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do nat set at all; diaphoretic medicines areadministered, which produce no secretions tifrom the skin-the local inflammation goes a

on increasing, the general disturbance gets tlworse and worse, and at last more, I sup-pose, by the efforts of nature, than by those D

oi 6e physician or surgeon, relief is obtain- iid. Now it seems to me, that the treatment Lof inflammation by direct depletion, appears c

under great advantage, when contrasted with c

that mode of proceeding. If you take a t

large quantity of blood from the system, you -vroduce immediate and decided relief; and,in fact, you find that those points you are t

endeavouring to gain by medicine, and do t

not accomplish for a long time, are at once

accomplished by a free loss of blood. Veryfrequently a free evacuation of the bowelscomes on after blood-letting. You will find,that soon after venesection, the patient willget into a free perspiration, and that the se-cretions are restored from the period of yourtaking away the load that oppresses the cir-Nhtion. When the system is relieved fromthat oppressive load, the natural action ofthe different parts goes on properly, and thusdimt free depletion, accomplishes at once,that which you are endeavouring to accom-plish by indirect means for a considerabletime.A notion has been entertained, that per-

sons who live in London, or in large cities,will not bear direct depletion, and that,therefore, the loss of blood which is properand advantageous in the case of persons wholive in the country, is improper in the caseof the inhabitants of London, and personsresiding in large towns. How this notion

arose, how it has happened to become so

general, I really do not know, for [ cannotconceive, that any idea can be more erro-neous. With the inhabitants of London,and large towns, we know that all kinds ofluxurious indulgences which tend to reple-uoa are carried to the utmost extent. Weknow that sedentary habits, which favoursuch repletion, are very prevalent, and,therefore, all the habits and circumstancescalculated to produce direct plethora—that!tate in which high inflammatory action willoccur, and in which that inflammatory ac-tion will require the most active means. Ican only say that I have constantly found inpatients in London, such a state of local dis-order, and general disturbance connectedwith it, as to require the most free use ofthe antiphlogistic means, and the directbleeding I have been speaking of. I con-ceive therefore, that the notion of a differentplan of treatment, in cases occurring in Lon-

and cases occurring in other situations,unfounded.

An other fear has been entertained respect-the mode of treatment I have been ad-

meeting to, which is, that although it may be

of efficacy in arresting the inflammatory ac- tion for the moment, the advantage is gainedat the expense of subsequent debility ; thatthe patient will be so weakened, that seriousinjury will be done to the constitution.Now, that is a fear of which I do not partakein the smallest degree. I do think thereis great fear of violent inflammation ; butmy fears of debility from inflammation are,.of that debility which is to be produced bythe continuance of the inflammatory process’ -of the subsequent weakening of a part,which will be produced by those changesthat inflammation is capable of causing inthe structure of the organ. In both theseways I think, there are real grounds forapprehension of debility ; but I have seenno reason whatever to induce me to fear theeffect of debility, as a consequence of theuse of those means necessary to reduce such

inflammatory action ; and I am convinced,that the real and effective way of pre-venting debility in such cases, is to adoptthe most vigcrous means for stopping theinflammation in an early stage. It has beensaid, if you take blood you will bring ontyphoid symptoms. The words typhus, andtyphoid symptoms, have been a completebugbear in medicine. Typhoid, and ty-phus symptoms, merely denote the state ofthe individual in whom certain organs are

, in a state of disease, and in whom such dis-ease has gone to a considerable extent.

I’yphoid symptoms are by no means a neces- sary consequence of inflammation generally,they merely denote a certain result conse-

quent on disease existing in a certain set of organs. The only fear then of debility in) the case of inflammation existing in thet body generally is, from allowing the inflam-mation to proceed unchecked, and to pro-, duce those changes of structure which willfsulsequently impair the function of thepart.

ABSTRACT OF THE THIRD CLINICALLECTURE

OF

DR. ELLIOTSON.

TREATMENT OF RHEUMATISM; ACUPUNCTU-RATION ; VENESECTION; COLCHICUM.

