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to pay a good deal of attention to the stateof the skin warm and tepid bathings areadvantageous, and in the warm season ofthe year, when the latter is not so muchused, cold bathing is very beneficial. Ineed not enter upon a consideration of whatelse is proper in cases of this kind, as theprinciples I have already explained are ap-plicable to them, and I can only say, as to

medicine, that nothing more is required thanthe mere regulation of the bowels, if theyrequire it.The general plan of treatment, therefore,

will be to strengthen the frame generally,and by this we shall expect to remove slightdeformity, if it have already begun, or toprevent the progress of that deformity, bythose means, and not by any local measuresdirected to the state of the apine.

It may be a question, how far our objectcan be assisted by the employment of ma-chinery, or any means which are calculatedto remove from the spine the weight of thehead and upper extremities, for such meanshave been devised; instruments restingupon the pelvis, with a steel or iron bandgoing round the body as a support, with aperpendicular stem rising up and curvingover the head, so that the head can be sus-pended fromabove, have been recommended.Other means also are adopted to supportthe head and shoulders, but we should con-sider, in these cases, that the skeleton isreally too weak for the support of thoseparts which it has naturally to sustain, andis very ill calculated to uphold the addi-tional burden of cumbrous machinery. Onthe whole, therefore, I am not at all inclinedto resort to measures of this kind. Whenthe affection is incipient, when it has notmade much progress, I am confident, fromIepeated experience, that the general meansI have pointed out will be sufficient, andare much the best calculated to prevent theprogress of the affection, without any assist-ance from machinery. If the disease haveproceeded further, machinery really willnot help us ; it will not at all remove theeffects that have been produced. We may,however, in conjunction with the gene-ral treatment that I have pointed out, ad-vantageously take off from the spinal co-lomn, during a certain period of the day, theweight of the trunk and upper extremities,by adopting the horizontal position. It willbe well for the patient to lie upon a couch,or sofa, for two, three, or four hours duringthe day, this recumbency taking place atdifferent intervals between the exercises Ihave mentioned ; and if the young subjectsexert themselves pretty actively, they willnot be disinclined to lie down for awhile.It is by no means necessary that patientsshould lie on an inclined plane, or board,which is often used for this purpose ; an

ordinary sofa, or couch, will answer the pur-pose very well.

I should mention further, that until thesymptoms which indicate this deformity arestopped, and the frame has completely re-covered, those parts of education which re-quire close and sedentary attention should,in a great measure, be suspended ; indeed,until this object is accomplished, thestrengthening of the body should be thechief object in view ; the branches of edu-cation which require confinement and ex-ertion of the mind, should be, in a greatmeasure, postponed until the more im-

portant physical point is secured. Thepursuits of young girls, the nature of theireducation, their attention to needle-work,drawing, music, and many other of thoseaccomplishments which they have to ac-quire, keep them constantly within doors,and in a sitting posture ; and I imagine it isparticularly to that circumstance, and theneglect of engaging in the more active

sports, that the greater number of spinaldeformities, as compared with those foundin the male, is to be ascribed.

CLINICAL LECTURE

BY

Dr. ELLIOTSON.

Delivered at St. Thomas’s Hospital,June 21.

ANEURISM OF THE ARCH OF THE AORTA

AND INNOMINATA.

THE first case for our examination thismorning, is one of true aneurism, or dila-tation of the arch of the aorta and inno-minata. The patient, James Elford, a sailor,aged fifty-one, was admitted May 6th,saying, that he had been ill four months.There was great difficulty of breathing onthe least exertion ; and on examining hischest, I found a small but firm pulsatingtumour immediately behind the upper partof the sternum, chiefly at its right half.The pulsation was very strong, and a loud

bellows sound was heard in it through the, stethoscope. It was evidently an enlarge-ment of the innominata. The difficulty of, breathing, however, was much more con-siderable than it could explain ; and as thelungs and pleura appeared healthy, and theheart, though diseased, not sufficiently so to; account for the difficulty of breathing ; and,) moreover, as the bellows sound was heard. very loud throughout the upper part of the! sternum, and weaker and weaker in the, cardiac region as the instrument was movedfurther and further from the top of the stet-

