335

I just wish, Gentlemen, to advert shortlyto the case of stone that was operated on lastSaturday, October 17th, which has termi-nated fatally. It illustrates the way inwhich elderly persons, of a debilitated ha-bit, sometimes die after serious operations.This patient was sixty-seven years of age,thin, weak, and much reduced by suffer-ing consequent on the disease, which hadlasted about three years. He came to townto have the atone removed; and the ope-ration was performed for him, although thecase could not but be regarded, at the time,asavery unfavourable one. Life, however, ishardly worth having in the serious state ofsuffering which frequently attends this com-plaint ; so that patients may well submitto a hazardous operation for the chance ofrelief. This man was operated on on Satur-day, and he lost, in consequence of the pe-rineal artery being divided, somewhere be-tween half a pint and a pint, probably 10 or12 ounces of blood, which is not a largequantity in this operation. He was removedto bed, and I had given to him immediatelytwo grains of crude opium. Some ad-minister large opiates after all capital ope-rations, but that is not my practice ; I do notapprove of it generally; but in the case ofan enfeebled patient, like this, who hadgone through a painful operation, I consi.dered the opiate might be very usefully em-ployed ; and so it was, for he fell asleepsoon after, and slept straight on for fourteenhours. When he awoke he expressed him-self to be thirsty, and his pulse was veryfeeble; in fact, so feeble that it was neces-sary to give him wine and water. Fromthat time; to the time of his death, which Ihappened yesterday (Tuesday) evening, liecontinued, I may say, regularly sinking, inspite of the use of wine or brandy. His

pulse was feeble, his muscles tremulous andstarting, as if he had no voluntary powerover them, and his voice so feeble that hecould speak only in a low whisper. The

tongue was rather dry, with a brown streakin the middle of it. He employed the ab-dominal muscles freely in respiration, andthe abdomen all over was perfectly soft andfree from pain, so that there was not a

shadow of suspicion of inflammation there.The urine passed through the wound, not,indeed, in the usual quantity; for you maywell suppose, that the secretion of the kid-

neys was not so great as it would have beenunder other circumstances ; but it passedfreely. In the course of yesterday, slough-ing of the back took place, at least of theback of the pelvis, on which he rested inbed. He had turned over to rest on one

side, and sloughing occurred over the tro-chanter of that side. His state may be de-scribed as one of general sinking ; a condi-tion of pure and simple adynamia, or weak-

ness. On examining the body, there wasno sufficient appearance of disease to accountfor death. The abdomen was perfectlyhealthy ; the parts all natural ; the cellularmembrane, about the bladder, quite looseand natural. There appeared to be rathera deficient quantity of blood in the vessels ;they were, indeed, perfectly empty. Thiswas also observed with respect to the cavi-ties of the heart. The kidneys were not ina healthy state ; they were paler, and the

glandular structure rather firmer, than na-tural. The mucous membrane of the excre-

tory part had some increase of vascularity ;and there was a little uric acid in a looseform in one kidney, and a little purulent se-cretion in the other. The bladder was rather

small. Thus, the patient has really died,as sometimes old patients do, without anyreaction after the operation, and without theexistence of any serious disease to accountfor his death.

ABSTRACT OF A CLINICAL LECTUREBY

Dr. ELLIOTSON.

PNEUMONIA.

THE Lecturer commenced by stating to theclass, that a post-mortem examination hadtaken place during the week, of a man whohad died of pneumonia ; but there was nothing of particular interest connected withthe case, and as he had just been examininga portion of the lung which had been re-served, and found that all the appearanceswhich it had exhibited in the recent state

were lost, he should not detain them longon that subject. He would, however, detailthe appearances usually found after deathin such cases.There are three stages of pneumonia, the

first denoted simply by great increase of red-ness and weight, and the expulsion of a largequantity of frothy fluid on squeezing. It is,however, the superior parts of the lung (thebody being supposed to lie horizontally)which should be examined ; for after a pa-tient has been dead a considerable time, andlying on his back, the blood will naturallygravitate to the inferior part of the luugs,thus in all cases causing that portion to be-come very red and heavy, and to afford a

! frothy fluid, on compression. Now, in thepresent case, the lungs were much heavierthan natural throughout; and, on being cutinto, remained distended, not from theair, but from the vast quantity of blood andthin fluid which they contained. It was. remarked also, that the blood was not

