MAY 4, 1844. 175

CLINICAL LECTURESDELIVERED AT

THE CHARITÉ (HOSPITAL), BERLIN,BY

PROFESSOR SCHONLEIN, M.D.Physician to the Hospital, Professor of Pathology andTherapeutics in the University of Berlin, and FirstPhysician to the King of Prussia.

(Prepared, for publication in THE LANCET, from the Reportsof DR. L. GUERTERBOCK, by G. L. HARTWIG, M.D.,Antwerp.)

ACUTE ARTICULAR RHEUMATISM.

AFFECTION OF THE HEART. MILIARIA. DERANGEMENT

OF INTELLECT. REAPPEARANCE OF THE ARTICULAR

RHEUMATISM. APHTHA. PNEUMONIA. DEATH. AU-

TOPSY.

NOVEMBER 9, 1840. Louisa Wustenhagen, twenty yearsold, a servant girl. From the patient’s account it is notdifficult to understand the nature of her disease ; she isattacked with rheumatism of the joints, and says that shehas suffered twice before with the same complaint. Thelast attack took place three months ago. At that time

symptoms appeared in the chest, that did not disappearwhen the rheumatism left the joints, but continued,although in a slight degree, and the nature of which gaveevident indications of an affection of the heart; the leastmovement brought on difficulty in breathing, and verysoon palpitations of the heart. Six days ago, she wasattacked for the third time with rheumatism in the joints.An emetic was prescribed, which brought on vomiting,but no alleviation of the symptoms, and in this state shewas brought the day before yesterday into the hospital.The violence of the symptoms of the heart, and of theconcomitant fever, required energetic treatment, andmade repeated venesections necessary (the first of sixteenounces, the second of twelve ounces). Each time theblood formed a considerable buffed crassamentum.At present we find the following symptoms :-First. Almost all the articulations of the body are

attacked, particularly the elbow and shoulder-joints, andthe articulations of the vertebrse, so that the patient isobliged to lie quite stiff. I have not unfrequently seen insuch cases the articulation of the lower jaw attacked,producing lock-jaw, as well as the articulation of the ribswith the breast-bone ; in this case we find nothing of thekind present.

Second. Symptoms of the heart.-This complication,which is so frequent in articular rheumatism, and whichhad already taken place during the second attack, doesnot only prove its existence by subjective signs, such asgreat oppression, want of breath, anxiety, palpitations ;but also by physical symptoms, namely, far-extended

beating of the heart, increased impulse of the heart, par-ticularly of the left ventricle, and not only the rubbing(bruit de frottement), but also the bellows-sound ; it istherefore evident that, not only the pericardium, but alsothe endocardium is attacked.

Third. Febrile symptoms.-The pulse beats I 10 timesin a minute, but is no longer so full and hard ; excessivethirst ; moist skin, alternating with dryness ; it is not acritical but a symptomatical sweat, which frequently ac-companies symptomatical miliaria, that have not yetmade their appearance. The urine begins to form a sedi-ment, but has not a very sour reaction. In our treatmentwe shall have to’ pay particular attention to the affectionof the heart; we shall therefore order a strong blister tobe placed upon the region of that organ, and prescribe,partly to moderate the fever, partly to favour the crisis byurine, the following medicine :-Infusion of digitalissix ounces ; mucilage of salep, two ounces;wine of seeds of colchicum, water of bitter almonds, nitre,of each two drachms; simple syrup, one ounce. Mix.Every hour a tablespoonful.

10. The articular affection maintains pretty nearly thesame degree, but its intensity is by no means alarming;

the seat of the affection is more tormenting to the patient,since the articulations nearest the trunk are particularlyattacked, which is never so favourable as where thefarther-removed joints suffer. The symptoms about theheart are more moderate, there is no longer that feelingof anxiety which previously existed ; no palpitations ; thephysical signs likewise show an amelioration ; the impulseof the heart is weaker ; the friction has completely disap-peared ; the bellows-sound is still audible, but with lessintensity. The fever, which had lost its sthenical charac-ter after the blood-lettings, and assumed the erethicalone, still maintains the same character, but in modera-tion (90 in the minute). The urine is no longer so darkly-coloured, nor so saturated, but we should have liked thistransition to the natural state to have taken place afterthe formation of a crystalline sediment, since we knowthat rheumatic endocarditis, when the critical excretionhas been missing, very much predisposes to the formationof concretions in the valves of the heart ; perfect arthri-tical concretions, such as are frequently formed in thearticulations. But we must not omit to mention thatwith women the want of this characteristic sediment in theurine is oftener observed than with men, without anyprejudicial consequence to the heart; and that with them,instead of the crystalline sediment, we not unfrequentlyfind a consistent acid mucus (probably cystin) which isoften accompanied with an acid, corrosive flux from thevagina. The skin is moist, but the colliquative sweat isvery much limited; the perspiration has a very soursmell. As yet there is no appearance of miliaria. Themedicine prescribed yesterday is to be continued.

