200

affection, keep it within a certain extent, and allow the patient to make all his ordi-nary exertions.

It is a question, whether we can, with , any safety, proceed further with the treat- ment of varicose veins, than what I havementioned 1 Whether we can do moi-t thanapply leeches, with means that are calcu-lated to reduce inflammation, and applypressure Whether we can, with safety,adopt any means for effectually removing, the varicose enlargemeBt of the vessels 1 ’For this purpose, it has been recommendedto tie the trunk of such enlarged veins, andto make a division of the trunk-to performexcision of the varicose part; that is, actuallyto cut away the varicose enlargement; andvarious other means have been recommendedfor the purpose I have mentioned to you.Now, if the main trunk connected withthe varicose vessels distributed over a limb lbe obstructed-if it be divided, or if it betied, certainly a very considerable diminu-tion of those varicose enlargements’of theveins will ensue. But here vou must recol-lect the danger that will arise from the ap-plication of a ligature to a vein under suchcircumstances, and a vein that is by nomeans in a very healthy state. You mustrecollect the danger of exciting inflammationof the vein-phlebitis-for, in truth, pa-tients have died in many instances, in conse-quence of the application of, ligatures to

veins for this purpose. Individuals wholiave been in good health, who have hadnothing the matter with them but this vari-cose state of the veins, and which, with alittle care, might have been kept within anextent, so as not to create a great deal of in-convenience, perhaps from a desire of get-ting radically rid of the affection, have hadligatures applied on the trunks of the ves-sels, and this has been attended ;o frequent-ly with a fatal result, that I bel:eve no onenow adopts that course of proceeding. An-other plan, besides cutting out a portion o:

the enlarged vein, and which has been con.sidered, in many instances, the only safeproceeding of this Mud (and that I shouldnot deem absolutely safe), is the one thatwas proposed by Mr. Brodie. It consistsin

dividing the varicose vein under the skin,making a very small opening, using a slenderand narrow knife, which is introduced by theside of the vein—flat and curved, cutting onits convex edge, and having a very -narrowpoint ; introducing that, I say, at the sideof the vein, carrying it with the flat surface

horizontally under the skin, between thevein and the skin, and then you divide thevein with the convex edge of the knife. Nofurther opening is necessary than is requil edto introduce the nariow knife through theskin at the side of the vein. In general,this operation is not attended with the risk

that accompanies either the excision of aportion of the varicose vein, or of the appli.cation of a ligature to the trunk. In in.stances, therefore, where it is necessary todo anything in that way, where it is sup.posed to be necessary, this is the preferableoperation; but the great danger of wound.ing veins which attends all these modes,particularly of wounding veins in this dis.eased state, has led, I believe pretty gene.rally, to the abandonment of all attempts ofthis kind; and surgeons are now satisfiedwith the means I have already described toyou, as being more simple and more safe.

EDINBURGH UNIVERSITY.

CLINICAL LECTURES IN MEDICINE

BYDR. DUNCAN.

April 13th, 1830.

PHTHISIS, AND ITS DIAGNOSIS BY THESTETHOSCOPE.

AFTER having made some observations ona most extraordinary case of catalepsy (areport of which we shall shortly give),Dr. Duncan alluded to the woman JanetRamsay, setat. eircit. 45, whose deathtook place on the day after her admissioninto his ward. He stated she had formerlybeen a patient of Lis, affected with severepneumonia, probably the consequence of afractured rib. When taken in on the 7th of

April, the countenance was depressed, faceirregulmly flushed ; respiration hurried, andabdominal ; great general debility was pre-sent ; the extremities cold ; pulse 110small, and indistinct. She lay entirely on

the left side, and complained of great sore-ness on pressure ; she coughed almost con.tinua1Jy, with purulent expectoration; andshe appeared to suffer much from profusfcolliquative diarrhœa. She stated that shehad been ill for some months, and that hersymptoms, recently, experienced a greatag gravation ; the colliquative diarrhoea was oshort duration. As Dr. Duncan did not seEher the day of her admission, no stethosco-pic examination took place ; in April, 1829however, she was under his care in thlfever wards, and he recollected, in the history of her case as then reported, that shhad been for some years subject to asthmatic paroxysms. By the stethoscope, th

respiration was then inaudible oyer certaiportions of the right side of the chest; in! distinct pectoriloquy was also noted on va

rious occasions beneath the clavicle at thiside. .

