No. 121.—Vol. IX.] [Dec. 24, 1825.

LECTURESON THE

THEORY AND PRACTICE OF PHYSIC,

BY DR. CLUTTERBUCK.

Theatre, General Dispenswy. Aldersgate-street.

LECTURE VII.Genttenren, IAT my last Lecture, I was pointing out

the general properties of disease, pre. Ivious to considering them individuallv.Diseases, I remarked, are to be studiedin several points of view, as, ’

1. In regard to their appearances, call-ed symptoms; as it is by them that weare able to discover disease.

2. In respect to their causes, both occa-sional andpredisposing.3. In regard to their intrinsic nature,

or proximate cause; and lastly,4. As to treatment.Without this division, we cannot have

that comprehensive knowledge of the

subject which is necessary to successfulpractice.

I mentioned, that diseases generallyconsist of more than one symptom, andfrequency of a great many ; and that theyare often not to be known by any singlesymptom, but by an observance of thewhole. Few diseases, for instance, canbe known by pain, as it is a symptom ofseveral, and those of different natures.We are obliged to inquire much furtherthan this, before we can arrive at a safeconclnsion as to the nature of the disease.Sometimes a disease is only to be knownhy a succession of symptoms, and requiresto be watched in its progress, before wecan determine its nature. For example,no person conld detect an intermittingfever by seeing it in any one of its stages.It is only by watching it’ through severalstages, that its nature can be ascertained.So, likewise, with regard to et’uptivefevers.A person seeing a patient labouring underthe eruptive fever of smallpox, could not

distinguish the disease until the eruptionhad taken place, and often not till theeruption has proceeded for several days.This shows us the necessity of payingclose attention through the whole courseof a disease, the symptoms varying almostdaily. Some symptoms give rise to others ; ;and frequently there is a series of symp-toms produced, one only arising out ofthe original cause, and the rest depend-ing in succession upon each other ; forinstance, in inflammation of the lungs,we see a series of symptoms dependingupon each other. At the outset, and inthe slightest affections of this sort, thesymptoms are very few. There is, per-haps, some uneasiness in the chest, occa-

i sionatty amounting to pain. There is

I slight disorder of the respiratory ftine-: tion, such as coughing, and a little diffi-culty ot breathing. These are the first

symptoms, and, in many cases, there areno others. If, however, the disease pro;-ceeds, and acquire.s an aggravated form,a variety of other symptoms soon maketheir appearance, some local, some gene-ral. If the inflammation be extensive,its ordinary effect, swelling, takes place,the consequence of which is obvious ; theair cells become pressed upon, and thisproduces oppressed breathing and wheez-ing. Another consequence is, that theblood does not undergo its properchange,and a livid hue of the skin is produced.This is particularly observable in thoseparts where the vessels run superficially.A deficiency of animal heat is the nextconsequence, for if the blood be not suf-ficiently changed in the lungs, there wiltlae deficiency of animal heat, which is ina great degree dependant upon respira-tion. Another effect arising from theswelling of the lungs, is, that the bloodvessels suffer a degree of compression,and hence the blood cannot pass withfreedom through the lungs, so as to reachthe left side of the heart. The conse-

qnence of this is, a small, feeble, and oftenirregular pulse. In severe cases, lifemay be destroyed from this cause. Thuswe see, that if the various symptoms beanalvsed, they will be often found depend.

