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in its unnatural position. The degree ofimmobility too differs in particular cases.In dislocation of the hip-joint, the limb hasfar less power of motion than in dislocationof the humerus. These, generally, speakingare the principal cases of dislocation.

CLINICAL LECTURE

BY

Dr. ELLIOTSON.

Delivered at St. Thomas’s Hospital,May 24.

PIlTIlISIS.

DURING the present month there havebeen twenty patients presented, and four de-ceased, in my wards. The case and appear-ances on dissection of one of the latter weredetailed in the last lecture. Two were casesof phthisis : both in males. The one patientwas Charles Freeman, aged 19, who wasadmitted, in the last stage, on the 22nd of

April, and died on the 20th of May. The

symptoms were those ordinarily observed inphthisis, emaciation, rapid weak pulse, debi-lity, cedemaof tlielegs, profuse perspiration,continual cough, copious greenish yellowexpectoration, and enlarged ends of the

finaers and thumbs. The aid of the ear

was not required to prove the nature ofthe disease, but as I see no reason whysymptoms learnt by the ear are not equallydeserving of notice with those learnt by theother senses, I ascertained that under eachclavicle there was loud pectoriloquism, andthat the respiration there was cavernous,-asthough the air passed into large cavities, andthat there was a strong mucous guggling,—proving that the excavations contained a

quantity of tenacious fluid. The indications Iwere merely to support his strength; he wasallowed meat and IJalf a pint of porter every ’idav ; as he afterwards desired wine and imilk, two ounces of the former and twopints of the latter were added to his dailyallowance; he took likewise two drachms ofthe subcarhonate ot iron, three times a day.All this probably protracted his life, for hesank very clowly notwithstanding the vastexcavations which auscultation discoveredin his lungs; his friends did not allow himto he opened.

The other case of phthisis occurred in apoor Irishman in William’s Ward, admittedlast autumn with signs, then, only of chronicpleurisy, but in wllom tubercles graduallyformed ; and hp had sometime before hisdeath all the characteristics of the disease.The last joint of the toes was equally en-larged with the ends of the fiugers and

thumbs. You may recollect that only onFriday last I poured water upon his expec.toration, which was decidedly purulent inappearance, greenish and copious, and Ftit nearly all swam to the top, and, indeed,would all have swum but for a little portionsticking to the sides of the vessel; and yetthis was a man dying of phthisis. You mayjudge what reason there is to think favoct;ahly of a case of pulmonary affection, merelybecause the expectoration does not sink inwater. The truth is, that a great part oithe expectoration in phthisis is derived fromthe bronchiæ, and is merelv mucus, and thatthis, together with the air entangled in the

expectoration, will bear up the pus. The

auscultatory signs were the same as in the

boy, cavernous respiration, mucous guggling,and, till just before his death, pectoriloquism,When a cavity becomes very large, and thewalls exceedingly thin, pectoriloquism is

frequently heard no longer. In him therewas extreme redness of the tongue withwhite, almost aphthous, patches, togetherwith severe diarrhoea. The friends wouldnot allow him to be opened.With respect to the fourth case of death

during the present month. I can give youbut little information. The patient was awoman found by some City otlicer on the ’

step of a door, early in the morning, quiteinsensible, and hardly alive, and she diedbefore my arrival at the hospital, so that Isaw her for the first time in the dead-liouse. ’

No morbid appearance was found in anypart of the body, but two bruises existed allthe forehead, and she therefore might havedied of concussion.

AGUE.

Of the cases presented, one was a tertianague, of six weeks’ stranding ; it illustrateda fact which T have seen, times innumerable,but which has been doubted by a writer ofhigh authority,—that sometimes ague willnot appear till long after the application ofits cause. The man had been at Gravescud(from which place we have continuallyagues sent us) last autumn, and the diseasedid not appear till the end of March, hehaving been in London all the time. Itis issaid that quotidians occur in the morning,tertians at noon, and quartans in the even-

ing. There is certainly some truth in this,particularly with respect to quartaus, butwe see exceptions every day. The parox-ysm of this tertian began always at elevenin the forenoon. The case showed the

power of the sulphate of quinine, of wh;chten grains were given immediately after thefirst paroxysm he had in the house, andrepeated night and morning’, with the efi’ectof at once preventing a single return of thehot or sweating stage, and converting thecold stage into merely a slight chilliness,