201

On dissection, the external form appeared rectly applied to the pained parts. The first

symmetrical ; on the thorax being open- time he ever noticed the occurrence, was illed, the left lung did not collapse, and on re- a case resembling elephantiasis, affectingmoving it, it seemed to be of a size consi- the leg. He ordered a blister to be laid on,derably beyond the natural standard ; when and excruciating agony was produced by itscut into, it was found in a state of complete application ; on removing it the next morn-tubercular infiltration, with the exception of ing, it was found that, by the effusion ofa few very small portions of healthy lung, coagulable lymph over the diseased surface,interposed between the masses of tubercular a new membrane had been formed, entirelydeposition. The right lung adhered exten- distinct from the cuticle, which was elevatedsitfty to the circumjacent pleura, especially by serous effusion in the usual manner. Theat the vertebral connexions of the 4th and great pain was principally produced by the5th ribs, where the force required for its quantities of serum secreted under the falseseparation was so great, as to leave a por- membrane, and tearing it up from its adhe-tion of the parenchymatous tissue behind. sions to the subjacent excoriated parts. OnIn the superior lobe, immediately beneath puncturing the membrane, instant relief wasthe anterior surface, and corresponding to conferred; and portions of’ it, being removedthe infra clavicular region, there was a ca- and submitted to analysis, were found toYitycftpaMe of containing a small orange ; consist entirely of atbumen; it was alsothis cavity seemed lined by a firm adveuti- ascertained to be totally devoid of vascula-tious membrane, and was partially filled with rity or organisation. Since then, in almostpurulent matter ; the surrounding portions every case of periostitis, in which he direct-of the lung were studded with miliary tu - ed the application of Misters to the painedbercles; the inferior lobe was in a state of parts, he observed such an effusion to be

hepatisation, approaching to cartilaginous produced. It was also a frequent conse-hardness ; the edges of the entire, transpa- quence of blistering in articular rheumatism,rent and emphysematous. The heart was as in the present example.entirely free from disease. The examination of the abdomen afforded no remarkable re- April 16th and 20th, 1830.sult, with the exception of some softened TREATMENT OF ACUTE RHEUMATISM BYpatches of the mucous membrane, surround- TREATMENT or ACUTE RHEUMATISM

BY

ed with hard and ulcerating edges. THE SULPHATE OF QUININE.

From the short time this patient was in Catherine Morgan, aetat. 30, admitted onthe house, Dr. Duncan said, the present class the fifth day of fever, accompanied withhad no opportunity of seeing her, and, con- symptoms of acute rheumatism ; she had

sequently, he would not dwell on the cir- likewise cough, diffused pain in the chest.cumstances connected with it. One fact was increased by full inspiration ; her respirationstill of interest to them all, namely, the early was hurried ; expectoration mucous and ad-detection of pectoriloquy, the diagnostic hesive ; pulse frequent; bowels slow ; shemark of phthisis. When this was iirst ob. had a similar attack two months before. Onad-

served, the cavity must have been extreme- mission, the symptoms of rheumatism werely small, and the occurrence consequently so prominent, as to hide or obscure many ofshowed what an important auxiliary the the others. It was to this affection, conse-stethoscope might be occasionally found by quently, that Dr. Duncan’s attention wasa scientific practitioner ; for when pectori- especially attracted ; indeed the pectoralloquy was first heard here, no peculiar or complaints were scarcely noticed at all till

pathognomic general symptom of that dis- the day after he had ordered the remedy heease was present, by which its existence considered it expedient to use against thecould be ascertained or even inferred. rheumatism, this was the sulphate of qui-