11. We have seen the morbid phenomena that relate tothe external membrane of the heart disappear, while thosethat belong to the muscular substance, and to the innermembrane, still continue. The state of the joints is prettymuch the same, only the pain is somewhat diminished onthe right side. The fever remains as it was. We havestill one phenomenon to notice, namely, that instead ofthe more consistent stools, we have since yesterday stoolsof a watery nature. We now hear that before coming tothe hospital the patient had diarrhoea, which, however,disappeared after the energetic antiphlogistic treatmentemployed. Wine of colchicum can produce diarrhoea,even when taken in very small doses; as long as onlytwo or three stools daily take place, we should have noreason for discontinuing its use, although I am not of

opinion that colchicum requires evacuations for its p roperaction. To correct the purgative properties of colchicum,some have recommended the addition of opium, but thisis by no means so sure a corrective as is supposed. If weconsider the reigning epidemical constitution, and thefrequency of typhus at this time ; if we consider, besides,that the fever has no longer a sthenical character, that itmaintains itself on the same height, and is out of propor-tion with the local phenomena, since the joints are notswollen, and the superjacent skin not reddened, we shallbe induced to be a little more circumspect with the use ofcolchicum, and prescribe the following medicine :—Infu-sion of digitalis ( 3 ss.), six ounces ; liquid acetate ofammonia, half an ounce ; extract of aconite, six grains ;opiated syrup, two drachms. Mix. Every hour a table-spoonful.

12. Radical changes have not taken place, nor could itbe expected. The most agreeable circumstance is, thatthe symptoms about the heart are diminishing ; thesounds in that organ, and the subjective phenomena,have disappeared; but the strong impulse of the heartstill continues. Our chief care must be directed to thatorgan. In all cases where the impetus of the heart is

. augmented, we are not quite sure the irritation will notpass again from the joints to that organ. The articu-lations of the right arm are again more affected ; the

, fever is moderate, the pulse risen (88 in the minute) ; theskin moist, but secreting towards evening a real colliqua-

; tive, very sour-smelling sweat, which so often announces, miliaria ; we must therefore not act too much upon the, skin, for we have to fear this complication, which so. easily causes the rheumatic affection to quit the joints,

and paralysis of the heart quickly to follow.14. The eruption of miliaria has now taken place, par-

; ticularly on the chest and neck of the patient,-anH2 2

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eruption we feared from the beginning. The alternationof.a dry skin and of colliquative sweats, with concomitantaffection of the heart, always makes this eruption to befeared, and warns to be moderate in the use of diaphore-tical medicines. (See first note at end of case.) But inthe case before us, the eruption has not been artificiallybrought on, for we have not made use of very activediaphoretics. I have also to observe that the eruption ofmiliaria frequently takes place in spite of a cooling anti-phlogistic treatment, as I have more than once seen atWurzburg, where it often appeared on the second day ofthe complaint in spite of blood-letting. The physiciansin Verona and Bergamo have made the same remark.The appearance of miliaria must therefore not be madean immediate subject of reproach to the physician, for,by inquiring at those places where miliaria has epidemi-cally reigned with fatal effect, we find that the exanthemaappears in spite of all medical care. If a physician findsno eruption of miliaria in the place where he practises,he should be thankful for it, and not forge weapons onthat account againt his colleagues. Nor can we be

reproached with having violently suppressed the diar-rhoea, and having thereby called forth the miliaria.

15 and 18. With the continuation of the former treat-ment, and the washing of the body with alkaline solutions(see second note at end of case), not only the eruption ofmiliaria, but also the phenomena in the joints and heartgradually disappear.