409

which, after two or three paroxysms, if they correspondent period, and that on a formerdeserved that name, ceased. I wished him occurrence of an increased prevalence ofto continue the medicine for a fortnight or ague, the same thing took place. Of coursethree weeks after his cure, to make sure of the higher the temperature, short of dryingrendering it permanent, just as we find it up moisture, the greater will be the degreenecessary to give mercury for a certain time of decomposition of vegetable matter, andafter the disappearance of syphilis ; but he the greater the extrication of malaria.had an opportunity of getting work, which he Perhaps I may mention that another newwas unwilling to lose, and, telling the sister continental medicine is said to be equallythat he was perfectly cured,he left the house, efficacious in ague as quinine. Piperin waswithout giving me any notice. The case discovered by Oerstaedt, in blaek pepper,was attended by violent headach, not merely and M. Melt published a report upon itsin the hot stage, in which the head is some- employment at the hospital of Ravenna sometimes aitected even with delirium, but con- years ago, declaring that he found it curestantly both in the paroxysms and in the ague even better than quinine. Dr. ltootsintermission; tlielctire of the ague was not employed it at this hospital in five or sixa cure of this. Leeches to the temples were cases of ague, about three years ago, and

required, and he had a dozen, and was ascertained that it cured the disease verypurged. The exhibition of the sulphate of well, but not better than quinine. Therequinine was no impediment to the means was no reason, therefore, to prefer it, andemployed to relieve this inrlammatory con- as it is far more expensive, none of us havedition of the head, and such it was, for they employed it since. The price of sulphateremoved it quite as quickly as they would of quinine is now but 7s. 6d., while that ofunder any circumstances. In Magendie’s piperin is 2l. per ounce. When I introducedfirst edition of his Formulas for new medi- the former particularly to the notice of thecines, he stated, that more than ten grains English by a report, published seven yearsmust not be ventured upon in the whole ago in the Medico-Chirurgical Transactions,twenty-four hours, as otherwise confusion, it was three guineas an ounce.giddiness, and other signs of dangerous de- --

termination to the head, might ensue ; but FEVER.

I have never witnessed anything of this Two cases of continued fever were pre-kind. When the medicine was first known, sented ; the one in a boy aged eighteen, theI have seen practitioners afraid of giving other in a girl about the same age ; theymore than two grains for a dose, and dis- were further illustrations of what I men-posed to discredit me when I informed tioned in the lectures on fever at the com-them I had given five. Some agues may be mencement of the winter.* Continued fevercured by a grain or two, two or three times in London is at present mild, showing, for thea day, and if this be sufficient, and it is not most part, no typhoid symptoms; but of anwished to arrest the disease instantly, it inflammatory character. I mentioned then,would be folly to give more ; but I have had that on account of these circumstances I had

many cases which would not yield to less not lost a case of continued fever for up-than forty or fifty grains in the twenty- wards of a twelvemonth, and it is now twofour hours, and one to not less than eighty. years, I believe, since a death has occurred1 believe the article sold now in tlis coun- to me in this disease. There was in bothtrv is not above half the strength it was. these cases intense heat of skin, a quickYou know it is my practice to give a large and by no means a weak pulse, a yellowishdose immediately after the fit, and perhaps white tongue, with redness of its anteriorbefore it (but the former plan is,I think, most margin and neighbouring papillæ, flushedpowerful), and then to give smaller doses countenance, pain in the head and pit ofthree or four times a day, to prevent the the stomach; they were presently conva-eisease which has been so checked from re- lescent under the simple treatment I former-turning. It is an object always with me to ly mentioned. They were both thoroughlystop the paroxysms immediately, as they washed with soap and water on admission, andcause a wretched state of suffering : no- tepid ablution was employed several timesthing but a full dose is so certain of ae. a day whenever they were hot. The boycomplishing this. This is the only case of had five grains of hydrargyrum cum cretaa,,ue that 1 have had in the hospital for a every six hours, and fifteen leeches wereconsiderable time. During every one of the applied to the scrobiculus cordis, on ac-

last four years, I had far more cases than count of the pain there being far more con-all the previous years together that I had siderable than in the head, and that form ofbeen physician to the hospital. Dr. Mac- mercury was preferred on account of themichael read a paper, at the College of Phy- slightly relaxed state of his bowels. Hesicians, to show that this extraordinary in- was discharged well at the end of afort-trease of ague was coincident with an un-

usually high average temperature during a * Vide pages 206 and 463 last vol.

