose state elicited the above remarks, began to improve the same day, and ultimately recovered by the use of other remedies.

On Jan. 12th, 1827, I first visited John Skinner's daughter, aged 14 years, who was then labouring under a severe attack of acute rheumatism for the fifth time. The general symptoms induced me to suspect that there was pericarditis likewise, and on examination with the stethoscope, the rustling noise was audible about the nipple-there was a dull sound on percussion in a large præcordial space-the heart's action was indistinct, and apparently distant. On the 15th, I gave my diagnosis “pericarditis with considerable effusion."

Under the use of general and local bleedings, blisters, antimonial and mercurial medicines, and active purgatives, much relief was obtained; but she was troubled with a violent cough, occasioned by severe acute inflammation of the bronchia, which greatly aggravated her sufferings. On the 25th, both the legs were observed to swell much when she was got out of bed, and the ankles became ade matous. On the 27th, she began to take tartarized antimony in doses of three fourths of a grain every third hour, and which she continued until she had taken eighteen grains, without any vomiting being excited. It produced a decided beneficial effect upon the bronchial is

flammation. On Feb. 1st, she was "much better-slept several hours in the night, and feels much refreshed-breathing greatly relieved, and the cough is now quite easy compared with what it was. The heart's action is strong, forcible, rapid and extensive, and seems rather mixed with some roughness of sound. Dry bronchial rattles in both lungs anteriorly-vomited this morning after taking tea," (for the first time.)

From that time, for a week or more, there was a manifest improvement in every respect except the edema of the lower extremities. Feb. 12th, I reported very ill last night-says she seemed as if something was strait on her stomach and tied up her inside, and prevented her getting breath, and lying down in bed: she feels better when she sits upthe ankles and legs are worse swelled. Effusion must have increased in the pericardium." Next day (Feb. 13,) the breathing was quite as bad-" dead sound (on percussion) in a very enlarged præcordial space”—there was likewise a distinct rushing noise at the bottom of the left side of the præcordial region, which induced me to add to my former diagnosis, "deposition of lymph on the mitral valve?" proposed tapping the pericardium if she

became worse.

The following day she was so much worse in all respects, that it was evident she could not long survive, unless some relief were given. The face, as well as the extremities had become cedematous respiration was impossible in any other posture except the erect, and there was much accumulation of mucus in the trachea. The operation having been consented to, I performed it in the following manner, the same afternoon, in the presence of Dr. Manson the consulting physician, Mr. Robert Jowett, my brother and pupil, and the patient's friends. Having made a small incision with a lancet through the integuments, between the 5th and sixth cartilages, exactly half way between the sternal extremity of the 6th rib, and the middle of the ensiform cartilage, I thrust a trocar, which had its canula guarded, so that it could not penetrate further than one inch, directly through the thoracic parietes; as I withdrew the trocar, two or three drops of serum escaped, and before I could adapt the pipe of the syringe

apparatus to the canula, a little air was sucked through it, during the act of in spiration. On attempting to work the syringe, no fluid was abstracted; imagining, therefore, that I had not punctured the bag, I again introduced the trocar, but with no better success. Certain of the correctness of my diagnosis, I then determined with Dr. Manson's concurrence to make another attempt higher up, where there could be no possibility of missing the pericardium, and I accordingly repeated the same process between the 4th and 5th cartilages, as near the sternum as there was space enough for the instrument to pass. Here the trocar seemed to push something before it which it did not appear to penetrate, and although, here likewise, I twice introduced the instrument, still no fluid could be sucked out by the syringe. I left the patient under the impression that I had failed in the operation-and my prognosis was "death in the course of the night." Late in the evening, I found her quite as bad, but no worse than before. On the following morning there was an evident amendment-the breathing was less laborious-she coughed more strongly-pulse 126,fullish-the right leg was less swelled, and she had made two quarts of urine in the preceding sixteen hours. In the course of that day she made 5 or 6 pints more water-the odema of the lower extremities decreased rapidly, and the improvement was rapidly progressive in every respect except the cough.