20. Since the last day or two we find a remarkablechange in our patient ; a strange inclination to cry, agreat irritability of the nervous system, the least thingmade her shed tears. Soon after she got the idea thatwe wanted to poison her. she therefore refused all drink,and from time to time screamed and raved violently, sothat she had to be removed to another room. Along withthis aberration of the intellect we could perceive no otheraffection of the brain, no febrile symptoms, they hadentirely vanished with the affection in the joints. Last

night she had some rest, but soon after fell again into theold state. We must observe that a moral contagion hadacted upon her ; she lay close to a patient who hadpoisoned herself with sulphuric acid. But this does notexplain the fact. We find two circumstances in this casefrom which this peculiar phenomenon of derangementmight be explained, and we have only to ask the questionwhich of the two deductions is the right one, since they

- have an influence upon the prognosis and treatment.The first explanation is that the derangement is an effectof the medicines we prescribed, since we have given thepatient, several days successively, colchicum, and after-wards aconitum ; from this point of view the aberrationof intellect would be a medicinal symptom. I must hereconfess that I have more than once seen this phenomenonafter the use of colchicum, and the more readily when itdid not act very much upon the intestines. I particu-larly remember the case of a barber’s apprentice, sometwenty years old, who suffered with acute rheumatism,and on whom, after four days’ use of the wine of colchi-cum in moderate doses (miliaria also was present), themost violent delirium, without any febrile symptoms,supervened ; it lasted furty-eight hours after the use ofthe colchicum had been omitted; a few doses of opiumwere given, and sleep ensued, from which the patientawoke perfectly cured. I have also observed that heavi-ness of the head, oppression in the forehead, unquietsleep, are the forerunners of this state, and that upontheir appearance one does well to discontinue the use ofthis remedy. In this case it is not probable that thederangement is owing to tie colchicum, since it has actedupon the intestines, and has been discontinued five daysago. Has aconitum a similar influence ? Of this I knownothing, but should not suppose it in this case, since allother narcotic symptoms are missing.The enigma might be explained in a different way. The

influence of diseases of the heart on the mind is wellknown; Professor Nasse, of Bonn, has shown that thecause of a great many alienations is to be found in theheart, though he has somewhat exaggerated the fact.Even the people make use of the expression, "He is asoft-hearted man." We have here a decided affection ofthe heart, though not a softening of the organ ; for the

increased impulse speaks for a thickening of its sub-

stance ; however, we find, not only in cases of softeningof the substance of the heart, but in all its diseases, adisturbance of the mind, which shows itself at first inanxiety and agitation, but frequently also becomes a fixedidea, so that the patients imagine they are criminals andabout to be led to execution. The question might, there-fore, also be explained this way. The prognosis will bedifferent according to the cause; for if the mental aber-ration proceeds from the medicine, it will be transient ;but if it is a consequence of the affection of the heart,it will persist, and is completely out of the reach ofmedical art. The treatment will, of course, differ withthe cause. In the first case the head must be fomentedwith cold vinegar, opium taken inwardly, and the patientmust smell camphor ; in the second case these remedieswould be of no avail. Reasons might be adduced forboth opinions. The influence of the medicines and theduration of the affection will soon throw light upon theorigin of this mental aberration. We shall begin byacting up to the idea that it proceeds. from the medicine,since the remedies suitable in this case will do no harmif the disturbance proceeds from the second cause.December 1. The constancy of the intellectual derange--

ment and the inefficiency of the remedies we have madeuse of, evidently prove that it cannot be attributed to themedicines we prescribed, but that it is owing to the affec-tion of the heart, which remained as the residue of aformer attack of rheumatism. The derangement appearedparticularly in paroxysms, and had very much diminishedduring the last days, when. suddenly, yesterday evening,a new attack of rheumatism showed itself in the articu-lations of the vertebrae of the neck and in those of the-fingers. It was accompanied with a violent fever, and thesymptoms of the affection of the heart increased. This

morning the rheumatism in the joints has again disap-peared, but the fever still continues, and there is alsodiarrhoea. Prescription: Oily emulsion, with laurel--water and liquid acetate of ammonia.