410

night. The girl took five grains of calomel being not yet tender, and the symptoms notnight and morning, but there was no local materially mitigated, nor he apparentlyinflammation of sufficient magnitude to ren- much the weaker for the depletion, I order.der detraction of blood necessary ; they ed him another venesection to the same

were both confined to slops, and she was amount upon the 30th, on which day hedismissed well at the end of little more than begged me to allow him such a little dehcacythree weeks, her general febrile symptoms as a pheasant or a pigeon, and, on my,tellinghaving been more intense than those of the him it was out of my power to treat him so

boy. In both instances the disease seemed handsomely, he said he did not mean that Ireferable only to vicissitudes of tempera- should provide him with them, but if Iture. I may remark that continued fever, no would allow him to eat them, he would pro.less than ague, has, in my practice, several cure them himself. When I expressed mymonths past been exceedingly rare. surprise at this, he gave me a very cunning

look, and said he was in the carrying line,HEADACH. took parcels from stage-coaches to gentle.HEADACH. men’s houses, and game among the rest;

I will now proceed with the rest of the and that a pheasant, or a pigeon or two,cases, in the order of the seat of the dis- could not help being lost now and then. Ieases-a capite. ud calcem. The first is a at once understood him, but still there wascase of inflammatory headach. Its inflam- this difficulty, that he was now in the hos.matory nature and internal seat were shown pital, and not engaged in practice. Ah,butby increased temperature of the head, throb- you know, Sir, said he, I have got severalbing of the temples, sensation of weight in friends in the same line. I however couldthe forehead on raising the head after stoop- not permit him to eat any sort of animal

ing, darting pains through the head, sense food, and, between being tired of low dietof tension of the forehead, as though it were and ashamed of what he had divulged, hebound, drowsiness, and vertigo. When these disappeared before my next visit.symptoms are of an acute character, they There is another case which will be pre.may arise from various ingesta, especially sented in a day or two, with all the same

narcotics ; and it is always right to ascer- symptoms in the head, but two others intain what has been taken ; and, if the cause addition, namely, great tenderness of thereside in the stomach, to unload this as forehead, and copious mucous dischargesoon as possible. It may also be the pre- from the nostrils. I presume that the tit-cursor of an attack of small-pox, and other ing membrane of the frontal sinuses wasfebrile diseases ; and when an individual chiefly affected. As the patient, Williamhas been exposed to their causes, less active Mason, was 59 years of age, I could nottreatment may be adopted than if the symp- bleed him so extensively, but ordered mere.toms did not appear explicable in this way. ly twelve ounces of blood to be taken awayThe cause of the chronic form of the disease, on his admission-the 6th of this month, andhowever, is almost always in the head, and twelve more upon the llth; a blister waspersevering antiphlogistic measures directed ordered to the forehead, and ten grains ofto the head, are the only means of removing pilula hydrargyri twice a day, and his dietit. The patient, Joseph Adams, No. 6, in confined to milk, bread, and rice. TheJacob’s Ward, a squinting odd-looking little blood was buffed each time. Ilis mouthfellow, 44 years of age, had complained of became very sore, but he presently got well,all these symptoms for 13 months together, and will be presented on Thursday next, suwith a frequent aching numbness in the that I shall not refer to his case again.left temple, after a sharp pain had darted -

through it. He complained also of palpi- HEMIPLEGIA.tation ; this I conceived to be sympathetic HEMIPLEGIA.

with the state of the head, as, although the The next is a case of hemiplegia in a wo-action of the heart was sharp and rapid, man aged 37, ill one year; the affection wasthere was no alteration, diminution, or in- on the right side, and of both sense and mo-crease, in the sound, nor disproportionate ao- tion. I need not say that the cause of lie-tion of anyone of its cavities, nor that power- miplegia is in the head, and here there wereful impulse which characterizes hypertrophy. at the time of admission, the same symp-He was put upon low diet, and ordered to toms as those which attended the simplebe purged every day. A pint of blood was inflammatory headachs already mentioned,taken away at his admission on the 15th namely, occasional drowsiness And severeof April ; another on the 20th; and another shooting pain. There was also tremor of theon the 23d. As he was still unrelieved, I hands. This, I presume, arose from the samethen, in addition to the mere evacuation, state of the nervous system as the bead-

began with mercury, and prescribed two ach and the hemiplegia ; it will arise from

grains of calomel twice a day. On the 27th some narcotics, as strong coffee or tea, or

he lost another pint of blood, and his mouth from habits of drinking spirituous liquors,

