No. 967.

SATURDAY, MARCH 12, 1842.

ST. MARYLEBONE INFIRMARY.

CLINICAL LECTURES

ON

MEDICINE AND MEDICAL PRACTICE,DELIVERED BY

JOHN CLENDINNING, M.D., F.R.S., SeniorPhysician to St. Marylebone Infirmary.

my last lecture, this day fortnight, I was=3ld,first, with the treatment of two cases,ilieumatism with disease of the heart,e other of phthisical diarrhoea, both ad-

during the month of January ; andards with an account of the effects ofics as substitutes for expectorants inbial affections. With respect to the

I wish before entering upon the spe-c usiness of to-day, to mention that theplan of treatment in each case already de-cribed has been persevered in, and with ap-

advantane up to the present time.The diarrhœa of the consumptive man had,von remember, resisted opium and copper,chalk and opium, &c., in such doses as thelomach, &c., would bear. The lunar caustic

ad laudanum injections, however, combinedacetate of lead and poppy extract,three grains each every four hours, haveecked and mitigated very much the loose-

ess, and without disturbance of any vital func--He has been for some days having in--ten grains of lunar caustic with fifteenof laudanum in four ounces of barley-water morning and evening: I have no hopeof succeeding in altogether suppressing thearrhœa, because his lungs are too far goneby half, and his constitution is too much

up to admit of cicatrisation of theof the rectum, colon, and ileum; and

le is now getting sore rather at the anus,owing to the frequent introduction of the in-a tube ; but the case shows the utilityremedy in very unfavourable circum-sances, and is therefore worth your notice.

The second case of the girl with hypertrophyheart with lesion of the mitral valve

(both sequelæ apparently of acute rheuma-. 967.

tism), continues under the iodine plan, andso far I have found reason to be satisfiedwith the remedy : she is now taking abouthalf a drachm of the iodide of potass in theday with restricted diet. I hope to be ableto give you a good account of her in somefuture lecture.*Now with respect to new cases. In the

course of the week ending Friday, the 18thof this month, twenty-five new patients wereadmitted under me. Of these several wereunder twelve months, and more than half adozen under five years of age ; the rest wereof various ages between fifteen and seventy;about half were of either sex; about halfwere cases of pectoral, and mostly pulmo-nary disease ; viz., phthisis in various stagesand combinations ; hooping-cough ; chroniccough, with emphysema of the lungs in seve-ral izistancew; two or three cases of disease ofthe heart variously complicated ; two werefemale cases of mental disorder, one con-

nected with epilepsy, and the other with

childbirth ; several were cases of pneumonia,especially in children; several of rheuma-

tism ; two of apoplexy, and of the followingsix, viz., convulsions of children, scarlet

fever, measles, hysteria, ulcerated sore

throat, debility of old age, of each one case.The discharges of my patients have amountedto twenty since my last lecture, of whichnine or ten have been by death, and the restby recovery more or less complete. Of thedeaths, two were of adult males admittedthe previous month from phthisis ; two wereby apoplexy in males turned of sixty ; bothdied within a few hours after admission. Oneof these, sixty-one years of age, had diseaseof the heart and old asthma; his heart wasenormously enlarged, and principally on theleft side ; and his lungs were emphysema-tous, as Dr. Boyd has informed me, for Iwas unable to attend the examination. Ofthe other deaths, five were under three yearsof age ; one from measles, two from doublelobular pneumonia simply, and one from thesame with convulsions ; the fifth was fromphthisis with gangrene of one cheek ; and thesixth was that of a boy seven years of age,

* This patient has been since (March 3)discharged convalescent.-Rep. L.

3 G

810

who had emphysematous lungs, upon whichvesicular pneumonia had supervened, andhydatids, as post-mortem inspection after-wards evinced, existed in his liver. Thischild required stimulants on the second day,and sank in about forty-eight hours. Of theother children, one died convulsed on the dayof admission ; a second, having incipienttuberculation of the lungs, the day after ad-mission ; a third, on the third day of treat-ment ; the fourth lingered after admissionabout a week, requiring wine on the third

day, and sank the ninth day of treatmentunder a low scrofulous pneumonia ; of thefifth I shall speak hereafter.

DIURETICS IN PIITHISIS, CHRONIC CATARRH,&c., CASES.