4. The rheumatism had entirely disappeared after ashort duration, but the fever still continued. As in theformer attack we witnessed the eruption of miliaria onthe skin, a similar exanthema now seems to form itself onthe inner mucous membranes; we find aphthse in themouth, and the watery stools continue; the same pro-cess that we find occurring on the mucous membrane ofthe mouth most likely, therefore, also takes place on themucous membrane of the intestines. If the formation ofmiliaria on the outer skin be already highly unpleasant,its appearance on the inner lining of the intestines mustbe still more so, particularly as the fever has also assumeda torpid character. Prescription : Against the affectionof the mouth, rinsing with a solution of borax and honey;inwardly, emulsio chinata, with a solution of carbonate ofpotass.However, the fever increased, the diarrhoea continued,

while the sensorium remained unattacked ; symptoms ofpneumonia appeared, and the patient died on the 7th ofDecember, after a severe struggle.Autopsy.-The brain was neither filled with blood nor

could anything abnormal be found in any part of it.Both the lungs showed, in their lower lobe, evident hepa-tisation. The volume of the heart was increased, theleft ventricle, particularly, was hypertrophied; the valvesof the aorta presented a cartilaginous degeneration. Theliver was very much increased in size, otherwise healthy.Nothing else worthy of notice in the abdomen.

Note I.-Another symptom announcing miliaria is thesubjectit’e sensation of palpitation of the heart, upon whichProfessor Schonlein made the following remarks in

another case of articular rheumatism :-Not long agoit was blazoned about as a new discovery that inflamma-tions of the heart are concomitant with acute rheuma-

tism. Bouillaud has had this ridiculous pretension ; itis an old song that the Italians brought to the north, andwhich, on account of the height of the Alps, the Frenchdo not seem to have heard. However beneficial! it maybe to direct attention to this well-known fact, and to

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conclude from thence that the heart must never be left

unexamined in this disease, even when the patient doesnot complain of any unpleasant sensation in that organ,still an error that has shown itself highly injurious inpractice has arisen in consequence, since this fact led tothe conclusion that an organic affection of the heart is a

constant companion of acute rheumatism, and that there-fore in all cases blood must be drawn. But cases have

been known where the patients perished in consequenceof venesection, and when the doctor found to his terror

no signs of the fancied inflammation ; for, besides cardi-tis, endocarditis, and pericarditis, symptoms about theheart take place in this disease that have by no means aninflammatory character, and against which the use ofvenesection has the most dangerous consequences. This

is the state that has been called innel’1;ation of the heart,and which may be considered as a forerunner of miliaria.The patients complain of oppression on the chest, wantof air, violent palpitation of the heart, but all these

symptoms are merely subjective, since the physical exa-mination of the heart shows nothing abnormal. This

phenomenon reminds us of a similar one that we find inchlorosis. It is of the highest practical importance to

distinguish this innervation from inflammation of the

heart, for which the latter requires copious venesection,though not in the rapid succession (saignées coup sur coup)that Bouillaud recommends; the former demands a

totally opposite treatment,-external stimulants on theskin, and remedies that derivate to the kidneys andintestines. The points on which the diagnosis is foundedare not dim cult:—

First. The palpitations of the heart are periodical ininnervation; in inflammation they are permanent, althoughnot always of the same intensity.

Second. In cases of innervation the stethoscope showsonly quickness of the pulsations, but not an increasedimpulse, as in carditis, nor the sounds that we find inendocarditis and pericarditis.

Third. The other phenomena, which likewise precedethe eruption of miliaria, such as colliquative sweats of anextremely acid quality, that come and go Tapidly, andsometimes small miliary vesicles that appear in variousparts, particularly at the neck. Sometimes we also find

more or less violent symptoms of angina, as in other acutee-xanthemata. ’

Note 2.-On the eruption of miliaria Professor Schönlein I,particularly recommends alkaline lotions, which he con- Isiders as the best means to prevent the highly dangerous Irepercussion of the exanthema, and which he prefers tothe volatile stimulants and warm covering of the patientrecommended by the older physicians (for this last pre-caution increases the tendency of the exanthema to dis-appear, since the mere throwing aside of the bedclothesis sufficient to make it vanish) as well as to the use ofcamphor and preparations of ammonia that can easilyproduce a paralysis of the skin by over-excitation ; for

these lotions neutralise the acid that is abundantlysecreted on the skin, and produce at the same time anirritation of this organ which prevents the retrocession ofthe exanthema. To prepare these lotions, take eithercommon lye of wood-ashes, or a solution of caustic alkali(3j to 3sS to one pound of water), begin with them luke-warm, and gradually proceed to cooler ones. The sub-

jective.irritability of the skin must be the measure of thestrength of the lotion, for after the washing a slightpricking sensation must take place on the skin. The

9jMM’e profuse the sweating the oftener the washing must

be repeated ; the patients generally feel this best them-selves. After the use of these alkaline lotions the exan-thema very soon dries.