411

from mere general debility, and from im.- the time she was in the hospital, that is,paired power, especially in the nervous sys- from the 4th of March to the 6th of May ;tem, so that it is common in many diseases she all the time took the extract of nux-

of it ; it is continually observed in congested vomica three times a day, beginning with aor inflammatory states of the head, so as quarter of a grain and arriving at three grainsactually to he relieved by evacuants only. and a half. It was found necessary also toThere were also, thirst, nausea, and great keep her bowels open with extracturn colo-tenderness of the epigastrium, in fact a de- cynthidis compositum daily. The nux vo-

gree of gastritis, and hence you see the ne- mica produced no sensible effect. Frombeingcessity of carefully examining various parts unable to move her lower extremities, sheof the system in every case; for had the acquired the power of moving them freely,prominent disease (the hemiplegia) only and of complete sensation, and was able tobeen inquired after, the other affection might stand alone, and even walk with assistance.have long remained undiscovered. On mi- She was so contented with her improvementnute inquiry, I also discovered that she oc- that she would not stay any longer in thecasionally had hysteric paroxysms. Twelve hospital, when I told her, that, to ensure herleeches were applied to the abdomen, with cure, it would be advisable to repeat thethe effect of removing the gastritic symp- moxas, as the parts to which they had beentoms. The same number was applied the applied were completely healed.next day to the head, and ordered for repe- I _

tition every other day ; and, for the purpose DYSPHAGIA; ENLARGED GLANDS.—of assisting to subdue the evidently inflam- I DYSPHAGIA; ENLARGED GLANDS.--

matory state of the head, two grains of calo- BRONCHITIS.

mel were given twice a day, and the hair There was also in the same ward a case ofwas cut off. If the paralysis had arisen spasmodic dysphagia attended with hysteri-from any effusion on any one spot of the cal symptoms, and which yielded to tonicshead, calomel, besides its anti-inflamma- and full diet with porter, and the applicationtory property, would have a tendency to of a bougie night and morning for the pur-excite absorption; and with a view of as- pose of lessening the morbid irritability ofsisting it in this respect, as soon as the heat the part ; but 1 believe I spoke of this caseand headach were removed, an ointment of in a former lecture.the hydriodate of potass, in the proportion of In descending from the head, we arrive ata drachm to an ounce, was rubbed into the a case of enlarged glands of the neck inhead night and morning. The latter medi- Jacob’s Ward. James Baxter was admittedcine was also given internally, by making a on account of rheumatism, and seized withsolution of it in the proportion of a drachm laryngitis, of which he was cured by evacu-to an ounce of water, and giving it three ant and mercurial treatment, and of this parttimes a day ; twelve minims at first, and by of his case I spoke in the clinical lecture onthe 7th of May she was taking half a fluid laryngitis. The leeches employed on ac<

drachm foradose. After she had been in five count of this affection, produced violentweeks, and the pain of the head and the affec- erysipelas of the neck, head, and face, thetion of the stomach were completely gone, disease being very prevalent in the hospitalshe went away of her own accord, because at the time. Of this he was also cured, butI would not allow her full diet. The para- the glands of one side of his neck becamelysis had existed a twelvemonth at her ad- exceedingly enlarged and tender. 1 havemission, and was of course no better at the generally found cold applications far moreend of five weeks, when she determined on useful in subduing intiammatory enlarge-nomg out, resembling a great many other ments of the lymphatic glands, or ganglionspeople, who had rather endure a serious as the French call them, than anything else.disease, than be deprived of the pleasure of Under the use of them and leeches, the paineating and drinking, and tenderness entirely subsided, but the

In the same ward was another case of induration and enlargement remained theparalysis, which 1 spoke of in the lecture same ; acute suppuration was prevented,upon paraplegia,* as illustrating my belief but it was prob3ble that suppuration wouldtliattlie paraplegia of adults is far more fre- after a length of time ensue if the swellingquently an affection of the spinal marrow were not dispersed. It was well rubbed withthan the brain. She was 29 years of age, ointment of hydriodate of potass twice a day,had been paraplegic three months, both as and he took the salt in solution, three timesto settse and motion. The first symptom a day ; under this treatment I was muchhad been pain of the loins, and the spine gratified to find the tumour and indurationwas tender tlere exactly at the spot to wl)icii lessen considerably, so that the individualthe paraplegia reached. Moxas were ap- glands of which it was composed becamehlted to the part, and a discharge kept up all after a time distinct, and I was able to pre-sent him on the 13th of this month.