336

equally diffused throughout every part, butparticularly accumulated in patches. This,too, is very commonly observed in inflam-mation of various parts, and the redness inthis case was so intense, that it could be ob-served through the pleura, giving the sur-face a mottled appearance. Notwithstand-

ing the vast quantity of fluid contained inthese lungs, they were quite pervious to air,and, on squeezing them, there was emittedmore or less of the healthy crackling sound,similar to that which had been distinguishedbefore death during respiration. When the

crepitating sound is heard during life, it is aproof, if inflammation exists, that this is inthe substance of the lungs, and in its flrst

stage, and it is heard only in the inflamedportions. There can be no doubt, then, thatthis patient died in the first stage, and deathoften takes place in that stage, if both lungs,or even if only one pf them, be inflamedthroughout

The second stage is different. The lungis stilt red and heavy, but does not give outa frothy fluid on compression, as in the first. IThe air cells are become impervious to air ;there is not any crackling sound on squeez-ing the lung after death ; and if the stetho-scope be applied duiing life, respiration can-not be heard at all in the inflamed portion,and on striking the chest, only a dead soundis heard on the inflamed spot. The lung hasbecome solid, or, in other words, hcpatiza-tion has taken place.

In the third stage, the colour of the lungis altered; we have no longer the dark-redappearance exhibited in the two formerstages, but it is now of a yeiloEVish or

strawcolour, and is still firm, heavy, and imper-vious to air ; respiration is not heard before,nor any crackling after death in the partaffected, and this contains an amber-colouredfluid, in short, suppuration has taken place.We do not generally find the pus diffusedthroughout the lung, but in patches ; neitheris it collected in a mass, for nothing is morerare than to find abscesses in the lungs fromsimple suppuration. The abscesses of thisotgan are the result of tubercles, but I donot remember to have seen simple inflam-mation induce abscesses above once or twicein my life. It is not, hovse;er, necessary forinflammation to go so far as this to producedeath ; the patient may die in the first stage,and 1 have before said, that such was thecase in the present instance. The treatmentwas not commenced here until five hoursbefore death, and I am satisfied that the case imust have been hopeless for several dayspreviously. The poor creature was pickedup in the streets, and sent to the hospital bythe Lord Mayor, in the cold fit of ague,with general dropsy, and the peripneumo-nia. I ordered him to be placed upright,and bled to fainting ; this was done, the

pulse lowered, but in a few minutes it be.came as full as before. The blood was al.lowed to flow again, the pulse was reduced,and the man laid down. Two grains of

opium were administered, five grains of ca.lomel ordered every two hours, and a blis.ter was applied to the chest.

1 have been asked by a gentleman (andvery properly), if I thought that in thisinstance, the bleeding at all hastened theman’s death Did I believe such to be the.

case, I would not hesitate to say so; but Ido not think it did, and I will tell you myreasons. In one or two instances in my life,where symptoms have been very urgent,and vigorous measures therefore requisite,I have reflected upon myself afterwards,under an idea that the event had beenhastened by the treatment, although per.fectly convinced, that the patient could nototherwise have recovered; but, then, as incases of death from haemorrhage, the pulsebecame small, weak, and fluttering, after thebleeding, that is, became decidedly worse,from the abstraction of blood : but in thiscase the patient was seen in the evening,about an hour before he died, when thepulse was not weak and rapid, but, on thecontrary, more ample, and less frequent;the pain in the side was relieved, and thebreathing much easier. When the pulsebecomes slower and more soft and ample

after venesection, it proves that the bleedmghas been of service. The man died rather

suddenly, and had the treatment been com.menced a few days earlier, I have no doubt the patient might have been saved, but therewas no time for improvement; the blister

could not rise, nor the mercury affect the, mouth. I now proceed to make a few moreremarks on

THE TREATMENT OF RHEUMATISM.

In my last lecture, 1 mentioned my con.viction, that active rheumatism, whetheracute or chronic, should be treated by localor general bleeding, and colchicum, or

mercury, internally, with lotions to theaffected parts when the heat is extreme;and that the only difference in the treatmentof acute and chronic rheumatism is, that inthe former we slieuld use bold and active

measures ; in the latter, where we cannotexpect the disease to yield rapidly, our

treatment should be, not bold, but persever-ing. In all diseases where we have carefullymade our diagnosis, not only as to the hind,but the variety of the disease, and wellweighed the patient’s powers, our businessis to be vigorous, without rashness, in acute,and persevering in chronic affections.Now in the opposite cases of rheumatism,

where there is not any increase of tempera-ture, nor any additional pain from the ap-plication of hcat, but, on the contrary, re.