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ing upon one or two. In practice, it is ofgreat advantage to discriminate betweenprimary and secondary symptoms; thelatter should be comparatively disregard-ed, and our chief attention turned to-

wards the former. The neglect of pro-ceeding in this way is often a source of

practical evil. Where, for instance, thegeneral circulation is weak, as indicated

by feebleness of pulse, attended with afeeling of weakness, practitioners havebeen often led to the use of stimulants,without considering the nature of thecause producing those symptoms. Sti-mulants naturally enough suggest them-selves as proper remedies, where the

pulse is observed to be feeble. But ifthis state is induced by actual inflamma-tion, as in the case alluded to, it is ob-vious that the effect of such remedies canonly be to increase the mischief. Again,on various occasions in fever, the pulseat the wrist is weak, and there is the

greatest prostration of muscular strength,

Iyet in most of these cases stimulants arehighly injurious, while bloodletting is noless serviceable; the reason is, that theweakness of pulse, as well as the muscu-lar debility, is the effect of an oppressedstate of the brain, proceeding from a vio-lent inflammatory action taking place inthis organ. Practitioners who study ap-pearances only, are very apt to fall intothis error. More need not be said to showthe importance of discriminating betweenprimary and secondary symptoms.The essential characters of diseases

must be distinguished from such as areoccasional or accidental only. Diarrhaeais thus often an attendant upon fevers,but it is not essential to them. Such ac-cidental symptoms throw no light uponthe nature of the disease, and if we allowthem to enter into our speculations uponthe point, we are almost sure to come toa wrong conclusion.

When a disease is presented to us, twoobjects should engage onr attention; thefirst is, the discovery of its seat, and inthe next place, we should inquire into itsnature. Commonly, it is not difficult todiscover the seat, unless the disease bylong continuance has become complicated.At the outset no such difficulty is expe-rienced. * By attention to the feelingsalone of the patient, and often by mereinspection, we can acquire this know-

ledge.It is not so easy to ascertain the na-

ture of a disease, and in some cases itcannot be accomplished. A great deal ofobscurity exists in regard to the intrinsicnature of disease, which will probably

never be wholly rernoved. It is nece4-sary to observe, that we consider diseaseas an affection of the solid parts of thebody. It does not consist in a vitiated

quality of the blood, or in any noxiousmatter mixed with that fluid. It consists,as I have before said, in " the imperfectand irregular action of the parts affected."This disordered action is in many casesattended with an alteration of structure;but this is to be considered as a remoteeffect. I may illustrate this, by refe-rence to inflammation, which is a state ofdisordered action, frequently, indeed,producing alteration of structure. Butthis alteration of structure is not essen-tial to inflammation; it is a consequenceof it, and that only where it has conti-nned for a certain time. Hence it is thatdissection will not always discover thedisease. For if death takes place, beforealteration of structure can be effected, itis evident that no change will be ob-served after death ; dissection, therefore,is of limited use in discovering either theseat or nature of disease. It is only inthose cases where the disordered action,has continued so long as to alter thestructure of the part, that visible traceswill be discovered after death. The mostviolent diseases may thus leave the partwithout any post-mortem appearances.Some have denied the existence ofinftam-mation in certain cases, because no red.ness has been discovered upon dissection.We have, Itowever, no right so to con.

clude, for there may have been the mostsatisfactory proofs during life, that sucha disease was going on. We can, in fact,trust better to symptoms, for these, ifminutely scrutinized, will rarely deceiveus.

It is important to remark that pain isgenerally a sign not to be relied upon, asindicating the nature of a disease. Itmay arise from different causes,—fromdifferent states of disease, requiring atotally different treatment. It is a symp-tom, and not a disease.

Diseases may exist singly, or be compli-cated with others. In general, diseasestake place singly. There seems to bean indisposition in the body to fall intodisease of various parts at the same time;and hence we more frequently meet withsimple, than compound diseases. Thereare no such things as universal diseases,except such as become so in a secondarvway, by sympathy with the part first af-fected.