____ nine, concerning the efficacy of wiiich, even-

in the most acute form of this disease, hePECULIAR EFFECTS OF BLISTERS IN had already given so decided an opinion ; inPERIOSTITIS ELEPHANTIASIS, &c. this case, however, its administration did

Matilda Dickson, admitted about a fort- mischief to a certain extent, for on the fol-

night since, labouring under articularrheu- lowing morning the cough and dyspnoeamatism and pneumonia, both of which could no longer be overlooked, and some an-yielded to antiphlogistic treatment, followed noying abdominal symptoms also made theirup by the use of the colchicum wine, in the appearance, the epigastrium being very ten-dose of three grains, repeated thrice dail3-. der to the touch, with considerable internalThis case Dr. Duncan said, ptesented no in- pain. The quinine was of course imme-teresting feature, except as far aa it afforded diately omitted, and leeches were applied ; ;an oxarople of a singular effect he had often their operation was followed with great relief,observed to arise from the application of a and during the night she slept better, andblister, especially in cases of periosteal in- perspired abundantly. After this, the treat-flammation, in which the epispastic was di- ment of the case.was exclusively alltiphlo-

202

gistic, and she was dismissed cured on the neys; but, on further examination, Dr.29th of March. Duncan was more than ever convinced of

— this not being dependent on a morbid condi-bIODTFIED SMALL-POX PRECEDED BY tion of that viscus; for pressure applied in

ROSEOLA. such a manner as to preclude the possibilityGrace Markeys, Dr. Duncan said, was of its affecting the kidneys, produced as

the only one of the several srnall-pox cases, much pain as when it was made directlywhich had recently been in the clinical above them; thus, pressure on the cristawhich had recently been in the clinical of the ilium, or the left side of the sacrum,ward that deserved the slightest notice, of the ilium, or the left side of the sacrum, ward, that deserved the slightest notice, as of the or the i d . sacrum, ’ .

ward, that deserved the notice, as could scarcely be endured for an instant;they all ran a mud course, unattended with the same dearee, and the same kind, of pain,they all ran a mild course unattended which the same degree, and the same kind, of pain,any of the pernicious symptonts which ac- was also produced by pinching up the in.quired for ’ disease * ti a cele brity. was also produced by pinching up the in’quired for that disease so terrible a celebrity. was also produce by pinching up the in-He particularised this case,merely on ac- tPgutnents in the lumbar regions. He was,He particularised this case, merely on ac- therefore, inclined to say, that the affactioncount of the uncommon degree of ro seola. therefore, inclined to say, that the affectioncount of the uncommon degree of roseola was rather connected with the skin, or the

which preceded the vario lous eruption; so was rather connected with the skin, or the

which preceded the variolous eruption ; so muscles, than with the kidneys, or any otherextensively was it dffused, andsodu’ersi- . internal m treatment ’ almost extensively was it diffused, and so diversi- internal organ. The treatment was almostfied in its appearance, that it strongly re- exclusively

fied in its appearance, that it strongly re- exclusively leeching and the administrationsembled rubeola, and accordin-ly Z3 it was ofenemata; the foetid enema was occasion.noted in the journal that there was no sore ally employed, and with some relief. Afterthroat, redness of the tonsils, or hoarseness leeches had been twice applied, and the ori. .’