I now perceived, from weighing all these circumstances, that the operation had really been performed, so far as regarded the penetration of the pericardium by the trocar, but in consequence of the canula having been introduced but a little way, it either had never entered the bag, or else had entered so short a distance as to slip out again immediately on the withdrawal of the trocar. Acting on this view, I renewed every exertion, and the improvement from that time, for eight succeeding days, was such as to warrant great expectations of ultimate success. Weakness was the most threatening circumstance, and that was attempted to be obviated by tonics, wine, and mild nutritious food.

On the 20th Feb. the sound on percussion was dull, only in a moderate sized præ

cordial space, and the heart (examined by the stethoscope) had returned to its na tural situation. Feb. 22, she felt better"not so low nor so faint-rested well in the night-appetite improving-tongue clean-pulse quick-ankles a little swelled." She partook more freely of food. The next day, (Feb. 23,) being the tenth from the performance of the operation, my report ran thus "has had much pain and soreness under the right ribs since last night, and has, twice, this morning vomited green slimy fluid-bowels rather costive. Hepatitis?" She sunk ex

hausted in the course of the afternoon.

At my earnest request, seconded by that of Dr. Manson, whose kindness on this and other occasions call for my warmest acknowledgments, the friends permitted an examination of the body to be made, at which Mr. T. R. Tatham also assisted. The exact situations of the punctures were found to be as before described. The diaphragm was drawn very high up into the thorax, so that if a pointed instrument had then been introduced perpendicularly at the place of the lowest operation, it would have been punctured. The pericardium adhered externally to the anterior part of the left thoracic parietes, through the medium of a layer of firmish recent lymph; and internally it was found every where adherent to the surface of the heart and large vessels, by means of a similar layer of lymph, which varied much in quantity in different places, being in some parts from one-eighth to one-fourth of an inch thick. The adhesion was moderately firm, and the lymph of a reddish colour. As the cavity of the pericardium was destroyed by this state of things, there was of course no fluid remaining in it. The pericardium proved to have been perforated at both the points of operation, and there were two holes at each place, so that every time the trocar was introduced, it had penetrated the bag. On the surface of the right ventricle, opposite the upper or last made puncture, there were two dark spots, which, on examination, proved to be drops of coagulated blood enveloped in the layers of lymph, and which had doubtless come from the wounds of the pericardium, as the surface of the heart was untouched. Both the ventricles and auricles were of the natural size. The muscular struc

ture of the heart was rather flabby, and paler than natural. The edge of the mitral valve, on its auricular surface, was beset with a small ridge of semi-cartilaginous lymph, evidently of recent deposition, although firm and hard.

To this long account I may add, that I have since tried the experiment of puncturing the free portion of the pericardium on the dead body, and I have found, that the point of the trocar readily penetrates the sac; but as soon as the edge of the canula (which of course is always rather larger than the instrument it contains) comes in contact with it, it pushes the pericardium before it, and does not enter it, unless it be introduced to a considerable depth. This explains the supposed failure of the operation in the first instance.

I conclude by observing, that the following propositions appear to me fair practical deductions from the case :

1st, That the operation of tapping the pericardium may be performed without injuring the heart, or endangering the life of the patient.

2nd, That the operation affords a probable chance of saving life, when all other means have failed.

3rd, That it is proper and justifiable under urgent circumstances.

Believe me, Dear Sir,

Your most obliged servant,
THOMAS JOWETT.

IV.

A Short Outline of the New MEDICAL DOCTRINE of Italy; in a Letter from a Medical Gentleman abroad, dated Jan. 27th, 1827.