Most diseases consist in disorderedvascular action. It is a most importantfact, that all the great and dangerous

435

diseases which occur in practice are,with very’few exceptions, states of dis-ordered vascular action ; and we are in

consequence, or ought to be, employedchiefly in regulating vascular action.When we come to speak of inflammation,it will be seen, that 99 cases out of 100,are actual states of inflammation, or itsimmediate consequences; commonly, how-ever, they are merely different degreesor stages of inflammation. It is true,that the names of diseases will not

always lead us to this conclusion ; for in-stance, the terms dysentery, diarrhoea,catarrh, and rheumatism, have no refer-ence to inflammation, and yet these dis-eases are all of them inflammations, dif-fering only as to the seat they occupy.Now as inflammation is chiefly a state ofdisordered vascular action, and as thisdisease constitutes so large a portion ofall that occur, it is evident, that the vas-cuiar system is the seat of the greaternumber of diseases.

One disease has a tendency to take offanother. This arises out of the circum-stance before mentioned ; namely, theindisposition there is in the system to fallinto different states of disease, at thesame time; so that when one disease iarises in the system, it is less liable to fallinto another ; and if a second shouldarise, the effect of it will probably be, torelieve, if not remove, the former ;the one proving thns a remedy forthe other. This may be remarked as

a general rule; there are, however, manyexceptions to it. The explanation of thisfact is to be sought for in the generallaws of the animal economy. There ap-pears to be a certain quantity of vitalpower present in the system, and whichis employed and expended in the per-formance of the various functions ; hence,only a certain quantity of action can bemade to take place in the system, in agiven time, consistently with health, oreven lite. If more than this be produced,exhaustion will be the inevitable conse-quence ; and thus it is, that general sti-mulants exhaust the vital power. Nowif any part of the body be in a state ofactive disease, a disproportionate quantityof the vital power will be expended onthe diseased part, and general weaknessbe induced. We find that whenever anyexcessive exertion is made,even in health,it tends to produce weakness of thewhole system. Thus over-exertion ofthe voluntary muscles will have this ef-fact : mental exertion does the sa1V<ething ; for we find that those who employtheir mental powers too intensely faitiato a state of bodily weakness ; the vital J

power is too rapidly expended. Thesame takes place in diseases. If therebe excessive action going on in any partof the system, all the functions will beill performed. Thus in cases of diarrhoea,where the intestinal canal is in a state otover-exertion, general weakness is pro-duced, and the same thing occnrs in allactive diseases. This appears to be thereason why, when disease is excited inany one part, it is less likely to take placein another. The fact, however, is so,whether the explanation be satisfactoryor not. It is in this manner that chronicaffections, (as an old ulcer, or cutaneousdisorder,) although troublesome in them-selves, are a sort of safeguard to the bodyagainst any other disease. In practice,we take advantage of this fact; knowingthat one disease influences another, inone case mitigating it, in another re-

moving it, we institute artificiai diseases,in the hope of taking off such as arisenaturally. Thus we excite artificial di-arrhcea, by purgatives; because experience

, sufficiently proves, that many diseases

may be removed by so doing. If wegive emetics, it is not in general for the

purpose of discharging any thing noxiousout of the system, but to produce anartificial disease-vomiting, in order to

influence the diseased action that was

previously going on. Emetics thus oftensucceed in curing ophthalmia, not bydischarging from the stomach any noxiousmatters which produced the disease, butupon the principle I have just mentioned,and which is called the principle of coun-ter-irritation. A blister can be consideredas acting only in the same way. It is apowerful means of influencing diseases,and one of the best means we have oftaking them off.

Diseases terminate variously. A largeproportion terminate in health, withoutthe aid of medicine. We are not to suppose,that wherever disease exists, medicine iscalled for. A great proportion of mankindhave not the benefit of the medical art,and yet diseases in such do not invariablyprove fatal. Disease has often a tenden-cy to subside of itself; and this tendencyis so strong, that in many cases it maybe safely relied upon, there t)eing no oc-casion for active treatment (f a diseasehas a natural tendency to cease of itself,it is often much better to let it run itscourse, than to attempt to interrupt its

progress, for the purpose of cutting it

short. In slight catarrhal affections, andin diarrhcea, we may have it in our powerto put a speedy stop to the disease; butthe remedies used for the purpose, suchas opiates and astringents, are often worse

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than the disease itself. In all cases, weshould weigh the effect, of the treatmentwith the effects of the tlbease; otherwisethe medical art wonld be be an injure,rather than a benefit to mankind. Todetermine the cases in which it is properto attempt the immediate removal of adisease, or, on the other hand, to allow itto run its cuurse, reqnires a minute ac-quaintance with all the circumstances.