BEFORE commencing his lecture, Dr.Elliotson produced a heart which was af-fected with concentric hypertrophy, andcompared it with the one which he hadexhibited at the first clinical lecture, as an

instance of eccentric hypertropby. He statedthat it had not been procured from a patientof his own, but be had learned that the pulsehad been extremely small, the reverse of

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wbat was observed in the former case. [Itwas a fine specimen of the disease, the pa-rietes being much thickened, and the cavityof the left ventricle so reduced, as to be notmore than large enough to contain a hazelnut, and showed well the distinction be-tween the two different states of hypertro-phv.l

Dr. Elliotson then observed, that the sub-ject of the present lecture was one of com-mon occurrence, the treatment of which wasgenerally successful, if, in attempting thecure, there were a proper distinction madebetween the different kinds of rheumatism; !namely, that form of the disease which wasrelieved by heat, and that which was aggra- vated by it, or even attended by an increase !of temperature. The subject would be wellilustrated by the three following cases:—The first was that of a man in George’s

Ward, named William Goodwin, aetatis 21,cdmitted October 8th. nine mouths, buthas been unable to work for the last sixweeks; complains of pain in the left thighand leg, which is increased on pressure,especially in the course of the sciatic nerve,down to the ancle ; thinks he is better whenwarm ; bowels open, tongue clean, appetitegood, and sleeps tolerably. Acupuncture ;one needle in the hip, one in the thigh, onein the inside of the thigh, about three inchesfrom the knee, and one in the calf of the leg;to remain two hours daily. From the greattenderness of the parts, continued the lec-turer, I conceived it to be an inflammatorycase ; but the patient stated that it was re-lieved by heat, which matle it doubtful; andthis is the distinction I make between thetwo forms of the disease, namely, whetherthe pain is increased or lessened by heat;for if the suffering be aggravated by warmth,even when there is no increase in the tem-

perature of the part, it is a proof that thedisease is inflammatory, though that inflain-mation exists in a minor degree to what itdoes if the temperature be actually increased.Trusting to his own account of the symp-toms, 1 ordered acupuncture to be had re-course to, but this did not afford him anyrelief. Now I have never found this treat-

ment at ail efficacious when the rheumatismassumes an inflammatory type; and, on

questioning him minutely, after a few days,I found he had been answering at random,without even considering whether he wasrelieved or otherwise by heat, and on mak-ing a more particular examination, I foundthat there now was, evidently, even increasedheat of the parts ; and I believe the discre-dit which the employment of acupuncturehas latterly fallen into, has arisen almostentirely from its having been employed incases of an inflammatorv nature, where therewas increased heat of the parts, or where,at least, the pain was increased by the ap-

plication of heat. The mode of applyingthe remedy is also of the greatest import-ance. If needles be merely thrust in, 2ndallowed to remain only a short time, thywill in general not be found of much sen-icf,they should be left in at least two hours.The relief they afford is local, therefore inrheumatism of the lower extremity, I am inthe habit of ordering one or two to be intro.duced into the hip, one or two in the thigh,and a similar number in the calf of the leg;but the principal good will lie in the lengthof time the needles are kept in. I was nctaware of this at first, and was afraid to let

them remain in too long, lest it should be

productive of mischief, but have not foundany ill effects result from it. I speak ofrheumatism only, for when they are used toliberate the fluid of anasarca (for which pur.

pose I have often employed them with greatadvantage,) it cannot he practised with per.fect safety lower than the knee. I know onegentleman who merely took a needle andpricked the skin all over ; and another, whotook them out, after having been in onlyabout five minutes, and both were siirprist-dthat no benefit resulted. I do not know the

mode in which acupuncture effects a cure;certainly not from irritation, because thesame benefit is derived, whether the intro.duction of the needles causes pain or not ;; neither can it depend on affection of the: mind, for the same good is done, whether- the patient has any fear of the operation ornot - nor on faith, for the relief is equal,whether the patient believes in its efficacy,or laugls at it, and merely suffers you to tryit, because he sees you are anxious to aff’irdhim relief. It may probably depend on elec-tricity, but this is a mere conjecture. The, benefit is sometimes felt before the needlesare removed, sometimes not until afterwards,

’ most frequently after the second application,- though several applications are in manyt cases requisite. I once ordered them daily. for nine days before I succeeded. It willnot, as far as I have observed, he found ofany use where the rheumatism is of a kindto be relieved by antiphlogistic remedies;we must then employ bleeding, whether lo.cally or generally, and, internally, colchicum,1 and mercury, carried on till it has producedsoreness of the mouth, wilt be found about

, equal in their effects. When heat relievesthe pain, colchicum is in general of no use;- I have tried it over and over again withoutsuccess. The present case being inflamma.tory, was relieved immediately by leeches- and mercury. By carrying the latter to gen.e tle ptyalism, and repeatedly apptying thet former, the patient has been gradually get-n ting better, and lias now no pain in the I.ipe or down the thigh, and can move the limbwith little pain, insomuch, that I find he hasleft his bed, and gone down stairs smoking

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his pipe, for the last few days, without myknowledge.