RHEUMATISM OF THE ABDOMINAL MUSCLES.

ITS FIXATION IN THE PYRAMIDAL MUSCLES. NO CRISIS

BY URINE. PASSAGE OF MATTER BY STOOL. CURE.

June !2, 1844. -Theodore J’i[",ller, worker in gold,twenty-two years old. The patient, a strong, full-blooded man, had oyer-heated himself at his work on the7th of June, and afterwards committed the imprudenceof going home in " full swea,t," in this cold, rainy wea-ther. The following night he was seized with a pain,which, beginning at the pit of th" stomach, shot vaguelyabout the abdomen, but at last settled and concentrateditself over the symphysis of the pubis; the slightestpressure increased the pain, and soon after difficulty inmaking urine took place. The physician who was calledto him prescribed an emetic, and afterwards a laxative.The consequence was, as might be expected, unfavour-able, and the patient was yesterday brought to theCharite, on the fourth day of his illness. The local and

general symptoms required immediate energetic treat-ment ; after a general and local bleeding the disease hastaken a more favourable turn, but has not yet dis-

appeared. We now find the following state : the abdo-men is not distended, but tense in the direction of therecti muscles. It is very painful only in one spot, justover the symphysis, in the region of the pyramidalmuscles ; but at present there is no difficulty in discharg-ing the urine. The urine is somewhat highly coloured,but without a sediment. The general reaction is almostabsent ; the frequency of the pulse is normal ; the skinsoft, open; the tongue slightly fun’ed. The constipationwhich had previously existed has ceased, a."ter the appli-cation of a clyster.There has here evidently been inflammation of the ab-

dominal muscles, with a tendency to extend to the peri-toneum ; for we frequently see peritonitis begin with arheumatic affection of the muscles of the abdomen, inthe same way as pleurisies are often preceded by an in-flammation of the muscles of the thorax. That there hasbeen an affection of the muscles in this case is provedby the wandering of the pain and by its character. Afterthe pain has wandered for some time it fixes itself andsettles. Generally, rheumatism oi the muscles of theabdomen chooses for this purpose the following parts :-1. The recti muscles, on the sheath of which the forma-tion of matter very soon takes place. 2. The pyramidalmuscles, which is the more extraordinary, as this pair ofmuscles does not always exist. Here, also, the formationof matter cannot frequently be prevented. I have knowncases where resolution was effected three times, butwhere, after the fourth recurrence, the formation ofmatter could not be prevented, even by the most severetreatment. I have witnessed is the formation of theseabscesses a remarkable circumstance, which at firstalarmed me, namely, that after opening the abscess thematter, which had a healthy appearance, smelt stronglyof urine. I was afraid of having perforated the bladder,but on a closer inspection this was found not to be thecase, but that the admixture of smell had been broughtabout by the process of exosi-iiois. Since then I haveseen several cases. In this, where the affection has con-centrated itself in the region of the pyramidal muscles,we shall have to take this eventuality into consideration,and must not make too light of the affair. We shall,therefore, immediately have the local bleeding repeatedon the painful part, order a war11, bath, and prescribe amore antiphlogistical diet.

14. It seems that what I told you the other day aboutthe possible event of this disease i5 aboutto be confirmed,for the part above the symphy,;is, corresponding to thefundus of the bladder, continues painful and swollen,though there is no difficulty in discharging the urine.The reaction of the circulating system is moderate, butthere is no sign whatever of a crisis-the urine remainsclear. The tongue is covered and the taste perverted.Let us cause frictions, with grey mercurial ointment andoil of hy.oecyamus, to be made in the region of the %14d--

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der, have the part fomented with a decoction of narcoticherbs, and prescribe to be used inwardly a solution ofmuriate of ammonia, one drachm, with one grain oftartar-emetic.

15. The pain remains fixed in the part above the sym-physis, a phenomenon which I have frequently observedin cases of rheumatism of the muscles of the abdomen.Yesterday evening a great aggravation of the local affec-tion took place; the pain was more severe, even on theslightest touch, and more extensively felt, on whichaccount we again ordered local bleeding; after which aremission in the symptoms appeared. And yet it is verydoubtful whether we shall be able to obtain a completeresolution. I repeat, that I have often seen, when theaffection frequently recurred, that in spite of the mostcareful treatment suppuration could not be prevented ;this is an axiom that has been proved by experience, incases of rheumatism of the muscles of the abdomen, or,as it is falsely called, of external or muscular peritonitis.We have still to propose the question, Whether the rheu-matic inflammation of the muscles of the abdomen has atendency to suppurate in those individuals who have

