No. 752.

LONDON, SATURDAY, JANUARY 27, 1838. [1837-38.

LECTURESON THE

THEORY AND PRACTICEOF MEDICINE;

NOW IN COURSE OF DELIVERY AT THE

THEATRE OF ANATOMY AND MEDICINE,WEBB-STREET, SOUTHWARK.

BY

MARSHALL HALL, M.D.,F.R.S. L. & E.&c., &c.

Table displaying the different degrees of tole-rance of loss of blood. Augmented tolerance;healthy tolerance ; diminished tolerance.Morbid effects of mercury. Erethisntusmercurialis. Symptoms of this affection.Dr. Bateman’.s case. Treatment of themorbid effects of mercury. Analogy be-tween erethismus mercurialis and the morbid

effects qf loss of blood. Erythema merctt-riale induced by opium, arsemc, artd gastricirritation.

GENTLEMEN :—In the present lecture I

propose to draw my observations uponbloodletting, and npon the theory of medicinein general, to a close. It will concludewith some remarks upon the morbid effectsof mercury, and on the state of sinking. Itwill be succeeded by lectures upon thenervous system and its diseases, to which,as you know, I have been devoting greatattention for a series of years. But first,now, permit me to direct your notice to thefollowing table, which exhibits, in a conciseand distinct form, the results of my investi-gations on the subject of bloodletting ; onpassing the eye over it you cannot fail to beimpressed with the value and importance ofthe facts it displays, with the diagnostic,the guide, the guard which it affords.

I. AUGMENTED TOLERANCE.Represented by the mean quantity ofblood which flows before incipientsyncope.

a. Congestion of the brain.1. Tendency to apoplexy.2. Apoplexy from congestion. xL—L,

6. Inflammation of the serous membranes.1. Arachnitis;2. Pleuritis ;3. Peritonitis;4. Inflammation of the synovialmembrane and of the fibroustextures of joints........ xxx--Lx.

c. Inflammation of the parenchyma oforgans.1. Of the substance of the brain;2. Pneumonia;3. Hepatitis ;4. Inflammation of the mamma. xxx.

d. Inflammation of the skin and mucousmembranes.1. Erysipelas ;2. Bronchitis ;3. Dysenteria .............. XVI.

II. HEALTHY TOLERANCE.This depends on the age, sex; strength,

&c., and on the degree of thicknessof the parietes of the heart, and isabout .................. XV.

III. DIMINISHED TOLERANCE.1. Fevers and eruptive fevers XII—XIV.2. Delirium tremens and

puerperal delirium...... x—XII.3. Laceration or concussion

of the brain ;4. Accidents before the esta-

’ blishment of inflammation;5. Intestinal irritation.... VIII—X.6. Dyspepsia ; chlorosis .. VIII.7. Cholera .............. 3vI.

Having thus fully detailed the morbidand curative effects of loss of blood, I shallnow, Gentlemen, make a few remarks on thestate of sinking, and then give a sketch ofthe morbid effects of mercury.

Besides the state of sinking, induced bythe loss of blood, and other direct sourcesof exhaustion, a state of things very similarnot unfrequently occurs in the course ofcertain diseases. It is apt to take us by sur-prise ; for it is sometimes very insidious, andsometimes sudden, in its mode of accessioa.Mr. C-, aged forty, was affected with

icterus, and reiterated attacks of pain in the.region of the stomach ; these attacks, toge-ther with the remedies necessary to relievethem, gradually reduced the patient to ex.

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treme weakness and great emaciation. In’.his state ite went to Leamington, and wasapparently benefitted by a course of theblue pill. At this period, feeling himselfbetter than usual, he rose early one morn-ing, dressed himself, and went (town stairs,with the intention of agreeably surprisinghis friends. He was overcome by the effort,however, and became faint; he was thentaken witli chilliness ; he was removed tobed, and became slightly feverish. On thesucceeding morning there was rigor, follow-ed by great heat of skin, and a sense of tight-ness under the sternum. On the next daythere were slighter rigor, less heat, a degreeof delirium, and then constant dozing; inthis state of dozing he continued for somehours, no danger having been intimated bythe physician in the morning, or felt by hisfriends during this sleep, from which theyexpected to see him awake refreshed. Inthe evening, when the physician arrived, I,the pulse could scarcely be felt, and thevital functions shortly afterwards ceasedaltogether. !