* Page 882, last vol. The next was a case of bronchitis in

412

William’s Ward, James Glynn, admitted on sures to be thought of. I felt convineedthe 8tti of April; he said he had been ill that mercury and even leeches would be in-three weeks. The skin was hot, pulse jurious, and endeavoured to strengthen herquick, the tongue foul, but I could discover system, supposing that the subinflammatorynothing besides, excepting a slight catarrh, state would subside by rest; and orderedIn a day or two, however, he was worse, her two drachms of the subcarbonate of ironand by means of the stethoscope I heard twice a day wIth the house allowance, onsonorous and sibilous rattle at different parts the 9th of April. The prescription wasof the chest. The case was one of decided neither added to nor altered, all the timebronchitis. By means of bleeding, calomel, she was here, and she was discharged onand blistering, he recovered, and was pre- the 13th of May perfectly well, with a

sented on the 13th of thismonth. good colour, plump appearance, excellent

__ strength, without palpitation, (Edema, bel-

DISEASES OF THE HEART. lows sound, in or any symptom with which sheDISEASES OF THE HEART. came in.

No diseases present more interesting phe- The next was the case of Mary Proverbs,nomena than those of the heart; and, though aged 62, and who had laboured under theoften incurable, many are far more manage- disease for fourteen months. The symp.able than some persons suppose. You will toms were violent pulsation of every artery,see in the hospital, that very great allevia- causing throbbing headach, particularly attion may in many cases be accomplished, by the occiput, extreme dyspnoea, so that shediscovering any signs of inflammation in the could not lie down for above a minute, andheart, stomach, or lungs, that may be pre- when she fell asleep, awoke suddenly forsent, and subduing them in the ordinary want of breath. There was osdema of theway ; by removing dropsical effusion, which lower extremities, some cough, and sibilousso often occurs in cardiac diseases; by less. rattle; but as respiration was heard low

ening the violence of the action of the heart ; down in the chest, on each side, back andor by strengthening the system chiefly front, there was no effusion into the pleura,through the means of iron. The first case though, without the aid of the ear, I haveis that of Caroline Kirk, aged 19, whore- no doubt that some would have instantly de.presented herself as having been ill four terminedthe case to be of that description,months. She was admitted on the 8th of as well as of’ affection of the heart. The veinsApril with pain and stiffness in several of of the neck were swollen; the action of theher joints, palpitation, tenderness in the heart was violent and irregular. On strik.

region of the heart, strong bellows sound in ing the cardiac region a dull sound wasthe situation and at the action of the left heard to a much greater than usual extent,ventricle, fainting on sitting up, weak pulse, showing probably either effusion into the

frequent but slight cough and expectora- pericardium, or hypertrophy and dilatationtion, and swelling of both legs. She said of the heart, or both. On applying the ste.she had been first seized with giddiness, thoscope, the pulsation of the left ventricleheadach, and severe pain of the left side. proved to be violent, and with less than theI considered this a case of slight pericarditis natural noise, excepting a bellows sound,and rheumatism, in which the tendency to which was heaid at the cartilages of theeffusion and general debility was the most left ribs in the upper part of the cardiacprominent symptom. She was exceedingly region. This was loud, and particularly sopale and feeble, and her features were sharp in the recumbent posture. In a line fromand thin. She had not menstruated for this point, but immediately at the ster-

four months, and her general condition was num, was heard another bellows sound, tak.decidedly chlorotic. As I believe the bel- ing place not at the same time, but beforelows sound will frequently arise from great and afterwards, that is to say, when thedistension of the right auricle, in which auricles contracted; and in the same linecase it presses upon the aorta, and thereby between both these points, both the bellowsgives a very slight impediment to the course sounds could be heard alternating with eachof the blood, and therefore to the bellows other. The auricular bellows sound wassound ; and as not only any obstruction in not louder in the recumbent posture than inthe heart, but mere debility of that organ, the erect. These observations upon theand especially the diminution of firmness ; effect of posture I have now very frequentlywhich a recent inflammatory state induces, made. 1 concluded that there was hyper-will occasion this distension ; I was dis- trophy of the left ventricle; and as 1 haveposed to refer the bellows sound in this in- never seen extreme violence of its actionstance, heard when the ventricles contract- without the union of hypertrophy and dila-ed, merely to this cause, and hoped it would tation, which is to be considered the highestbe but temporary. The inflammatory signs degree of hypertrophy (since to be dilatedwere too slight, and the debility and pale- and not thinned, but even thickened, showsness too considerable, for antiphlogistic mea- a great addition of matter in the organ),