337

lief from it, colchicum and the abstractionof blood would be useless ; we must thenemploy internal and external stimulants, asguiacum, ammonia, steel, fermented liquors,the hot-bath, and various irritants. Weshall find a combination of guiacum withammonia, as in the tinctura guiaci ammo-niata, very useful. The dose is cf coursevariable in different persons, generally fromone to two diachms may be given ; butthree, and even six drachms, I have knownborne. However, in doses so large as thislast, it will often cause nausea, and other-wise disturb the stomach of some persons,and should be taken diluted with barley water;yet I have known these doses i,.ot only borne,but required by the extreme coldness of somepersons in the disease. Iron also will befound of great benefit. The ammoniatedtincture is very g’c.od, but requires the doseto be increased, often from 60 to above 100

drops. It has been suppoeed by some per-sons, that the carbonate is the best 1)repara-tiou of this metal in rheumatism ; but in mvown practice, 1 have found the sulphate sui-ceed fully as well, and of’ this also, the doseis variable ; we should, therefore, in rx:ah-ing use of either of these medicines, as in somany others, feel our way, beginning withsmall doses, and gradually increasing, as wefind the stuma(h will bear, and the diseasedemand it. This is also proper for anotherreason; we shall find with most medicines,that they lose their effects by continuance,and a larne dose is required at last to effectwhat a small dose was effecting previously.Iron is often preferable to ammonia, &:c.,especially when there is great debility, notbecause the disease is chronic rheumatism,but because the disease is of a form that

requires stimulants, on account of the painbeing increased by co’d and relieved bywarmth. It is here, too, that the warm.bath is so useful, and I ordered the first pa.tient, whose case I will mention, the slipperbath dail :-Elizabeth Perry, mtat. 53, adnutted Octo-

ber 29th, says, that about seven weeks agoshe became very wet and cold during a jour-ney on the top of a coach, and immediatelyafter was attacked with severe pain in thelimbs, and gradually lost the use of herlower extremities until a week after, whenthey had become quite motionless ; cannotmove the toes at all, but the loss of powerdoes not appear to extend higher than thebiiets, and there is no loss of sensation. liasfrequent cold chills; tliirst ; tongue clean inthe middle, red at the tip and edges. Whenfirst attacked, had pain also in the back andbetween the shoulders, and then perspired agood deal, but does not now. Pulse 150,soft, and rather full ; urine high-coloured ;tongue whitish; paia relieved by warmth.Semicupium calidum quotidie liuimeutum

saponis cruribus bene infricandumbis die.Ferri sulpliatis, gr. v. ter quotidie. Dietacommunis; porter a pint daily.Nov. 2. Pain in lower limbs to-day is di.

minished, but so bad duiing the nigilt as toprevent sleep ; cannot yet move the toes.Complains now of severe pain in the righthand ; none in the back or between shoulders.Pulse 126; bowels not open since adniis-sion until last evening, when she took a dosemistura sennæ compos., and she has sincehad four stools. Tongue clean; pain al-ways worse at nirht.

3. Not more use of limbs ; complains ofmuch pain in ancles ; bowels open, pulse132. Pain severe during the night, but nowbetter. Ferri sulph. gr. x. ter die. This

plan was steadily continued, and she is nowfree from pain, and moves her limbs, andwili probably soon recover completely. Goodnourishmeat also is proper, therefore I puther on house diet, and, in addition, ordereda pint of porter daily, which will be in-creased if I fied she requires it. Stimulatingliniments are in such cases very beneficial,and one of the best is the linimentum sina-pis. It is in cases of rheumatism attended

by boldness, or relieved by heat, that acu-

puncturat:on is beneficial, excepting when ajoint is the part affected; for of course youwould not think of introducing a needle intoa joint, at least I should not do so, thoughsome among the French say they plunge italmost every whee. There is a second. case admitted on Thursday last in King’sWard, similar in its nature to the former.

Samuel Now, thirty-one years of age,. stated, on admission, that lie had been illthree mouths; he complained of pain ex-; tending’ down the course of the sciaticl nerve, accompanied by a sensation of cold,and much rel’.e’.’ed by the application of

^ warmth. The pain is clueiiyinthe calf of

’ the leg, and in the hip ; not extending tothe ancle ; and is increased by motion. Hadbeen standing in the water for some hours

- previous to its coming on. Dowels open) daily; pulse 90. Acupuncture: two needlesto be introduced into the hip, and two inT the calf of the leg.