Diseases sometimes terminate sponta-neonsly, witlrout any perceptible change.’At other times, they go off by some in-termediate or perceptible change, such2s increased secretion. If any part ofthe mncons membrane be inflamed, thenatural termination is bv increased secre-tion ; as is seen in diarrh&oelig;a, and catarrh.The<e are cases, that seldom call for theaid of artificial means ; for the increasedsecretion that takes place proves a na-tural cure to the disease.

Another way in which disease mayterminateis by disorganization, or changeof structure. Inflammation has alwaysthis tendency. Now as disorganizedparts cannot perform healthy functions,it is of consequence to put a stop to dis-eases which have this tendency, parfictt-larly if the function be essential to life ;as for instance, respiration. If inflam-mation of the lungs take place, it is ofessential importance that it should be puta stop to as speedily as possible.Diseases in many instances terminatefatally, often in spite of the most judi-cious treatment. We are not to imaginethat we have a perfect control over dis-eases. There is hardly one disease whichwe can with certainty cure. Every nowand then, cases occur which disappointour best hopes ; where we have had rea-son to believe the disease was under ourcommand, it has nevertheless proved fa.tal. This should render us cantious onall occasions in giving a prognosis.

Diseases may terminate fatally in avariety of ways: sometimes it is from theimportance of the organ to life. Thereare some functions which cannot he inter-rupted without destruction of life; as

those of the brain, heart, and lungs. Ifthe disease be of that magnitude, as to

materially disturb the functions of eitherof these organs, it may prove fatal fromthat cause. Diseases, however, often.times prove fatal, when seated in parts ofno immediate importance to life, as theskin. Extensive burns thus frequentlyprove fatal. In these cases, we attributethe fatal event to the general disturbanceof the system, or irritation. A certain

quantity of disease, sitn;tted in any palof the uystent, may kill, by producbrgsuch a dtstnrb.tnce of tlie geiiei’al systemas is incompatible with life. This is allthe explanation we can give. We are fatfrom knowing the exact way in tvhicft theffect is produced.

ERRATA in Dr. CLUTTERBUCK’S lastLecture.

Page 370, column 2, line 25, for " de-cayed" read diseased, Page 373,colnmn J, line 28, tor " exposes" readdcsposes.

LECTURESON SOME

PRACTICAL POINTS OF SURGERY,DELIVERED TO THE

Students of the late Borough DispensaryBY MR. ALCOCK.

LECTURE VI.Gentlemen,IT has been suggested to me, by one

whose experience and knowledge of hisprofession entitle his opinions to respect-ful deference, that it might be useful tothe junior student, to point out, moreparticularly, the mode of restraining ha-morrhagefrom leech-bites, much difficultyhaving’been occasionally met with, andunsuccessful attempts not unfrequent,whilst the opinions of professional menare by no means unanimous, or conclu-sive, as to the best means to be employedon such occasions. Having alluded to theexcellent work of the late Mr. Haden,whose premature decease is a loss to me-dical science, I should not deem it neces-sary to revert to this point of practicewere it not that in Mr. Haden’s publica-tion, in addition to clear and definitedirections for the restraining of haemor&middot;

rhage by pressure, other methods are

pointed out which I conceive to be unne-cessary and objectionable; I allude to theapplication of caustic, and to the passinga needle through the bleeding orifice andwrapping thread round it, as is doneround the pin which is used to secure thevein when horses are bled. Should I evermeet with a case in which I could notcommand the haemorrhage by more sim-ple means, I should not object to adoptthis method, and I am aware that it has.