Some diseases are apt to issue, even at arather early period, in a state of sinking;in other cases, sinking supervenes in thelater stages of these diseases. This stateseems sometimes to be the result of a direct

/ influence of the disease in lowering the vitalpowers ; sometimes the disease has subsid-

ed, but the state of sinking has continued,and destroyed the patient; and sometimesthe sinking has appeared to annihilate themorbid actions which constituted the dis-ease, and thus to prove a cune, though a

; fatal one. In the latter cases the physician,whose eye is fixed on the disease alone, andthe friends of the dying patient, are apt,from the apparent truce in the actions orpains of the disease, to be led into a san-

guine, but delusive, hope that the patient isbetter; there is, perhaps, a degree of doz-ing, mistaken for a long wished-for sleep, orsome painful symptom has subsided, andthe patient expresses himself as easier;hut there are some of the appearances, or

symptoms, about to be described, whichwill not fail to undeceive the careful ob-server.

This subject has been treated, in theauthor’s peculiar style, by Hunter, in hischapter on 11 Dissolution." It has also beennoticed by Sir Henry Halford, in his valu-able paper,, published in the " Transactionsof the College of Physicians," vol. vi., p.398, republished in his " Essays and Ora-tions," and entitled, " On the Necessity ofCaution in the Estimation of Symptoms inthe last Stages of some Diseases."

Hunter observes, " Death, or dissolution,appears not to be going on equally fast inevery vital part; for we shall have manypeople very near their termination, yet some ital actions shall be good, and tolerablyPtrong ; and if it is a visible action, and life

depends much upon this action, the patients Bshall not appear to he so near their end asthey realty are ; thus, I have seen dyily

J

people, whose pulse was full and strong asusual, on the day previous to their death,but it has sunk almost at once, and then Le-come extremely quick, with a thrill: on

such occasions it shall rise again, making astrong effort, and, after a short time, a mois-ture shall probably come on the skin, whichshall in this state of pulse be warm; but,upon the sinking of the pulse, shall becomecold and clammy ; breathing shall becomevery imperfect, almost like short catchings,and the person shall soon die. ’

" It would appear in many cases, thatdisease has produced such weakness at lastas to destroy itself ; we shall even see thesymptoms, or consequences of disease, get ’well beforo death.

-

" Even when in the state of approachingdeath, we often find a soft, quiet, and regu-lar pulse, having not the least degree of irri-tability in it, and this when there is everyother sign of approaching death ; such asentire loss of appetite, no rest, hiccup, thefeet cold, and partial cold, clammy sweats,&c."

Sir Henry Halt’ord remarks, that « it ’often happens at the latter end of some dis-eases, both of an acute and a chronic nature,that appearances present themselves of art

very equivocal and delusive nature, withwhich the issue of the malady does not cor-respond. This is most frequently the casewhen the resistance of the constitutionagainst the influence of the disease has beenlong protracted, or when the struggle,though short, has been very violent. Here,a pause in nature, as it were, seems to takeplace ; the disease ’ has done its worst,’all strong action has ceased, the frame is

fatigued by its efforts to sustain itself, anda general tranquillity pervades the wholesystem. This condition of comparative

~

ease, the eager wishes of friends miscon-strue into the commencement of recovery,and the more readily so, as the patient him-self being appealed to, to confirm theiranxious hopes, having lost some of his suf. Bferings, admits, perhaps, that he is better." I have seen this fallacious truce in fonr

or five instances of inflammation of the brain,particularly where the membranes whichcover it have been inflamed, producingphrenzy." In inflammation of the bowels generally,

it is so notorious, that mortification oftenfollows a cessation of pain, that I do notthink it necessary to dwell upon this formof disease with a view of cautioning physi-cians ; but in that partial inflammation ofthe intestines which a strangulation of aportion of it in hernia produces, how oftenhave I had occasion to deplore the disap-pointment and broken hopes of relatives,who, having been made happy by the as-

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surance of the surgeon, that he had reduced symptoms of sinking. On examination therethe protruded bowel, and that now all were no morbid appearances whatever. Inwould be well, in only a few hours after- one case of suppression of urine, the secretionwards were doomed to lanrent the patient’s was somewhat restored in the last stage, ordeath. It is an invariable rule with me still sinking state.to consider life as in jeopardy, until the in- III the more chronic cases leading to sink-testines shall have performed then-functions ing, there are various slight efforts of re-

again, all irritation having left the stomach, action, as flushes and heat of skin ; some-and the skin remaining universally and times there is shivering, followed by heat;equally warm." slight dozing, or delirium, catching, crepi-The diseases in which the state of sinking tus, or labour in breathing, mucous cough,