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num, there was every reason to conclude, breathing, however, increased; he wasthat not only the innominata, but the arch of obliged to be kept in nearly a sitting pos.the aorta likewise was enlarged. The left ven- ture in his bed, and the legs became œde-tricle beat with morbid force, we therefore matous. He died upon the 16th of June,concluded that it was hypertrophied. The having suffered dreadfully from dyapntastate of the parts found after death, proved for a week previously. The bellows soundthe diagnosis to be perfectly accurate. The which occurred in this case loudest at theinnominata, you see, is dilated all around, innominata and arch of the aorta at the mo.to about the size of the top of the thumb at ment of the pulse, was explicable upon theits lowest part, and less above, so that it has circumstance that the blood had to flow fromsomething of a funnel shape, while the ca- a preternaturally large cavity, the proportionrotid may represent the stem of the funnel. of the channel into which it had to pass fromThe arch of the aorta, from which the in- the arch and the innominata being muchnominata springs, is, you see, greatly di- smaller than in the natural state. That alated; the substance of both is much thick- diminution of the natural proportion of aened and indurated, the inner surface rough, channel to the cavity through which it leads,and beset with innumerable yellow specks is the cause of the bellows sound, I do notand patches, many of which are scales of doubt, since whenever this proportion isactual bone, exceedingly brittle. The heart lost in any of the openings of the heart, orappears sound, excepting in the left ventri- in the course of an artery, a bellows soundcle, which is enlarged, the cavity being di- is heard. You may produce it, for exam.lated, and the walls not thinned in conse- ple, at pleasure, in a patient in Luke’squence : they must, therefore, be hypertro- Ward, in whom there is a violent pulsationphied,-have a considerable addition of sub- in the whole abdominal aorta, without anystance, or the dilatation would necessarily bellows sound, unless you press the vesselhave made them thinner. I should have firmly with the stethoscope, and of coursementioned, that the pulsation of all the ar- narrow its channel, when it instantly occurs,teries, particularly those of the head, was and its intensity may be regulated at pleavery strong, and I do not recollect having sure. There was, however, in the case ofobserved this in such a degree as to have the deceased patient, a second bellowsdistressed the patient, unless the hypertro- sound, the cause of which I do not under-phy, if any existed, was accompanied by stand ; it took place.after the first bellowsdilatation of the cavity ; and simply, I sup- sound, at the time the auricles contract, andpose, for this reason, that when dilatation of yet there was no obstruction, nor any dis-a cavity exists, the addition of new sub- eased appearance at the opening of eitherstance to maintain or augment the natural auricle. I am inclined to believe, that thisthickness of the - walls, must be propor- second bellows sound, though it took placetionably so much greater than when there at the time the auricles contracted, had no.is no dilatation. The interior of the arch thing to do with them; for, in the firstof the aorta is also exceedingly red be- place, the auricles and their openings weretween all the yellow patches, and proba- healthy ; in the second place, this soundbly inflamed ; but I will not assert this, was not loudest in the auricles, but at thebecause a quantity of blood has been lying root of the innominata; and, thirdly, be.in contact with it, and this will sometimes cause although arteries do not appear ordi-dye the interior of the vessels after death. narily to dilate at the moment of the pulse,

Although from the great probability, the arch of the aorta in this case of diseasenearly amounting to certainty, of disease of is very likely to have dilated at the strokethe arch, and the evident existence of dis- of the heart, and if so, would of course re-

ease of the left ventricle, I considered a sur- cover itself, and slightly propel the bloodgical operation quite out of the question ; onwards into the comparatively narrow in-yet as aneurism merely of the innominata is nominata and its branches immediatelynow and then treated surgically with suc- afterwards; that is, at the very time that thecess, it was my duty, both to Mr. Green and auricles were contracting, and the secondthe patient, to desire the opinion of Mr. bellows sound would thus ensue.Green upon the case, and he very properly --

declined operating. I put the patient upon ENLARGED LIVER.

merely milk diet, and bled him from time to The second case was one of enormouslytime, and exhibited tincture of digitalis. I enlarged liver, to which I alluded in thedo not know that I prolonged his life, but lecture of last week, as being beyondhe was always easy for a time after bleed- hope. I will not trouble you with the symp-ing. Great tenderness of the epigastrium toms and treatment again. The man wasand sense of heat came on, as are frequently admitted on the 22d of April, and died onobserved in chronic diseases of the lungs the 17th of June,- having been ill two yearsand heart, and required the occasional ap- before his admission; and his liver, when Iplication of leeches. The difficulty of first saw him, extending to below the navel,