The second case was in Abraham’s Ward :Benjamin Richardson, admitted Oct. 8th,æta. 34, 111 six months, complains of great;tit in his joints, especially in the hip andknees; the latter are swollen and inflamedgreat heat at night, with sweating. Muchtuv down the tibia; never had any venerealdesease; bowels open, sleeps badly ; has nopain in the chest; pain worse when he iswarm; caunot walk.Hydrarg. submur., gr. ij., bis dieOpti, gr. i., omni nocte 12 leeches to

- the right knee, and the same numberto the hip.

p. Pain much relieved by the leeches.perJat.

lo. Pain much less, mouth sore ; contin.brucines; omittr.medicamenta.

23. Mouth still very sore, though much t

better; pains nearly gone, except down the Itibia; walks, though lamely. The leeches Ito be applied to the knee and down the leg. tHere the disease was of an active character,ihhough it had continued for six montlts ; itLere was swelling of the parts, heat, pain,md sweating. On the very next day thepain was mitigated; he became better fromday to day, and has now hardly any paiu,aud will be discharged shortly ; and this ish poiut to which I wish particularly to directyour attention. An inflammation may bechronic, and yet active ; and an acute in-fiammation may be of a passive or weakcharacter. The terms acute and chronicinflammation, are by no means synonimouswith active and passive ; thus a sore throat,an ophthalmia, or a gonorrhoea, may requirestimulating applications from the very first,and an inflammation of the liver, of above ayear’s duration, may require bleeding, purg-ing, and loiv diet :-so with rheumatism; itmay at the first require stimulants, or after. long duration, may be still attended withsuch heat, as to be telieved only by local

bleeding and other antiphlogistic means.

There is a note in the furegoing case thatno pain existed in the chest, aud this leadsto a remark which it will be necessary toattend to in the treatment of rheumatism.You will frequently find, during this dis-ease, that pericarditis takes place. Amongstthe French, it is known only that infiamma-tion frequently occurs in the pericardium, ona cessation of the rheumatism in the joints.In h,egland, we as often see pericarditistake place, without any alleviation of therheumatism; indeed it is so frequent anoccurrence during the acute and active rheu-Mt.sm of young persons, that in attendingcases of the latter disease, I make it as inva-liable a rule, constantly to observe the state

of the chest, as in enteritis, to ascertainwhether hernia exists. A great proportionof cases of diseased heart, especially in

children, may be traced to pericarditis, and

on minute investigation, this disease will befrequently found to proceed from rheuma-tism. Several eminent practitioners have beenknown to say, there was no danger in casesof acute rheumatism, which have terminateda few days after in death from pericarditis.The peiicardium (not the substance of theheart) is by far the more frequent seat ofthe pectoral inflammation; sometimes, thoughrarely, it exists also in the pleura. The

symptoms are, palpitation, more or less dif-ficulty of breathing, with pain in the regionof the heart, extending to the left clavicle,and shoulder or scapula, and perhaps down

. the arm; and what is curious, the pain willfrequently stop, just short of the eJbow, or

. sometimes just short of the wrist; pain, too,is felt on pressure, between the ribs, overthe heart, or on pushing upwards under theleft cartilages, so as to press up the dia.

phragm. In many books, inflammation ofthe pericardium is said to exist frequentlywithout any pain or tenderness, but I haveinvariably found some pain on pressure

in these situations; and, in my opinion, acareful examination and attention to theseparticulars may enable us to save life, bytreating the disease in its early stage, and ifnot, it will prevent that most distressingcircumstance, the occurrence of death unex.:pectedly, after our assurance to the friendsthat no danger exists. The following caseis also of the inflammatory kind, and equally

! instructive with the two former. It was

treated, not with mercury, but with colchi-, cum.

Stephen Clements, ætatis 57, admitted.October 8th. About ten or eleven davs be-fore, thinks he caught cold whilst wa;tinafor his work. In the evening of the sameday he had chills and some pain in his limbs,,which in a day or two increasing, he hadnot the power of moving them, withoutcausing excessive pain ; he now (at thetime of admission) complains of a numb-

ness in the lower extremities, extending tothe loins, and has a sensation of chilliness.There is pain on pressure, deep seated; skinhot and dry, and the pain very much in-creased by heat ; tongue furred ; bowelsregular ; pulse 96, full. Is unable not onlyto walk, but to put his feet to the ground,and the least motion makes him cry out.Cupping on the loins to eight ounces.

Vini colchici, f. 3ss., bis die.Pulvis ipecac co. gr. x., omni nocte.