Of the twenty cases above alludedto as discharged by recovery or death,several had been treated on the plan shortlyglanced at in my last lecture, where I spokeof the use of diuretics in bronchitis compli-cated and uncomplicated ; of the cases, ofdeath one, and of the other discharges, twohad been under the influence of such meansfor a week at least before removal. Theformer was a man of twenty-one, admittedJanuary 26th, with unequivocal signs ofphthisical mischief, viz., more or less de- pression, dulness, and inexpansibility, with ! the sounds of breathing correspondinglychanged, in both subclavian regions; somegurgling in the left side; more or less dulnessof the superior scapular and axillary regions ;haemoptysis a month previously, &c. Other

signs evinced the existence of bronchitis

throughout the lungs, and to this I attributedmuch of the difficulty of his breathing, thestill spongy and respirable portions of thelungs being encumbered by thick, toughmucous fluids varnishing the air-passages,and obstructing the air in its passage to andfro. To relieve the man’s breathing withoutincurring risk of some new inconvenience,such as debilitating sweating or loosenesshad I given antimony or ipecacuan or pur-gatives, I gave him the following:-

B Compound juniper mixture, iss ;Nitric ether, ss;Acetate of pot ass, j.

To be taken every four hours.Under this medicine he continued from

Feb. 4th to Feb. llth ; and from the first tothe last he told me he felt his breathingeasier for it. The mixture acted freely onhis kidneys from the first. On the llth thecolliquative sweating was a deal good com-plained of, and seemed to disturb his sleep,which is of all restoratives the most valuableperhaps in such cases, and I consequentlyrather reluctantly suspended the diuretic, andgave him lead.

Diacetate of lead, gr. ijExtract of henbane, gr. iij.

To be taken every four hours.

Lead is well known to possess great astrin-gent power over all passive fluxes and si-charges from weakness, and not less againstthose of the air tubes than of other surfaces;I therefore hoped still to effect the doubleend previously aimed at of checking sweating,and at the same time restraining bronchialcatarrh, on a diilcrent principle, however.But though relieved again by the astringentit was too late; he sank on the 22nd, andthe post-mortem confirmed the diagnosis.The two other cases in which the like use

was made of diuretics, were both personsbetween fifty and sixty; one male and onefemale. In both the symptoms complainedof were cough, difficulty of breathing ; in theman of twelve months’ standing and in thewoman of at least several weeks: in each.:there was ground for suspecting tubercula-tion of one or both apices of the lungs; thefemale had sufficiently distinct dulness onthe left side about the clavicle and shoulder.and the man had similar but obscure traeetof phthisical tendencies. They were both -treated with light antimonials and low dietat first, but in the course of a few days wereboth placed on a diet, including animal food;-in limited quantity, with half a pint of ale,and were ordered diuretic mixture nearlythe same as that last mentioned. The manused the diuretics for a fortnight, when Sewas discharged to follow his occupatioos ;the woman took the medicine for a fortnightwith apparently very good effect, and wasdischarged to her home on the 22nd, convales-cent. In both these cases the action of thékidneys appeared to me to be decidedly in-creased.

’

Remarks.—Now the use of these diuretics.in cases where what are called expecto-rants are commonly chosen, seems worthy oftrial in many cases of chronic pulmonarycatarrh, simple or complicated. There is nouse, I think, in stimulating action in the ex-halent surfaces or secreting vessels of the air-.passages by means of expectorants, exceptin the acute or actively inflammatory stagesand states of catarrhs of the lungs. Whenthe disease has become indolent, chronic, orpassive, the best treatment is that which ismost analogous to the proper management ofother habitual fluxes or excessive discharges;namely, first, by direct repression of the dis-ease by inhalation of appropriate vapours orgases, or circuitously by means of astringents,such as lead, alum, zinc, or copper, by thestomach, &c. ; and, secondly, by derivativeswhich cause determinations of blood, and ofnervous action to other organs and tissues,and therefore away from the surface of theair tubes ; such are emetics, purgatives,blisters, warm-baths, &c. This view is con-firmed by the partiality of some of the firstauthorities of the profession to several drugswhich are unquestionably diuretics, and arealso supposed to be possessed of expectorantpowers; I mean squill, terebinthinates, par-

811

arly copaiba and other balsams, lobelia,ether, &c. &c. The occasional effi-

each of those in chronic catarrh isquestionable, and the diuretic propertyof them is quite certain, but their ex-

t power in some measure, if not

altogether, hypothetical. The view I am

sow explaining is further confirmed by thect, that in chronic catarrhs, antimony, and

rtar-emetic particularly, are rarely em-as expectorants merely, while ipeca-is less frequently used very much and

less successfully, I am satisfied, than in acutebronchitis; yet none can doubt the power ofeither of those over acute inflammations of

the pulmonary surfaces or substance.