537

from one side of the abdomen to the other, anything more than simple chronic inflam-The liver, you see, is exceedingly hard, mation. On examination per vaginam, thenearly double its natural size and weight, only thing found was a fulness of the mar-and of a pale dingy yellow appearance. You gin of the os uteri, rather an enlarged statesee innumerable minute granules in it, which of the latter, and tenderness; menstruationare supposed by Andral to be so many hy- was regular. I began by cupping her onpertrophies of the minute bile-vessels; their the loins to twelve ounces, and in a weekinduration, however, in many parts, is be- ordered thirty leeches to be applied to thecome such, that granules are no longer pubic region every other day, purging herseen, but a uniform whitish and very hard daily with salts and senna. This treatmentcondition only. A similar change has also would very probably have subdued the com-taken place in the kidneys, so that from the plaint; but at my visit last Monday, to myhypertrophy and induration of many of the astonishment I found that since my visit onsmall vessels, a section of them has a per- the Friday, she had been seized with peri-fectlymottled appearance. The same change tonitis, and died. I found by the book thathas likewise taken place in the peritoneum, five grains of hydrargyrum cum creta hadand particularly in the omentum, which is been given her every six hours, and I sawbecome so thick and hard, as to resemble the on the body that leeches had been applied.spleen of an ox, excepting in colour; for, On examining the body, there were thelike the indurated portions of the liver and marks of as intense an inflammation of thekidneys, it was pale. Crude tubercles were peritoneum as ever I witnessed, both parie-formed in various parts of the lungs. The tal and intestinal, and indeed almost everyimmediate cause of his death, however, part : a large quantity of opaque straw-colour-was peripneumonia and peritonitis, with ed fluid was seen, and the peritoneum cover-which he was attacked between my visits; ing the fundus of the uterus and one ova-and I was surprised to find him nearly dy- rium, were of a dark colour, from excessiveing with this affection when I happened to congestion of blood. The uterus was freebe in the hospital on Monday. I of course from all organic disease, as I expected; butattempted to get away a little blood, both bv larger throughout its substance than usual,venesection and leeches, but none could be as is observed after chronic inflammation.obtained by the lancet, and only a very mi- Menstrual fluid was in its cavity.nute quantity by the latter, so that he died The three former patients died of incu-three or four hours after I saw him. The rable diseases, which were near their termi-breathing was rapid, and with crepitous nation when admitted into the house.rattle; the whole abdomen tender on the ————

slightest pressure. Some reviving liquid ABDOMINAL INFLAMMATION.

medicine had been prescribed for him in The following case, in the same ward, of £

my absence, which I tasted, but no state- abdominal inflammation, well illustrates thement of its nature was given. advantage of active treatment. S. A., aged

——— 18, admitted May 27th, had felt sick, andPHTHISIS. had a headach, for which she took some

The next case was one of phthisis, which aalts of her own accord, upon the 24th.

was admitted into the hospital in the last She felt them hot in her mouth, throat, and

stage on the 3d of June. The patient was stomach, as though she was being burnt bysent by the Lord Mavor, and therefore them, and from that moment pain began incould not be refused; and finding that he the head and abdomen, with vomiting andhad neither home nor friends, I could not constipation. I found her exceedingly hotdischarge him ; no good could, of course, be throughout, the pulse quick, every part ofdone, and lie died in thirteen days. The the abdomen painful, and likewise tender.lunas were rotten throughout, and one large The tongue was brownish, she was thirsty,cavitv, just before his death, burst into the felt sick, and vomited. She had had no

pleura. ’ stool for three days. I had her instantly

’

’

___ bled to faintness, which required about a

CHRONIC INFLAMMATION OF THE pint, and she took twelve grains of calomel,UTERUS followed by castor-oil every two hours till itThe fourth case was that of a woman ad- operated, and she was confined to barley wa-

mitted on the 27th of May, aged 40, who ter and gruel. The next day I found the painhad been ill six months, with signs of chro- not sufficiently relieved, and the bowels notnie inflammation of the uterus. The symp- freely open. The bleeding therefore wastoms were, pain of the loins, hips, and hypo- repeated to the same amount, and the calo-gastrium, slight bearing down forwards, and mel and castor-oil. The blood each timea white vaginal discharge. As she was was buffed. On the 1st of June she was astout, and altogether of very healthy appear- great deal better, but there was still con-ance, I could not refer these symptoms to siderable heat and some little pain, and IMY malignant disease of the uterus,-to deemed it necessary to bleed her again.