. I - , zz ,. , r

Thinking this a case for acupuncture, Iordered it to be employed, but it could notbe done on that day ; and the next, whenthe dresser came to introduce the needles,the pain had entirely cessed. Now here itwas very evident that the cessation of painhad been caused by alarm, at the idea of

having needles introduced into the skin;but a similar occurrence may happen in theemployment of any kind of medicine. Forinstance, if a person believe he has takenI opium, the effect of sleep will he sometimesinduced, although the substance given mayhave been perfectly inert, as bread-pill. Ihave known a copious evacuation take place

338

from the bowels from alarm, at the idea ofan enema. It might be ohjected, that hadthese medicines been administered, theevent would have been supposed to resultfrom their action; but yet no one wouldattempt to dispute the fact, that opium has asoporific power, nor that salts can purge ;therefore what happened in this man, is no

argument against the power of acupuncture;no argument that, in every case where acu-puncture appears useful, the benefit is acci-dental. It had been applied before my arri-val, according to my prescription, notwitli-standing the loss of pain; but thinking itsuse could afford no ground for interference,under these circumstances I directed it tobe omitted; and the next day, when theeffects of fear had subsided, the pain re-

turned ; I therefore again ordered it to beapplied, and the patient is now considerablybetter, though still lame. I mentioned in

my last lecture, that the length of time, be-fore any perceptible improvement takes

place, is variable ; it is sometimes evidentbefore the needles are removed, most fre-quently after the second application, andsometimes not until after repeated trials.There is also a patient, in George’s Ward,

formerly treated for me by Dr. Roots,whose rheumatism is of the cold character,and is subsiding under the use of stimu-lants.

William F. Searle, a fisherman at Billins-gate, admitted on the 17th of September,stated that during the last five or sixmonths, he had had three or four attacks ofacute rheumatism affecting chiefly the ancles,and attended by swelling and redness; forthe last three months it has assumed a morechronic form, and he now complains of greatpain in his loins, and in the feet and ancles,when he first attempts to stand or walk.The pain in the loins is much increased; onrising from a low seat, or on turning overin his bed, there is much pain in the armand shoulder, and he complains of a painfulstiffness in the thumb and fore-finger of eitherhand ; thinks the pain less when warm; ’,has frequent cramp in the calves of the legs,and occasional pain of the head ; has drunkhard ; tongue whitish ; is uneasy after food,though his appetite is good ; bowels open ;urine high-coloured; pulse 84, weak, al-

though he has been taking porter and brandyto-day. Ordered a warm-bath daily.Ammoniated tincture of guiacum, two

drachms;Wine of tartarised antimony, half a

drachm every six hours. Milk diet.

On my return to town, I found him lyingin bed upon his back, unable to move hislower extremities, even his toes or his rightshoulder. These parts were all very cold,and in great pain, which was relieved by

warmth, and he complained of great debilityand depression of spirits. I continued the

stimulating plan commenced by Dr. Roots,and ordered acupuncture. Two needles tobe introduced into the right deltoid, and toremain two hours daily. Since which hehas been gradually getting better; is nowable to walk about the ward on crutches,and improves daily. Here I employed acu-puncture in the shoulder with great relief.He then caught cold from a draught from thewindow behind his bed, and the symptomsreturned. 1 had recourse to it a secondtime with success ; afterwards it attackedthe ancles, where, of course, I cannot use it;he is going on extremely well, but per.severance is required, and I have no doubthe will ultimately recover. During the ex.hibition of stimulants, the character of rheu.matism will sometimes change from the coldto the inflammatory type. It is needless to

say, we must then alter our treatment; soalso the inflammatory kind may change tothe cold, and then too it would be absurd tocontinue the same remedies. Mercury isoften useful in this inactive form of the dis.ease, as well as almost always in the moreactive kind ; bark also is very proper here,though inferior to iron; but there is one

period of rheumatism, in which it is muchmore serviceable ; namely, as soon as theactive stage is over, to prevent the inactivestage from being established ; but, in merechronic rheumatism, iron is by far the morepreferable. Dr. Haygarth is often adducedas authority for the exhibition of bark inactive rheumatism, but he did not give ittill he had freely purged and sweated, andthus overcome the activity of the disease;of course where bark is useful, quinine willgenerally be still more so. As for nor-

cotics, the best means we can employ forre-lieving pain, when it arises from inflamma.tion, is the application of leeches, and othermeans, to produce this effect, by subduingthe inflammatory action ; but there may beno harm in administering, at the same time,opium, belladonna, or strammonium, if thepain is very severe, or out of proportion tothe inflammation. The pain of cold, inactive rheumatism, is exactly adapted fornarcotics ; opium, strammonium, and bella-donna, are the most to be relied on ; butthe two latter do not produce torpor of thebowels, and are, therefore, often preferableto opium in moderate doses. They only,produce sleep in a negative manner by re-lieving pain, but for this purpose are quiteequal to opium, and in one form of rheiima-tism, I think superior. That form is the in-termittent or remittent; the pain perhapsattacking one side of the face only, and

generally coming on in the afternoon; insuch cases the sulphate of quinine, and otherpreparations of bark, and the arsenical solu-

339

tion, are of great service ; but especially anarcotic, given just as the pain is expected.