9. No relief from the cupping.10. His arms are now affected, particu-

larly the right, which he is unable to raise

274

to his head. Unable to sleep last night;pulse 90, full; tongue furred, but moist.Twelve leeches to the right elbow.

Vini colchici f. 3ss. 8vis horisOpii, gr. j., omni noete.

12. Pain in the right arm considerablybetter; in the left rather worse. Pain inthe legs more confined to the hams; tonguefurred and dry ; bowels open twice daily ;slept better last night; pulse 90, full.

13. Much as yesterday. Twelve leechesto the left elbow.

Vini colchici f. 3ss. 8vis boris.16. Pain in arms worse, in legs better;

five stools daily ; pulse 102, full.Vini colchici f 3ss., 8vis. horis. Omittr,

opium ; 20 leeches to both elbows. ’

17. Painless; bowels open twice; tonguewhite and dry. Has a troublesome cough,and cannot sleep at night. Pulse 84, full.

19. Nearly free from pain; slept welllast night; tongue dry, and slightly furred;bowels open ; pulse 96, soft and compress-ible.

20. Free from pain ; bowels open ; sleepsbetter.

Vini colchici, 3 j., 8vis horis.23. Free from pain, but complains of

wind on stomach, and nausea. Omittr. vi-nnm colcbici.

Acidi hydrocyanici, m ij., ter die.

The man was discharged on the 29th per-fectly well. The hydrocyanic acid instantlyrelieved his stomach.

Colehicum rarely does any good in acuterheumatism, without purging the bowels;then it is certaiuly more beneficial thanother medicines, which produce equal purg-ing. And I hav0 seen a few casea in whichcolchicum has effected a cure, and in a verydecided manner, without producing anyeffect on the bowels.

The illustration of the opposite kind ofrheumatism and its treatment, I must deferto another occasion.

REMARKS ON DR. ELLIOTSON’S CLINICALLECTURE ON FEVER.

By DR. CLUTTERBUCK.

I HAVE read with much interest, in a lateNumber of ’1’xs LANCET, an abstract ofa clinical lecture delivered by Dr. Elliot-son at St. Thomas’s Hospital, on the sub.ject of fever, two cases of which are givenin detail, with appropriate comments f Hisremarks are entitled to respect, both fromthe ample field of experience enjoyed by

the author, and from his known zeal and de.votion to pathological investigations. Al-

titougb differing in some respects from Dr.Elliotson, yet, in point of theory, he ap-proaches so nearly to the opinions I bare formany years advocated, that I cannot but flat-ter myself that were I fortunate enough tomake myself distinctly understood in Teuardto the views I entertain on the subject, therewould be found but little, if any, discrepancybetween us. The conclusion come to on the

subject of the pathology of fever, willneces-sarity have a considerable influence on thetreatment of the disease. I am naturally,therefore, solicitous to establish a point that,to my seeming, has so strong a practicalbearing.

I agree entirely with Dr. Elliotson in

thinking, that the two cases he has de-scribed are clearly marked cases of the dis.ease (the febris of Dr. Cullen’s arrange.ment-the idiopathic fever of other writers);and that, from the same signs which he ad.duces in proof, namely, " anxiety of COU1t-tenance, heaviness of the eyes, heat of skin,quickness of pulse, and an extreme feelingof debility," which he justly considers as theprincipal circumstances upon which the

diagnosis of fever is founded. To the samepurpose, and nearly in the same language,he further remarks, in regard to these cases,that in both there was the peculiar couu-tenance expressive of fever"—" that peculiarcombination of heaviness and distress, whichalone is enough to characterise the dit-ease."

Speaking of the disease generally, Dr.Elliotson observes, " we almost universallyfind more or less of pain in the head andepigastrium." With regard to pain in thehead’ as a symptom of fever, I am inclinedto speak in a less qualified manner than hehas done; for I have no recollection of hav.ing ever witnessed a case of real feveriawhich pain of the head was not a leadingsymptom, provided the patient retained his..consciousness, and were able to express hisfeelings. It is very common, indeed, forthis symptom to disappear after a time,though strongly marked at first; but thiioccurs under circumstances where the dis-turbance of the sensorium is on the in-

crease, and where either delirium or stu-por is approaching. The cessation of painin such cases, serves but to mark mora

strongly the brain as the seat of disease.As to the nature of fever, Dr. Eitiotson

seems not disinclined to admit, that the dis-ease may consist in inflammation; but stillif it be such, that the inflammation is gene-ral, and not confined to one particular organ,as I conceive to be the case, In some in-stances, he says, one part, as the head; inothers, another, as some one of the abdomi-nal organs, is more affected than the rest.