538

Her mouth becoming slightly tender, the FEVER.

bowels were kept open with salts and The next female patient laboured undersenna. On the 4th I found her perfectly continued fever, with the ordinary mild ia.well as regarded the original complaint, but flammatory symptoms. She had been ill,troubled with drowsiness and giddiness, for fortnight, and was 16 years of age. I hadwhich she was cupped to a pint at the back her thoroughly washed with soap and waterof the head, being a stout damsel, and in the first place, and afterwards spongedstill having a florid complexion. She was with tepid water whenever she was hot;presented on the 17th of the month per- she took five grains of calomel, followed by i

fectly well. half an ounce of castor-oil every day for four ,———— days; no abstraction of blood was required;DROPSY. she was kept on slops ; was presently con.

In the same ward are two cases of what valescent, and presented well upon the 17thyou have seen so frequently lately, viz., in- of June, having been admitted on the ist,flammatory dropsy. The one, a strong old She was allowed milk at the end of a week,woman, aged fi3, in whom a decidedly and meat a day or two before she left.inflammatory condition of the head was ———

shown by headacli, giddiness, throbbing, OVARIAN DROPSY.

and heat of that part; the tongue was very Two patients left the same ward verym.red and dry; the chest was perfectly un- satisfactorily. The one with dropsy of theaffected, and so was the abdomen, except ovarium. She had not been in the housethat she was very costive. The inflamma- two days before she grew melancholy, not.tory state of the head, with her general withstanding I allowed her a pint of porterhearty appearance, determined me on bleed- a day, and wished to return home to die.ing her, though, of course, not to any great It is curious that her successor in the bed,amount. I ordered only eight ounces, and has also a dropsy of the ovarium.gave her a grain of elaterium, to be repeated ———

every two hours, till evacuations were pro- PARAPLEGIA AND DISEASE OF THE BLADDER.

cured. A grain was afterwards given every The other case which left unsatisfactorilyday for a week, then suspended for a few was one of paraplegia and diseased bladder,days, and afterwards employed again. She the consequence of a blow upon the loins. H.got perfectly well, and was presented well W., aged 55, ill a year and a half, had fallenupon the 17th of June, taking, at the time, flat upon her back, and from thattime expe.compound infusion of gentian and acetate of rienced a gradually-increasing weakness ofpotass. the lower extremities ; she could not reo

Although this patient required bleeding, tain her urine long ; it was not acid as iton account of the state of the head, and to should be when made, and contained a largeunload the vessels generally, as there was quantity of white tenacious mucus. It isnot the slightest sign of debility, the case very common, after injury of the loins, foris not one of regular inflammatory dropsy. It the urine to be deficient in acidity, so

had not come on suddenly, had not affected as to become alkaline soon after it is made,the face, and was not attended by albumi- and to deposit the phosphates; they werenous or abundant urine, all which circum- not deposited in this instance; but after astances are more frequently observed than great lapse of time, if she is not cured, Inot in acute dropsy. have no doubt that they wilt be deposited,The case to which I shall now direct your and the mucous membrane of the bladder

attention at No. 9, was a genuine instance may probably be thickened, if it is not al.of acute or acuto-chronic inflammatory drop- ready. The remedy on which I placed thesy. The patient, a female, was 16 years greatest reliance, in the treatment, was se-old, admitted May the 20th. and had been tons in the loins, at the highest part to whichill a month. It arose from her feet getting the paralysis extended ; to assist, however,wet ; affected the face as early as any other the healthy secretion of urine, I gave her

’ part; she was hot; the pulse was 100, and muriatic acid at first, in the dose of five mi.rather full ; the urine albuminous ; she was nims, gradually increasingit to twenty-threebled twice to a pint; purged regularly with minims a day, not finding that the urine be-the supertartrate of potass and jalap, and put came more acid. To assist the mucous coatupon milk diet. Under this treatment she of the bladder, I gave her, three times a day,was steadily improving, but it was found an ounce and half of decoction of uea nrsi,that her friends brought her meat puddings made with an ounce to any quantity of waterand other improper articles of diet. This I boiled down to a pint. Not finding herpassed over once, as I was anxious to cure improve, I began with the stricbnine, in theher; but as similar things were found under quantity of a quarter of a grain three timesher bed soon afterwards, all ready to be a day, intending to increase it accordinglyeaten, I discharged her on the 17th of this as I found it was borne; but soon after shemonth. - began it, as her seton had worn -out &4.d

539

healed, and I wished another to be made, ,

she tefused having it, and made up her immd never to get better, so that she wasdischarged at her own desire.