413

I concluded that the left ventricle was both who had been ill two months. He was a

hvpertrophied and dilated. This opinion remarkably muscular man, and every super-was also strengthened by the extensive dull ficial vein and every artery lying near thesound over the region of the heart ; for surface, could be observed amazingly dis-mere hypertrophy or mere dilatation rarely tended ; his pulse was eighty, very full, andcauses this, while hypertrophy and dilata- rather irregular in force and frequency ; hetion together commonly do ; still this complained of dyspnoea; a deep inspirationmight arise in some measure also from gave him pain, and he was frequently oblig-effusion into the pericardium, especially ed to stop when walking, and rise in theas anasarca actually did exist. The two night on account of a sense of suffocation ;bellows sounds also showed an impediment walking often produced a sharp pain acrossto the course of the blood from an auricle the lower part of his chest ; if he lay on theand a ventricle. The auricular bellows left side he had pain there, and more dys-sound, I do not doubt, arose from an orga- pnoea. He had a little cough, some vertigo,nic constriction of an auriculo-ventricular a sense of debility, and occasionally a dis-opening, for it was very loud, and I have charge of blood and white stuff from thenever seen it arise from any other cause. bowels. The action of both ventricles wasThe ventricular bellows sound did not arise stronger and louder than natural, and that offrom any extreme constriction, as it was not the left accompanied by a rough bellowsvery loud, and sufficient blood escaped at sound. It appeared to be a case of mode-every contraction of the left ventricle to rate hypertrophy and dilatation of the ven-cause a full pulse. It might have arisen tricles, with slight obstruction at the com-from such compression only of the aorta, as mencement of the aorta, slight because themorbid dilatation of the right auricle press- pulse was so exceedingly full, and probablying upon it would produce. The situation from nothing more than a temporary morbidof the ventricular bellows sound showed the dilatation of the right auricle ; and probablyimpediment to affect the left ventricle ; but an inflammatory state of the heart and peri-although the auricular bellows sound was cardium. The indications were the same asbeard in the right half of the cardiac re- in the former case; but from the great evi-gion, it probably arose from an obstruction, dence of strength of constitution evacuationsnot in the right, but in the left auriculo- were not to be feared. He was ordered twoventricular opening. For disease of the mi- grains of calomel twice a day with 3j tinc-tral valve is very common, and of the tri- ture of digitalis three times a day, and bledcuspid very uncommon; and, secondly, to a pint; the blood proved buffy. The digi-when the left ventricle is both hypertro- talis was continued during nearly the whole ofphied and dilated, the heart frequently ex- the treatment, and the calomel till his monthtends to the right, and the left auricle and was sore. He was bled again on the 6th ofventricle only lie in front, while the right April, on the 13th, on the 20th, and on theare turned somewhat backwards. 27th, each time to a pint ; and was dismissedThe indications in this case were, to lessen at the end of six weeks from his admission,

the quantity of blood stimulating the heart, free from difficulty of breathing, pain, orto lessen the congestion of blood which the bellows sound, and anxious to return to hisobstruction was producing, and to lessen the employment.effusion which probably existed in the peri- The next was an unsatisfactory case atcardium. I ordered her to be cupped in the No. 5 in the same ward, of Robert Badies,cardiac region to eight ounces, and prescrib- aged 30, who said he had been ill a year anded a scruple of tincture of digitalis three a half with sudden pain across the lower parttimes a day, with three grains of calomel of the chest, and constriction and pain ontwice a day. Her symptoms were at once much motion. The pain ran along the leftmitigated, so that she could lie down very arm in the course of the nerves as far as thecomfortably ; after the calomel had unloaded elbow. He said lie had also an aching underthe abdominal vessel., I changed it to the the left nipple, aad a pain lower down of ahydrargyrum c. creta, uf which she took five stabbing kind, together with tenderness.grs. three times a day, and at the end of a These are symptoms which will arise inwee wished her to lose a few ounces of various diseases of the heart, but especiallyblood more, and allowed her fish every other when the coronary arteries are either merelyday ; she appeared, however, rather wrong indurated, or ossified ; and are sometimesin her head, and between being probably a merely a neuralgic affection. The two latterhttle tidgety old woman and her sufferings, kinds of cases afford no evidence to the ste-she went away of her own accord before my thoscope, and no organic disease discover-fourth visit, alleging that she was sure I able by the stethoscope was found in thishad ordered her fish every day, and unless instance. The case appeared to be one ofthat was allowed she would not stay. angina pectoris, in which affection I thinkThe next was the case of John Thompson prussic acid produces more alleviation than

in William’s Ward, a hop porter, aged 58, any other remedy ; I therefore prescribed it