GANGRENE OF THE MOUTH.

e next case I shall bring under yournotice is a case from Davey’s ward of gan- s

grene of the mouth, nearly the cancrum orisof the old writers, occurring in a weaklychild of three years of age. The patient wasSjtBitted January 21st with cough and feverof a low character, so that a little wine wasordered for him by the resident physician on admission. I examined the chest a day"two after his admission with some care,a suspicion that some organic mischiefexisted from the account I received, and theappearance and mode of breathing ; evidenceof tuberculation was readily detected in theof the right lung, and there was little

room for doubt that the fever was symptoma-$merely. This child was consequentlytreated as a phthisical subject with animalfood, such as should be found to agree best ’,on trial, beginning with fish, and, as before,*6ntioiied, a little wine daily. On the 9thFebruary I ordered five grains of tartrate ofiron every four hours, instead of a mixture ofaromatic spirit of ammonia and paregoric;4iith mucilage. On this plan he seemedstationary nearly, feeding well, and sleepingpretty well, but looking ill, and not gaining;fesh, until the 22nd, when some swelling ofthe right cheek was observed by Dr. Boyd,which went on increasing with little appa-rent suffering to the child, and without al-

most any reaction. Next day I becameaware of the swelling, and prognosticatedpretty confidently the mischief impending, orrather insidiously begun : proper means,local and general, were then employed, butthe child sank on the 25th, feeding to the lastnearly.Early in the current session a similar caseoccurred in the same ward, and the resem-blance extended to so many particulars thatthe present case reminded me early of theformer. This subject also was a boy ; he hadltalike manner tuberculation at the top of theright lung; his gangrene was in the samecheek ; he was of somewhat similar age ;èthere was the same absence of active suffer-ing and constitutional irritation ; the appe-

tite, as in the present case, continued to thelast. The gangrene in the former case,however, extended quite through from sur-face to surface, occupying the whole cheeknearly from the zygoma to the lower jaw;several of you must have seen the case Iallude to; he was admitted Nov. 13th anddied Nov. 30th. The treatment of these casesis very rarely successful, and principally,I believe, because it occurs only or mostlyin broken cachectic subjects, whose constitu-tions have lost the spring and elasticity thatare necessary to recovery, under the best di-rected efforts and happiest combination ofinfluences and remedies. The best methodof treatment is with constitutional strengthen-ing means and diffusible stimulants, such ascinchona, ammonia, camphor, wine, &c.,conjoined with the local application of astrin-gents, escharotics, and even in some cases

the actual cautery to the inside of the cheek,&c.

HALLUCINATION AND EPILEPSY.

There was a case amongst the dischargesof the last week which had been about threeweeks under treatment for mental hallucina-

tion, connected with fits, which I mustnotice. This woman was fifty-seven yearsof age, and had for nine years been subjectto occasional fits of an epileptic character.The night before her admission she had one,and after her recovery from the fit her mindwas affected; she said that she had beenbewitched by somebody in the workhouse;on every other subject her mind appeared tome quite clear, but on this subject she neverhesitated ; she seemed quite satisfied of thereality of her fancy. I listened to her storygravely, not attempting to dispute with herabout it, as I knew I might add to her ex-citement materially by doing so, and that Ishould certainly not succeed in undeceivingher. On examining her person, I found thehead hot, the carotids full, and resistingcompression strongly; her manner and expres-sion indicated excitement; she complainedof headach. She was put on broth diet,and was cupped on the nape to eight ounces,and had a senna draught immediately. Coldwas then applied to the head, and light anti-monials were ordered. In a day or two the headwas much relieved, and she told me that shehad no trouble from the witch after the second

day of treatment. On the fifth day, how-ever, I cupped her again to eight ounces,and on the ninth day all trace of determina-tion to the head was gone, and weakness

only remained : her hallucination had dis-appeared some days earlier.

Remarks.—This witchcraft i3 a commonfancy of this class of wrongheads, or acommon form of what is now called mono-mania. We have another example of theillusion up stairs at this moment : it is a case

you have all seen in Alderton’s ward, of a3 G 2

812

woman of seventy-eight, admitted January24th, with head symptoms, like those of thecase just detailed. This old lady assuresme that for a long time the spirit of someperson that is dead has lain on her, andcaused her sharp pain in every part of herbody, so that she suffers torture from it.The oddest feature in her case is perhapsthis, that though a Protestant she says nonebut a Roman Catholic clergyman can releaseher from the spirit. We meet strange things inthe practice of physic ; facts stranger thanfiction : but few things in physic are strangerthan the phantoms of the crazed mind.There was formerly (now many years ago)an official register kept by the house-sur-