pyramidal muscles ? This would serve to corroborate the

general pathological law, that every organ whose exist-ence belongs to an anterior degree of development is

particularly disposed to disease ; that the morbid processcorrects, as it were, what has been omitted during theevolution of the body, and forms a kind of supplementaryevolution.At present, in the morning, the local and general

symptoms are very much diminished; the pain in theattacked part is inconsiderable ; scarcely any febrile re-action ; copious perspiration ; while the urine remainsclear, and shows nothing of the critical rheumatic sedi-ment.

16. Last night a new exacerbation of the local affectionover the symphysis appeared, which was again combatedby local bleeding, after which the patient had a quietnight. At present he feels no pain in the muscles of theabdomen; the part formerly swollen is collapsed, notpainful; the febrile symptoms have completely dis-appeared ; the skin is open and moist; the urine is dis-charged in greater quantities, its colour is natural, andit contains some mucus, but no red brick-coloured sedi-ment, as we wished. Instead of this the gastric dis-turbance is more evident, the tongue is more stronglycovered, there is a want of appetite, and a bad taste inthe mouth. Prescription: Acetate of ammonia, withtartarised antimony wine, in a decoction of salep, forinward use.

17. The fever has entirely disappeared ; the pulse 72,its frequency is but very slightiy increased in the evening;the skin moist; the urine is copious, and leaves nothingto be wished for, except that it had accomplished the actof critical secretion. This want of a crisis by urine is themore unwelcome since the inflammation of the affected

part has such a strong tendency to suppuration. Indeed,an accident has happened which confirms our fears. Forthe last few days the patient felt a continual desire to goto stool, a kind of tenesmus ; and yesterday, after a greatmany efforts, and the previous evacuation of fasces, puru-lent masses were discharged, after which the tenesmusceased. We have seen rheumatism of the muscles of theabdomen terminate in a similar manner in the case of agirl, where matter appeared also in the urine. (See noteat end of case.) Here, in this case, matter has beenformed between the bladder and the rectum, not, as isgenerally the case, through the vagina of the muscle. Toacquire a more accurate knowledge we shall be obligedto examine the rectum.

18. The evacuated matter had all the physical proper-ties of pus ; it has been examined chemically and micro-scopically by Dr. Giiterbock, whose examination hascompletely confirmed our first impression. With thisevacution of matter the morbid process seems to be ter-minated ; there are not the least local and general symp-toms ; since yesterday there have been two feculentstools, without any admixture of pus. As there was not

yesterday evening, the least febrile movement, the

process must be considered as finished.On examination of the rectum, a small painful spot

was discovered on its right wall, but no solution of con-tinuity. The direct road of evacuation remains, there-fore, problematical, or we must admit that in this casethe opening closed immediately after the discharge of thematter, as one generally finds with abscesses of the ton-sils. We find, too, that the patient has had tenesmus,but no other sign of an inflammation of the rectum.Since the direct way of the discharge of the matter isnot to be found, we must admit an indirect one ; but thisit is extremely difficult to admit, for we cannot conceivehow such a metastatical suppuration can have takenplace without being preceded by the most violent symp-toms. One circumstance might be cited in favour of thismetastatical evacuation, namely, the totally changed,irregular form of the globules of the pus, as they appearwhen they have taken a long road. We, therefore, inthis case, see the beginning of the complaint, the inflam-mation of the muscles, and its end, the passage of pusthrough the rectum; but the intermediate links are

missing.19. The fever has completely left the patient; the

rheumatism of the muscles of the abdomen has disap-peared ; the tongue gets clean; the taste is no longerperverted ; the appetite reappears; but yesterday therehas been another stool of a liquid, yellow, and flocculentnature, which creates the suspicion of an admixture ofpus, for it was accompanied with significant phenomena,having been preceded, for about an hour, by repeated andstrong desires to go to stool; after the evacuation thepatient felt easy. We must have recourse to micro-

scopical examination to confirm the real admixture of

pus, as it must be done with other evacuations of thesame kind from the intestines : in cases of intestinal

phthisis and abdominal typhus, where the nature of theevacuation cannot be known by a simple inspection. Atall events there is much less matter contained in theevacuated mass than the first time, and we may expectthat it will not be followed by another.