414

for him, beginning with two minims three is very common in affections of the heart, Intimes a day, and increasing the dose gradu- this position the heart is, of course, nearerally to six, in peppermint water. As he was the ribs, and therefore strikes more tie-

only 30 years of age, however, and the lently against them, and it is no wonder

pulse justified it, I cupped him over the therefore that persons with disease of the

region of the heart to a pint ; by the 7th of heart should generally find this position un.April 1 thought him somewhat relieved, easy and perhaps impossible.but he disliked the restraint of the hospital, In the same ward was another case of dis.and got out two or three times into the eased heart, also hypertrophy of the leftneighbourhood ; and so being a nonconform- ventricle, and connected with rheumatism,ist, took his departure without leave, but attended by a loud bellows sound in theAnother unsatisfactory case of diseased region of the left ventricle and when this

heart was that of Thomas Murphy in the part contracted, increased by the horizontalsame ward, aged 28, a tailor, and I should posture, and heard also in the left carotid,think a dram-drinker, who had been ill two This sound probably arose from the com.years. He could not lie at all upon his left pression of the aorta by the right auricle, asside, nor sleep, unless sitting up. There the right auricle gave signs of dilatation, bywas palpitation, swelling of the legs, tender- acting with a loud clear sound, and the pulseness of the hypogastrium, and at and below was by no means small, so as to indicate anythe left hypochondrium, with costiveness. great narrowing at the valves of the aorta.

The impulse of the If ft ventricle was very He was aged 17, ill three years at differentstrong, and with less than the natural noise; times with rheumatism, but had now la-the pulse was small. He had also some rheu. boured under acute rheumatism for sevenmatism, and had frequently been the subject days. I make it a rule to examine the stateof it. This was a case of hypertrophy of the of the chest in acute rheumatism, and soleft ventricle ; and from the smallness of the discovered that there were some signs ofpulse, notwithstanding the violent impulse pericarditis, and then found that be had hadof the heart, and from the absence of the decided pericarditis for five days previ.bellows s.und, I presume this smallness of ously, for which he had been bled, &c..the pulse arose not from any obstruction at with considerable relief. As the signs of pe.the mouth of the aorta, but from a climinu- ricarditiswere now much reduced, I thoughttion of the cavity of the left ventricle, that it sufficient to put him on milk.diet, andis, from the hypertrophy being concentric. give him f. 3ss of the vinum eolcluci threeThe tenderness of the epigastrium, and of times a day. The tenderness in the regionthe left hypochondrium, arose, no doubt, of the heart, and the dyspncea which I badfrom an inflammatory state of the stomach discovered, gradually subsided under thisand neighbouring parts, which is common, treatment, but the bellows sound has gra-from time to time, in affections of the heart dually increased. He regained his generaland lungs, though easily overlooked. He health and strength, and lost his rheuma-was put, like the last two men, upon milk tism ; but the bellows sound remained, to-diet, and, on account of the violent action of gether with too strong an impulse of the leftthe heart, and the abdominal tenderness, ventricle, and on the 7th of lilay he waswas cupped at the prmcordia to a pint. He cupped over the region of the heart to

was ordered a scruple of tincture of digi- twelve ounces. He felt himself sufficientlytalis three times a day ; and, on account of well to go out upon the 20th of May, havingthe rheumatism, a scruple of the vinum col- been admitted on the 25th of March, andchici with each dose, which would co-operate having taken the same dose of vinum colchiciwith the digitalis in increasing the urine, during the whole of his stay. He had aand perhaps in diminishing the action of the supply of medicine with him for a fortnight,heart: it did not appear forbidden by the in. and was cautioned not to return to his work,flammatory state of the stomach, as I was that of a man-servant, too soon.convinced this would be removed by the There was another case of diseased heart,previous cupping. I did not give him mer- with great effusion, I have no doubt, into thecury, lest it, and the colchicum together, pericardium, and intense anasarca, whichshould produce too violent an action upon shows how much good may be done bythe bowels. On the 20th lie could lie down, active treatment ; and I cannot do better

slept much better, had less tendellless of than speak of the case now, although thethe epigastrium and side, and no swelling of man will not be presented until next week.the legs. The noiseless impulse of the left John Westphalia, admitted into William’sventricle, however, continued strong. On Ward, April the 22d. The lower extremi-the 27th 1 ventured to take a few ounces of ties were so distended, that as be inblood from the arm, but as he disliked con- bed I am satisfied they were larger belowfinement and restraint in his diet, he too de- the knee than the thighs of any person incarnpfd without notice. The inability to lie the ward. They were shining, and very red ;on the. left side, which was observed in him, he was unable to lie down from the difficulty