.

Belladonna, or strammonium, are admirablehere. There are two cases of this kindnow under my care. The first is that of a

voung man in Henry’s Ward, aged 20, admitted on the 29th of October, with pain in

i the right half of the head extending down-wards to the face and neck, also pains in thelimbs. It always becomes worse at six orseven o’clock in the evening, but he is

’

never entirely free from pain. Sweats much.I ordered one grain of the extract of

! ttrammonium to be given at five in theafternoon, and to be repeated every three

_ hours, until the pain was relieved; alsohalf an ounce of castor oil immediately. ’

On the 31st the pain continued, but withsome mitigation, and the exacerbation didnot occur until much later in the evening.I then ordered the dose to be increased totwo grains every three hours, whenever thepain should be severe. He has since re-

quired the pills frequently, and had a re-turn of pain, though much slighter, at fouro’clock this morning, when he took a pill,and slept until eleven, since which he hasbeen entirely free from pain. The pills have

! once induced delirium, and were thenomitted until the recurrence of the pain.

JJJ You will observe that the exacerbation of

pain, which at first took place between sixand seven in the afternoon, has (whilst be-coming slighter in degree) come on alsolater and later, until now it was protracteduntil four in the morning. Strammonium

commonly produces great thirst and dimnessof sight; this is of no great consequence;but when the patient complains of giddinessalso, or confusion of head, it is as well notto repeat the dose until these effects have

’ subsided. These means will often subdue I

the disease at once, but sometimes per-severance is necessary. Frequently whenthe pain does return, it comes on later andlater (as in this instance), in the same man-

, ner as ague, when this disease is subsiding.We should always pay particular atten-

tion to any pain within the head, or any in-flammatory marks attending the externalpain, although satisfied that the latter isrheumatism. Throbbing, heat, and swell-

. ing of the external parts, or heaviness, gid-- diness, and sense of tightness, may demand’ bleeding, general or local ; and should these; he considerable, narcotics may be impro-! per; if not considerable, these antiphlogis-

tic’measures may be used in conjunctionwith them. Now this was the case witha man in King’s Ward.John Franks, about twenty years of age,

who had been a patient of Mr. Green in

King’s Ward, complained, on the 27th 01October, of pains at the right side of the

head, increased by cold, extending down to

the face and neck. The attack came on

every afternoon at four o’clock, and lastedabout six hours ; he was then free from painuntil four o’clock the next morning, when itreturned, and continued about the same timeas before. As the disease assumed an in-termittent type, I ordered ten grains of qui-nine to be given at three P.m., and repeatedevery eight hours. Two days -after, findinghim notmuch relieved, I ordered two grainsof the extract of strammonium to be takenjust before the pain was expected, and re-peated every three hours, in addition to thequinine. This was continued for a day ortwo, when I found some inflammatorysymptoms; namely, throbbing, and in-

creased heat. I therefore ordered twentyleeches to the head, and the quinine to becontinued as before ; he has since been

going on extremely well, and is now muchbetter, though not yet perfectly recovered.When rheumatism affects the head, the

pain generally extends from the head to theface, and back of the neck ; the scalp istender, rheumatism often co-exists in theextremities, and the pain frequently is re-

! mittent, if not intermittent ; the attack oc-curring towards the close of the day, andusually confined to one side ; but though. external, it is often attended by congestion,f or determination of blood within the cra-nium, and this requires to be treated, inde-pendently of the rheumatism, in the ordi-) nary way. Just as in these two cases, I

1 frequently employ strammonium; half a

i grain, or even so much as two, or three,s grains, should be given, just before the pain; is expected, and repeated about every threes hours till relief is obtained, or the headt affected by the remedy; and on the recur-e rence of the pain, it should be repeated ine the same wey.

PRACTICAL STRICTURES ON PUER-PERAL FEVER.

By JOHN ALEXANDER, M.D., Manchester.

11 It is quite time that physic shouldcease to assert, and commence to prove ;that it should re-examine what it has hithertobelieved, together with its giound of belief,and not be content, in these days of a bet-ter philosophy, with its ancient dogmas, orwith that which it acts on from habit, notfrom conviction."—Macculloch’s Essay on

Malaria, p. 476.

IN the earlier and darker ages, medicinehad but few followers, and those few knewlittle of the art they professed. The irra-diating light of knowledge, however, gradually diffused itself, and, despite of the bar..