21. Since the last-mentioned purulent evacuation no-similar one has appeared ; a normal stool has taken placewithout tenesmus. The part above the symphyses is

completely collapsed ; no sign of fever. For the last few

days the patient has taken no medicine. We shall nowbe able to give him more nourishment for the recovery ofhis strength. In the beginning of the following monththe patient was dismissed.

Note.-On this occasion Professor Schönlein made the

following important remark, to which we shall have fre-quent occasion to allude :-There is a fact to which I feel myself the more called

upon to direct your attention, since I did not know it

formerly myself, and have learnt it in several cases too

late, namely, that though the principal object of exami-nation must be the local affection, and the symptoms ofreaction are of secondary importance, still there are caseswhere the local phenomena are no more ascertainable,and the fever continues with a changed character, withremarkable remissions in the morning, and exacerbationsin the evening. Where this takes place without a distinctcrisis you may be sure that sooner or later the inflamma-tion will reappear, and frequently with such violence thateffusion is no longer to be prevented ; a false crisis takesplace, and, in most cases, suppuration. In rheumatic.affections, particularly in rheumatic pleurisy and perito-nitis, I had frequent occasion to make this remark. Onlybe more attentive to find out the local affection ; it isbetter that you should discover it during the life of thepatient than in another place, where the mistake can nolonger be remedied. I shall merely state one case whereI committed a great error on account of not knowingthis fact. A strong carpenter’s apprentice who hadsuffered with pleurisy breathed suddenly more easily andwithout pain ; the anterior part of the chest was aloneexamined, and nothing abnormal discovered ; but towardsevening violent fever arose, which daily increased ; soonconsiderable collapse took place, and nervous fever deve-loped itself, which had a fatal termination. On autopsy,a cyst filled with matter was discovered in that part ofthe lung which is covered with the scapula. A similarevent has taken place in this case; the patient formerly

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laboured under rheumatism of the muscles of the abdo-men, the local symptoms disappeared, but the fever con-tinued ; now the catastrophe comes ; real matter in consi-derable quantity is discharged by stool and by urine,-therefore formation of an abscess, which has made its

way outwards through the bladder and the rectum; sincethen the patient feels considerably relieved, and has lostthe fever.

ORIGINAL COMMUNICATIONS.ON THE

SUCCESSFUL TREATMENT OF OVARIANDROPSY,

WITHOUT THE ABDOMINAL SECTION.

By ISAAC B. BROWN, Esq., London., Consulting Surgeon-Accoucheur to the Paddington Lying-in-Charity.

THE subject of ovarian disease has of late engrossed theattention, not only of the profession, but of the public atlarge, and the general opinion regarding its incurabilityhas been much modified. I now purpose, convinced bypositive facts, to open a new field for observation, and willendeavour to prove, by practical truths, that this diseasecan be cured by a plan free from danger or any ill conse-quences ; but before going into my own views, I will brieflystate the opinions of some old writers, and of someliving practitioners, who have noticed this subject in amedical point of view.

Dr. Burne writes on the subject of ovarian disease:-11 I wish most distinctly to state my conviction that,

beyond the object of palliating symptoms the medical artcannot at present extend, and it argues, in so far as ourskill as yet goes, a most unsupported confidence in ourpower by physic to propose more."Again-" Diuretics have been prescribed, but without

success, and often with detriment."Dr. Denman observes-" That diuretics have no effect."Dr. Hunter observes-"That dropsy of the ovarium

is an incurable disease, and that the patient will have thebest chance of living longest under it who does the leastto get rid of it."

Dr. Burne again observes, when speaking of tappingas a mere palliation of symptoms,-" Dr. Denman advisesthe operation to be deferred as long as possible, and Ibelieve he is right, for every operation is followed by re-accumulation, which is a debilitating process."Again-Dr. Elliotson, as quoted in Mr. Walne’s last

case, writes " that he was convinced of the inefficacyof medicine in the treatment of that malady," and that"he at once told her not to be tapped, nor to takemedicine likely to weaken or even annoy her."And that able surgeon, Mr. C. Aston Key, writing of f

his case, as published in " Guy’s Hospital Reports," says" Is ovarian dropsy a disease so difficult to treat, souniformly fatal, or attended with so much suffering, as to ’justify excision of the cyst, with its dangers ?" " No one, II apprehend, will dissent from the admission that medi-cine and surgery have been equally unsuccessful in

suggesting a remedy, or, indeed, even a palliative for thisdisease. Medicines of all classes have been tried, to in-duce absorption, or to stay the secretion, and withoutany, even the least, diminution of the tumour, or anyapparent power of checking its progress."