, ,. leeches had been twice applied, and the on.present, The roseola, however, soon dis- ginal pain much abated she waspresent. The roseola, however, soon dis- ginal nam much abated, she was suddenlyappeared, and gave place to the small-pox. attacked with a similar pain under the ster-appeared, and r place i - i attacked witii a sinnlar pain under the ster.A slight degree of ophthalmia also accompa- num, as she described it ; a sinapism- was’ ? as she described it; a sinapism wasDied the latter, but both were readily sub- gave very , nied the latter, but both were readily sub- put on, which gave very speedy relief. Somedued by the ordinary treatment. ’r after this the lumbar pains again re-dued by tlte ordinary

treatment. days after this the lumbar pains again re-

,

turned, and she was bled to 163 ; the eva. ANOMALOUS LUMBAR PAIN produced the effect of immediate

The next case noticed was one which Dr. nausea and faintness, and the pains soonDuncan considered, of an extremely puzzling after abated, and have never since returned.character. The patient was a youn;; woman, During her stay in the infirmary, scalding who was admitted for acute pain in the re- micturition was another and prominentgion of both kidneys, stretching down along source of complaint, but as it was habitual ,

the right thigh ; the abdomen was very ten- and (as Dr. D. conceived) unconnected with ,der, especially at the epigastrium ; the pulse the anomalous symptoms thus described, he106, full, moderately firm ; tongue foul and passed it over in his consideration of thewhitish ; bowels confined ; she complained case.

also of headachs, thirst, increased heat, —

and the several other concomitants ofsymn- ANASARCA AND ASCITES. tomatic fever. She stated, that for many ANASARCA AND ASCITES.

years she had been subject to pectoral com- Ellen Chapman’s was the only other in-plaints, with occasional pain in the Joins, by teresting case noticed. She was admitted which affections she was so disabled as to be with very severe dropsical symptoms ; thereconfined to her home, till about about twelve was general anasarca, characterised by themonths since, when a slight improvement usual appearances ; fluctuation in the abdo-in her health enabled her to make some minal cavity was also indistinctly felt, yetexertions. She continued in a moderately sufficiently decisive, Dr. Duncan conceived,good state of health till the 1st of April, of the presence of certain quantity of fluid.when the lumbar pains recurred with ex- The heart’s action was irregular and diffused,treme severity, accompanied with nausea, the pulsations at the wrist synchronouslyvomiting-, and pain along the right tlvigh. intermittent; the urine was scanty and high-

All these symptoms, Dr. Duncan pro- coloured. She stated that her complaintsceeded, were indicative of nephtitis, and, if were of recent standing, and were inducedoccurring in a male subject, would he al- by cold ; she confessed an occasional excessmost considered decisive of the existence of of at dent spirits. She was first, she said,that disease ; yet lie entirely disbelieved attacked with liquid diarrhoea. ; this soonthat the kidney was the seat of the lumbar gave place to a scantiness of urine, and thepain, or even BBas concerned in producing it. oedema pedum quickly followed. The stateShe was ordered to be bled ; leeches also to of the urine was the principal point hebe applied to the loins; the bleeding’ pro- considered worthy of attention in the con-duced nausea and faintness, but the blood sidetation of the causes and symptoms ofwas of a perfectly natural appearance, and this case ; it was scanty, high-coloured, andnot at all indicative of inflammatory action ; contained no albumen ; this, when coupledsome relieffoliowed the bleeding, though she with the irregular action of the heart, wentstill complained of the pain over the kid- far-to corroborate that the symptoms were

203

owing to obstruction to the free circulation of three months’ standing was thus removedthrough that organ; it being generally ob- in six days. By this time the hoarsenessserved that hight coloured urine is the con-

was also relieved. ’

Si’quence of obstruction either in the heart Hoarseness, Dr. Duncan remarked, wasor.tiwr, while the pale and albumenory an effect of many causes, either functional oruriue depended on disease of the kidneys. organic, interfering with the motions of theThe first treatment pursued in the infirmary parts concerned in producing the voice. Mostwas the use of elaterium and squill, but commonly it depended on relaxation, verythese medicines not being found to answer, frequently too on an inflammatory condition ;Dr. Duncan next directed the supertart. of this inflammation, however, was often of thepotash, a remedy which he considered al- atonic kind, and for it and the state of re-most of inestimable value in numerous hy- laxation, the same kind of remedies wasdropic cases; its use was here attended found to be most successful, viz., astringentwith the most signal benefit; several stools and stimulating applications. In ordinarywere daily produced, and the urine became life, lie continued, hoarseness is of little’