415

of breathing; and he had been in this

frightful state, confined to his bed, for six

weeks, but had been subject to difficulty ofbreathing, and some swelling of the lowerextremities, for ten years. He ascribedthis recent aggravation of his complaint tohaving walked very quickly for ten minutesabout nine weeks before his admission. Hemade little urine ; the pulse was weak, andranged irregularly from 80 to 90, being irre- pilat also in strength. I heard respiration Ilow down on each side of the chest ; thecase was not one of dropsy of the pleura,but there was a dull sound to a great extentover the region of the heart. There was a

general vibration at the heart’s action overthe left side of the chest and the epigas-trium. The heart’s action could scarcely beheard, except very far to the left side, andwas there heard with a bellows sound ; Icould not avoid considering the case as oneof hydrops-pericardii, and the indicationwas clearly to get rid of the effusion as

quickly as possible. I ordered a grain oftlaterium to be given immediately, and re-peated every hour till it began to operate ;lie was also to take two grains of calomeland a scruple of tincture of digitalis threetimes a day. He took five doses of elateriumbefore the bowels were moved, and then hewas purged very briskly for a length of time,and passed a quantity of water, so that, onthe 7th, he had been able to lie down, andbis legs were much less swollen and red. Iordered the elaterium for repetition, andtwo doses only were requisite to affect thebowels. On the 30th the swelling was stillmore reduced, and he was able to lie down

longer, and no bellows sound could beheard in the heart. I ordered him to takea grain of elaterium once daily. By the 11thof Mav, there was not a single dropsicalsymptom left, but for the purpose of keep-ing up the renal and alvine secretions, I

ordered him half a grain of elaterium everyother day. On the 18th,nnding him stillvery well, and able to go about, I orderedhim merely the compound infusion of gen-tian, which he is still taking, together withtwo scruples of the acetate of potass in eachdose, as his urine is somewhat scanty ; andbe takes a grain of elaterium every four orfive days, as the bowels are disposed to becostive, and, of course, there will remain adisposition to a return of all the symptoms.You will find that the elaterium prepared atsome places, is much stronger than that weemploy. I knew the strength of the articlebefore I prescubed it; and this is alwaysnecessary m prescribing active medicines,or you may overdo your intention, or, onthe other hand, fail. I believe that it is notsafe with the elaterium of some houses togive more than one-eigbth, or, at the ut-most, a guarter of a grain. [Left cured. J

EDINBURGH UNIVERSITY.

CLINICAL LECTURES IN MEDICINE,BY

DR. DUNCAN.

April 1830.

FATAL CASE OF DIFFUSE CF.LI.ULAR

INFLAMMATION.

ON the 8Srd, Dr. Duncan drew the atten-tion of the class to the case of BridgetDoherty, aetat. circ. 40, observing that heshould at that time take but a very cursorynotice of it, for he feared that before thenext lecture they would become perfectlyacquainted with the true nature of the dis-ease under which she laboured. She wassent into the clinical ward by Dr. Alison, asan example of the diffuse inflammation ofthe cellular tissue. Indeed her appearancepresented a striking similarity to that dis-ease-so much so, as to render the diagnosisa matter of considerable nicety. Dr. Duncanhad, however, come to the determinationthat it was not diffuse inflammation, butdropsy of the cellular membrane. His reasonsfor this decision would be presently per-ceived. On admission, the lower extremitieswere swelled and distended almost to burst-

ing, acutely tender to the touch, pittingdeeply on pressure, red in some places,purplish in others, but generally of a pale,dropsical colonr. It was remarkable thatwhere the redness was most intense, thepain was less severe. Many of these phe-nomena were explicable on the idea of dif-fuse inflammation, but it rarely or never

happens that more than one limb becomesafl’ected with that disease at once, and itstill more rarely occurs that the pitting isobserved, which is so characteristic ofanasarca. In fact, the diffuse inflammationnever pits, but a sensation is conveyed tothe finger of a peculiar and almost inde-scribable kind, conveving the idea of some-thing semi-fluid or unsound beneath, or asit had been aptly described, communicatinga 3 "boggy" feet to the touch. For thesereasons, principally, the doctor considered

the case one of simple though severe oedema,and ascribed the pain and tenderness to

. inflammation produced by excessive disten-sion. The patient was apparently moribund,so the mode of treatment required no obser-

vation.Dr. Duncan commenced his lecture on

the 27th, by observing that this, as he had. anticipated, was amongst the fatal cases

which had occurred during the precedingweek. At his former lecture, he had drawna cursory distinctiou betweea the disease of