I could easily multiply, were it necessary, quotationsand opinions of other physicians and surgeons who havedwelt on this subject, but I shall prefer briefly alludingto another class of surgeons, who maintain that this dis-ease can be cured by surgical means. This point requiresvery serious consideration, because it has of late beenmuch insisted on by those who have been fortunateenough to be successful in the cure of their patients, andbecause these gentlemen maintain, with much apparentforce of argument, that no other remedy exists ; whereasI purpose to show that other and more rational means ofcure hare been discovered, and will bear the strictest testof inquiry. Those who consider operations advisable aredivided into three classes, viz. :-

First. Those who recommend the small operation.

Second. Those who recommend the large.Third. Those who recommend the median.Among the first we may mention Jeaffreson, King, and

West, who have recommended making a small openingmidway between the umbilicus and pubes, puncturing thecyst, and then gradually drawing it through the smallopening.Among the second class, we find Lizars, Clay, and

Walne, who divide the abdominal muscles from ensiformcartilage to pubes, and remove the cyst entire.Among the third, we find Bird and Lane, who divide

the muscles only from the umbilicus to pubes, and thenremove the cyst. Now it cannot be denied, that in allthese cases there is considerable hazard, and in manyinstances the patients have not recovered. Of the threeplans, I confess that I prefer the median, if an operationmust be performed, but I do firmly believe, and proposeto state my reasons hereafter, that none of these plans arejustifiable, before this or a similar plan of treatment hasbeen tried; that many of the cases as cited of late are thosewhich could have been cured by a more rational, andcertainly less hazardous, mode of treatment ; and Icannot too strongly recommend to those able surgeonswho have hitherto been successful in their bold opera-tions, to pause, and consider well the plan of treatmentwhich I suggest; and I would particularly wish to drawtheir attention to the following cases of ovarian dropsy,admitting of no doubt in my mind as to their charac-ter, or as to their permanent cure. I then simply pre-mise by stating that mercurials, diuretics, tonics, andtight bandaging, followed by tapping, constitute the chiefpoints of treatment, which I illustrate by four cases,in which the patients were permanently cured ; butbefore doing so I would state that they all occurred inyouny and unmarried females, and most probably suchcases are the most likely to prove successful, as the

powers of nature are more vigorous, and the spirits morebuoyant, whereas, after the cessation of the catamenia,we know the constitution of females is not so ready toremedy any mischief set up in the system.I The first case is that of Miss C-, aged 17, who residedin the country.

In February, 1S39, she came to town to consult meabout a pain in her side, of a gnawing character, some-times more acute than at others, and nearly constant.She had been suffering for some years, more or less, fromuneasiness in her side, but her sister, having beenaffected with enlarged mesenteric glands, her motherconsidered that similar remedies would be applicable toher case, and had occasionally given her grey powder andwarm carminative medicines. The catamenia had ceasedfor five months, but slightly appeared after the journey totown. On examining her, in the recumbent posture, Idetected a small tumour in the left iliac fossa, and imme-diately pronounced it ovarian. Advised leeches, if thepain became again acute, some gentle aperient medi-cines, and to use Amesbury’s patent reducing stays ; herdiet to be simple, yet nutritious ; to avoid all stimulants,and to take daily exercise, though without fatigue.

In November, 1840, she again came to town, when, onexamination, I found the tumour enlarged, and circum-scribed. I requested my friend Dr. Locock to see her,and, without stating my own opinion, he decided it to beovarian, then about the size of a five months’ fcetal head ;fluctuation distinct. As the catamenia were more regular,and the health tolerably good, no fresh treatment wasadvised.

In November, 1841, she again came to town to consultme, when, finding that the cyst was decidedly larger, Irequested my old friend Dr. Bright, together with Mr.Arnott, Mr. Martin, and Dr. Locock, to see her with me ;they all agreed that it was ovarian, and that the fluid was.distinctly to be felt; they advised blistering, and liquorpotassse in small beer. This treatment was continued for

many weeks, still the cyst gradually increased ; thehealth was generally good, although the catamenia wereirregular and scanty.

In July, 1842, she again came to town, when I foundthe cyst very much increased,-to the size of a seven-months’ pregnancy; fluctuation most distinct; the

breathing slightly affected, otherwise the general health