geon of this infirmary, of the illusions andairy visions of the inmates of our vesanialwards, and it contained some curiousmatter. Witchcraft frequently recurred iu

it, but of course amongst various otherdreams. In the very same ward in which theformer woman was located, I met the fol-

lowing examples, amongst others, within afew years, while it was a male ward. Oneday, on entering the men’s vesanial, I saw a

patient sitting up in his bed, covered overwith the bed-clothes; he was moaningsadly. I asked what was the matter, and he whined out that tie had wrappedhimself up because of the cold, for the

angels he said were pouring water on himdown from the ceiling; and he added, hethought it very unkind of them, as he wouldnot serve them in such a manner. In thesame ward, not long after, was a man (a’quondam campaigner under the Duke inthe Peninsula) who, after being some timein the house, had become comparativelytranquil, from a state of cerebral excitementand even dangerous violence. His thoughtsalways savoured of the magnificent. He took a fancy to me, and promised to make aman of me. He told me he was going totake a tour on the continent, with the royalfamily in his suite, and he intended to ap-point me travelling physician to the party, ata salary of 10,000l. per annum. Another

day he told me he had a famous plan for thepoor, about whose wants he often spokewith apparent feeling. He said he intendedsoon to put gunpowder under all the townsin England, and blow them up, to makework for the poor in rebuilding them. 1 donot mention these things for the idle purposeof raising a titter. My object is very dif-

ferent, namely, to excite curiosity in you re-

specting the inmates of our vesanial wards.I can assure you, that amongst the ten ortwelve, or more, persons commonly, for a

longer or shorter period, under treatmentin that part of the infirmary, you will oftenmeet with facts of high interest. I nowdraw your attention to them in this

pointed way, because they are, so far as Ihave seen, less attended to by our pupilsthan other wards, and less, I think, than

they deserve. Those wards will show youthat, as in the two cases just alluded to, so inmost cases, if not all, madness, in whateverform and degree, involves some cerebraldisturbance more or less amenable to medi-cine and professional care. You will aft inthem the effects of bleeding, antimony mer-cury, stimuli, opium, cold applications, &c.,administered on the same general prineiples-as in other diseases, though with importantdifferences as to degree of activity, mode ofcombination, and other details. It is verymuch during the acuter states, when medi----cine has most direct power, that our insanepatients are admitted, being passed to vari-ous asylums, when confirmed or chronic. Ifyou are ever called before a court of inquiryrespecting lunacy, &c., you will feel the ad.vantage of having familiarised yourselves =-with the signs and effects, physical andmoral, of mental derangement. Let me addone more reason or inducement to watch thepatients in these wards. It is this :-In allages medical men have been large contri-butors to the progress of science ; every de.partment of human thought and research it.indebted more or less to medical learningand talent ; and none more than mental

science, for which perhaps more has been doneby medical men than by any other class ofmen whatsoever. Not to go too far a field, Imay refer to our great reformer Loeke as anphysician. His system has gone to piecesnow some time since, and out of the frag..’ments have been constructed, as a Frenchphilosopher (Baron Degerando) has clearly-shown, some seven or eight different andjarring systems or sub-systems. But the-business of reform in mental science hasbeen resumed on other and sounder prin-ciples, and by a physician, I mean Dr. Gall;and phrenology, or the science of mind, whenit shall have been disencumbered of nume-rous crudities, heaped on it by its founderfor the most part, will, I make no doubt,generally be regarded as the only system be-fore the public that makes any tolerable ap.proach to what the enlightened common

sense of mankind can recognise as real inscience, or useful for practical purposes.Now it was the study of insanity very muchthat gave Gall the clue : mad people are un-con3cious witnesses against, and telling illus-trations of, the unsoundness of the earliersystems. But I have said more than enoughon the point, and must conclude with this,which, if you will, you may consider anapology for alluding to such things as philo-sophy and mental science in this place ofsickness and suffering, or for a moment turn-ing your attention away from practical medi-cine,—and it is this. Having been for manya long year a physician and practitioner be-fore I had been able practically to study in-sanity, owing to the exclusion of lunatics,&:c., from our hospitals, and of medical stu-dents from our lunatic establishments, I have

813

sonally experienced the want of that

iarity with mental disease againstwhich I now warn you in time, to provideyourselves as to a considerable extent, you

may in a moderate period in those wards.

CRAMP IN THE STOMACH.-

To the Editor of THE LANCET.