EPILEPSY.

Among the men, I was obliged to dismissa patient for irregularity of conduct, whosecase was also paralytic, the man whom Ispoke of in my lecture on epilepsy, as an in-stance of the union of the different affectionsof the nervous system. He laboured under

epilepsy and amaurosis, with severe pain inthe head. By frequent repetitions of leechesto the head, and the formation of a seatonin the neck, with the constant application ofcold wasli to the head, he entirely lost theepilepsy and pain in the head, and under theuse of these, mercury and iodine; theamaurosis also was gradually declining. He,however, slept out one night, which I for-gave, as he had been in thelhouse for manymonths, but he so soon afterwards went outfor the greater part of a day, when, of course,any irregularity of diet may have beencommitted, that I was obliged to dischargehim.

ECZEMA.

A case of eczema of the leg was presentedon the 17th of June, having been admittedinto the same ward on the 20th of May.The man’s age was 56, and he had beenill five years, at intervals ; the whole legwas red, hot, and beset with thin crusts,formed by the exsiccation of a thin discharge.This was one of those cases in which Dr.Johnson’s saying is true, that philosophydoes not warrant much faith in a lotion, how-ever useful lotions may be, and they reallyare useful. The disease would not havebeen cured without more energetic, andindeed, constitutional measures; as his

pulse was good, I bled him to 3xij, and, not.withstanding the long duration of the disease, the blood proved both buffed ani

cupped. In eczema and impetigo I gene.rally find mercury beneficial, and I therefonordered three grains of calomel twice a dayOf course he was put upon milk diet, anienjoined to keep the leg in a horizontal posture. The effect of these measures wa

instantly to render the leg much cooler an,less painful ; it rapidly improved, and othe 17th of June was perfectly well. Asoon as his mouth was slightly affected, saltand senna were given daily, instead of thcalomel. At first, the yellow wash, consising of corrosive suhlimate, decomposed ilime water, was employed, which is a f!vourite application with many surgeons, btit proved irritating, and cold water was sulstituted in its 100m, the powdered oxide Izinc being sprinkled upon those parts fro:

which any exudation came. Latterly, whenall heat had ceased, the ointment was usedalone to those spots which were deficientin cuticle, and I do not know a better oint-ment than this, where a mild application isrequired to a raw surface. Yet frequentlyI have seen it and every other ointmentirritate, simply from their greasy nature ;and on substituting the plain oxide in pow-der, or cold water, or Goulard water, nogrease being brought near the part, the irri-tation has all ceased and the part healed,whatever minht be the disease. I have the

highest possible opinion of the applicationof cold water to any part of the surfacewhich is above its natural temperature. Infever and other diseases of general andsteady heat, I always employ cold effusionor, more frequently, ablution. la acuterheumatism, erysipelas, &c., and all cuta-neous diseases attended by morbid heat, Iemploy it locally, never with ill effect, andalmost always with the best, while the pa-

tient’s feelings are consulted. If it producespain, chilliness, or discomfort, it is pushedtoo far, or does not suit that particular pa-tient. But as a general rule, it cannot bewrong to reduce morbid heat to its naturaldegree, provided, perhaps, that this is notsuddenly done.

ii __________________________

ON FEVER.

" Commenta opinionum delet dies, naturae judiciaconfirmat."

HowEVER we may pride ourselves on themarch of intellect ", in the pursuit of phy-sical science, it is to be regretted that wecannot boast of the same unequivocal andprecise ideas upon many subjects of patlio-logy. The connexion between anatomy,physiology, and pathology, is not obvious,although we might wish to infer that a

knowledge ofmorbidehange should uniformlyconduct us to a true diagnosis in the differ-ent periods of a disease, during the life ofthe patient. We know indeed that a greatproportion of diseases is founded on mor-bid action only, and consequently produce -no change that we can anticipate by anatomi-cal research , and we may with confidenceassert, that in a multitude of cases of fever,where recovery ensues, the integrity of themachine is preserved, or very slight disorgan-isation occurs. No disease has challengedso much inquiry as, and few have yielded agreater discrepancy of opinion than, fever,which, though clothed in mystery, and oftoo subtle and complicated a nature to admitof a concise definition, presents a uniformseries of phenomena, sufficiently obvious to