again of the natural quantity and colour. moment, comparatively speaking ; but, inShe now rapidly improved, and was dis. certain professions, such as those of advo-missed in the course of a fortnight, relieved, cates, preachers, and especially singers, thefor a time, from all the unpleasant symp- full command over the vocal organs becomestoms of her disease. a matter of the most serious consequence,

____. requiring the attention of the physician,-TREATMENT OF HOARSENESS.

both to prevent its accession and to re-,TREATMENT OF HOARSENESS. move it when actually present. When de-

One patient only, dismissed since the pending on relaxation, the proper treatmentlast lecture, Eliza Coffey,—admitted for (having ascertained that no active inflamma-two affections, extreme hoarseness, and con- tion is present) is the employment of thesiderable leucorrhaea; besides the hoarseness, most powerful astringent and stimulatingsymptoms of pneumonia were also present. applications. If the degree of inflammationShe coughed much, with scanty expectora- forbid such measures, leeches to the faucestion, and complained of pain in the chest, will be of service, and a blister will natu-increased by coughing and full inspiration. rally arrest their operation. Commonly,The pulmonic complaints were of three however, we might rely (Dr. Duncan con-weeks’ duration, but had suffered a consider- tiuued) on the tonic treatment alone ; he hadable exacerbation eight days before admis- known individuals seized with almost com-sion. She ascribed her illness to exposure plete aphonia, after standing a short time onto cold while fatigued : the leucorrhoea was a damp fionr, and to these persons the appli-of three months’ standing. On the day he cation of Cayenne peeper to the tonsils andfirst saw her, the thoracic affection was not uvula, he had found to be productive ofvery prominent, and the hoarseness and as speedy relief. Strong gargles of port-’leucorrhaea seemed to be the only symptoms wine, or oak-bark, were also very effica-

requiring attention; 3i of cubebs was con- cious, but he considered the Cayenne pepper,sequently directed three times daily, to be superior to both; he understood, too, thattaken in milk. The following day the leu- theatrical singers were in the habit of using’corrbcea had entirely ceased, but the pain Cuyenne lozenges, both as a preventivein the chest was much increased, the cough and cure. Sometimes hoarseness originatedsevere, and respiration impeded ; the cubebs in a deficiency of the mucous secretion ;were of course omitted; she was bled to 3xii, this defect was to be remedied by emollientsand the blood appeared slightly buffy, indi- and lubricants of various kinds ; for thiscative of a certain degree of inflammatory purpose the yolk of an egg was a favoariteaction; the bleeding was followed by the remedy, and was advantageously combinedspeedy alleviation of all the thoracic symp-. with a little brandy, wine, or ary other sti-toms, except a slight degree of pain and mutant liquor. Another point (Dr. Dun-sensation of constriction about the chest, can continued) remained to be briefly no-The hoarseness continuing, she was directed ticed in this case, namely, an experiment heto gargle with the decoction of oak bark ; made on the activity of Euphorbium resin,the decoction of the polygala senega was as a cathartic medicine. The patient wasalso ordered for internal use. The leucor- of a costive habit, and for trial he gave her’rhoea now returned , and, as no inflammatory one grain of the euphorbium. No effectsymptoms remained to contra-indicate the was produced, though 3i of castor oil givennecessary practice, the cubebs were re- next day-caused free evacuation. He next’sumed; the next day the discharge was less, tried two grains, and with similar results;alld it gradually and constantly declined finally three grains were given, and no pur-under their employment, ceasing altogether gative action was excited. After this she oa the 28th March, the cubebs having been continued free from complaint for severalcommenced on the 22d, so that leucorrhoea days, and was finally dismissed cured.