[Communicated by Dr. B. of Bn.] THE doctrine of contra-stimulants had its origin in the year 1799, during the prevalence of an epidemic fever at Genoa, and at a time when Brown's doctrine of excitability had numerous followers among the medical schools of Italy. Such ill success had those who followed Brownonianism in the treatment of fever, and so opposite were the results of the antiphlogistic plan, that Dr. Rasori, then a celebrated physician of Milan, began to entertain doubts of the most essential dogmas of Brown's doctrine; and though himself a zealous follower of it, and the first by whom the elementary work of

that once celebrated man had been translated into Italian, with notes, yet he, after prudently substituting remedies of an antiphlogistic kind in the disease, obtained such favourable results, that he finally became convinced of the insuf ficiency of excitabilism.

On considering the circumstances which thus undeceived him, and observing the effects of several articles of the Materia Medica on the system, he professed the following positions, which, although not systematized in any particular work, are considered the rudiments by which the spirit of the new doctrine was disclosed to the world; namely,

1st. That the universal stimulant property of every thing on the system (which was inculcated by the Brownonians) was to be disproved; for there were substances that act with a contrary effect to that of stimulation, and which produce effects on the excitement, similar to what are produced by negative powers, as bleeding, purging, &c.

2nd. That by these substances, which have been called contra-stimulants, the effects of stimuli, or of increased excite ment, are to be removed; and that when they are used beyond what is necessary, they are productive of bad effects, which can be removed by having recourse to the stimulant remedies again.

3rd. That, according to these premises, the morbid state, whatever it may be, that arises from the stimulant diathesis, is to be cured by contra-stimulants, as by bleeding, &c.; while, on the contrary, in stimulants we have a remedy for the contra-stimulant diathesis.

4th. That the living fibre bears doses of stimuli according to the prevalence of either diathesis.

5th. That this ability of the fibre is one of the most significant indications of the prevailing diathesis and its degrees, and more to be trusted to than the symptoms, which are fallacious and uncertain, often being common to both diatheses.

Such are the principles on which the New Medical Doctrine of Italy is founded. They never would, perhaps, have been divulged publicly to the world by Rasori, though, as one of the authors above specified says, they formed one of the most remarkable epochs in the history of medicine, had not Professor Tommasini, of Bologna, been their zealous advocate.

1

By this eminent man, these rudiments have been systematized into a body of medical doctrine, and they have thence become rapidly diffused among the most celebrated schools of Italy.

The term diathesis is still retained; and, originating as this doctrine does from that of Brown, excitability is also held to exist, as that principle or property of life, on which the inherent powers of all animal organization depend. The doctrine being thus formed on the same basis, and being a reform of Brown's, has caused it to be styled the Daughter of Brownonianism.

Although it has been agitated among the schools for more than 20 years, it does not seem as yet to be wholly perfected. Its principal advocates, however, appear confident in the validity of its general principles, though there seems to exist some difference of opinion as to the classification of disease; and, in addition to the two diatheses, which are stimulant and contra-stimulant, some hold the existence of a third, to be termed the irritative, and which is to be cured without the use of either stimuli, or contra-stimuli, but simply by the removal of the cause of irritation. As to the importance of this, Tommasini is, however, not satisfied, for he considers the pathology as hinging on the simple division of disease into the stimulant and contra-stimulant diathesis.

This simplicity of classification has also been adopted in the Therapeia, and all remedies have been ranged under two grand classes, and consequently divided into stimulants and contra-stimulants. The principal ones belonging to the former are, opium, sulphur, æther, alcohol, camphor, and ammonia; while among the contra-stimulants are enumerated some noxious vegetables, as cicuta, aconitum napellus, atropa belladonna, linum palustre, lausocerasus, solanum, lactuca sylvestris, digitalis, nux vomica, and other vegetables, highly pernicious, whether indigenous or exotic, and even bitters, iron (which before were thought to be tonic), mercury, zinc, antimony, and other minerals, with the acids in general, all of which, opportunely administered, are held to produce directly the same effects which are indirectly produced by bleeding and purgatives, as before observed. As to poisons, the advocates of the new doctrine seem to hold, that there