SIR,—I send you an account of a mode ofarresting cramp in the stomach, which I amnot aware has been used by any other medi-cal practitioner._bout eight or nine years since I had apatient in Glasgow, a married lady, aboutthirty years of age. She had had a largefamily previous to my acquaintance with her,but had for many years been subject to vio-lent attacks of cramp in the stomach ; on

account of one of which I was first called tosee her, and at which time I thought shewould have died. I need not enumerate theantispasmodies which were used at that

time; having then and subsequently tried alljose recommended for the complaint, with-out being able to say that I had succeeded ineven checking the spasm for the time. It

seemed eventually to wear off of itself. I

had bled her, which gave relief for once ; butit was followed by such weakness, that whencalled to witness another attack two or threedays after, I dared not repeat it.The thought, by and by, crossed my mind,that I could produce a counter-spasm ; so Itook a strong tumbler, and with a bit of

lighted paper applied it as a cupping glass.-per the stomach, when almost immediatelyI had the satisfaction of hearing my patient,who could not speak a moment before, ex-claim, " The pain is gone." Since that timeit has invariably been a source of relief withher when attacked ; and I do not recollect ofever failing, if a large cupping glass wasapplied firmly once or twice over the part.Your obedient servant,

ROBERT GRAHAM, Surgeon.Helensburgh, March 1, 1842.

THE

PHYSIOLOGY AND PATHOLOGYOF

THE SALIVA.

By SAMUEL WRIGHT, M.D. Edin., F.S.A.Physician to the Birmingham General Dis-pensary, &c. &c.

(Continued from page 789.)OF the fatty acid I have nothing further

to say, than that it appears to increase theodour of ptyalin, and is, perhaps, in somecombination with it ; for in healthy saliva,which is constantly alkaline, this fatty acidis always obtained unsaturated, in the pro-cess which I have employed for its removal.

Though in the saliva it may have been neu-tralised by the soda present, in which casethe fluid would not be rendered neutral, asthe proportion of soda is always greater thanthat of the fatty acid. Supposing it to beneutralised in the saliva, the decompositionmay perhaps be effected in its removal by theether, in the same manner as water decom-poses subacetate of copper and chloride ofantimony. I offer this merely as a conjec-ture, for it is difficult to imagine a free acidand alkali existing in the same solution,without each entering into chemical combi-nation with the other.

Another principle peculiar to saliva,* uponwhich much stress has been laid, is sulpho-cyanogen. Treviranus (Biologie, iv., 565,)first observed the blood-red colour whichsaliva acquires on the addition of a neutralper-salt of iron, t and believed it to be pro-duced by a constituent, denominated by Win-terl " acide du sang," and which Porretafterwards proved to be hydrosulphocyanicacid. The observations of Porret were sul-

sequently confirmed by Gmelin, and after-wards by Ure, though the conclusions weredoubted by Kuehn, who was unable to obtainsulphuric acid from the supposed sulpho-cyanogen, by the process either of Gmelin orUre ; and he further believed, that the redcolour produced by the addition of a per-saltof iron to the saliva, is referrible to the pre-sence of acetates. (Kuehn, in Schweigger’sJournal, lix., 378 ; Schultz, de Aliment.Concoct. Berot., 1834.) Kastner very judi-ciously meets Kuehn’s objection with thefact, that the colour produced by acetic acidon a per-salt of iron, is not distinctly blood-red ; and he might have added, as a strongerargument, that acetates are very rarely metwith in the saliva. This subject has latelybeen investigated by Dr. Golding Bird, whoadvises the production of sulphuric acid, asconclusive of the presence of sulphocyanogen.He says, 11 If any specimen of saliva capa-ble of reddening the per-salts of iron be aci-dulated with nitric acid, mixed with chloride

* Peculiar to saliva in comparison withother animal fluids; it exists in the seeds andblossoms of the cruciferæ.

’ t The quantity of mucus and albumen ex-isting in saliva often obscures the action of asalt of iron upon it. And to the impedimentswhich they furnish, or to an examination ofmorbid specimens of saliva, may perhaps beattributed Müller’s failure with the iron testwhich he says produced only a " yellowish-rcd/’ or " rust red" (loc. cit., 125, 515). Toensure the full effects of the reagent, it is ad-visable to use either filtered saliva, or analcoholic solution of its dried residue. Evenwith the ordinary mode of testing, Pereirasays,

" in a large majority of cases, I findsaliva is distinctly and unequivocally red-dened by the per-salts of iron." (Elements ofMateria Medica, vol. ii., p. 1287, 8.)