is most marked are, I think, typhus, deli- cold extremities, the eye being bedimmedrium tremens, pneumonia, bronchitis, errte- by a film of mucus.ritis, and dysentery, though many other dis- Sinking is sometimes induced by undueeases lead to this state, and especially some and inappropriate depletion; at other timeswhich consist in repeated attacks, each it is the peculiar tendency, or effect of dis-attack leaving the patient weaker than ease. Altogether, especially in reference tobefore, until they issue in sinking of the the prognosis, and the reputation of the phy-vital powers, sician, I regard this subject as of peculiarAmongst the first symptoms, coldness and interest, very imperfectly known, and still

lividity of the hands are frequently observ- requiring the most attentive investigation.ed, the livid colour disappearing imper- I have here only pretended to offer hints andfectly on pressure; the cheeks and nose are some materials for thinking, leaving theat the same time usually cool. There are matter for future inquiry. Remedies seemoften much general and indefinable suffer- to be vain.ing, distress, and restlessness ; sometimes We now arrive, Gentlemen, at the effectsslight dozing, at others slight delirium, and of mercury. The principal morbid effect ofin some cases convulsion, followed by coma; mercury is that designated by Mr. Pearson, tothe breathing is sometimes imperfect, the whom we owe its detection, the erethismusinspirations sudden and catching—a fatal mercurialis. This term must be carefullysymptom; and I have, in some cases, ob- distinguished from erythema, which it mayserved the crepitus in breathing, also a fatal be thought to resemble. I must take this

symptom, of which I have spoken, for some opportunity of referring you, on this anddays even before there was any other decid- similar occasions, to the invaluable" Dic-ed symptom of sinking; the voice is fre- tionary of Medical Terms," by Mr. Hoblyn.quently altered and rather husky; the pulse This little work should be on the table ofis small and frequent, and perhaps irregu- every member of the profession, whatever hislar; the motions are apt to be passed in- degree may be. It contains more informa-voluntarily, and sometimes there is tympa- tion, in a short space, and at a trifling price,nitis, or retention of urine. It is usual for than any work I know. To this affectionsome distressing symptom, as delirium in the late Dr. Bateman, the-friend of Mr. Pear-phrenitis, cough in affections of the chest, son, fell a victim, and that from the want ofand pain in those of the abdomen, to have a prompt diagnosis. The first symptoms ofceased as the state of sinking has come on. this terrible affection occurred on the ninth

In typhus, sinking is very apt to occur in day of the mercurial inunction ; this wasthe later stages, and after undue exertion, nevertheless continued to the thirteenth. Dr.as in getting and sitting up. Laennec ob- Bateman observes, in the detail of his ownserves,

" in some subjects peripneumonia case, given in the ninth volume of theproves fatal before it has affected one-fourth " Medico-Chirurgical Transactions,"—" Itof the lungs, a fact," lie adds, " calculated, is evident that the features of the maladylike many others, to prove that death is fre- are not sufficiently known, even to the mostquently owing more to the failure of the enlightened members of the profession; forvital principle than to the extent of the local the failure on the part of the medical ad-disease." In some diseases of the bowels visers, in the instance about to be related,this state sometimes occurs early in their to recognise its first symptoms, and the con-course. In such cases it has been usual to sequent repetition of the dose of the poison,conclude that gangrene had taken place; after its first commencement, had nearlybut, on examination, no such appearance has proved fatal."been observed: the sinking state is, equally The detail itself is full of interest; andwith gangrene, attended by a subsidence of not the least affecting part of the story is,the abdominal pain. There is a puerperal that, eventually, the disease did carry offaffection of the bowels, the course of which this able physician.is similar. In two instances there were Mr. Pearson observes-" Iu the course ofvery severe attacks of pain ; the surface be- two or three years after my appointmentcame cold and livid, the voice changed, the to the care of the Lock Hospital, I observedbreathing imperfect, the pulse frequent and that in almost every year, one and sometimessmall, and the patients expired with all the two instances of sudden death occurred

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among the patients admitted into that insti- stance, walking hastily across the ward;tution; that these accidents could not be rising up suddenly in the bed to take foodtraced to any evident cause ; and that the or drink; or slightly struggling with somesubjects were commonly men who had of their fellow patients, are among the cir-

nearly, and sometimes entirely, completed cumstances which have commonly precededtheir mercurial course. I consulted Mr. the sudden death of those afflicted with theBromfeild and Mr. Williams upon this inte- mercurial erethismus."resting subject, but they acknowledged In Dr. Bateman’s case it was remarked,themselves unable to communicate any " that the action of the heart and arteries,satisfactory information ; they had carefully which was extremely feeble as well as irre.examined the bodies of many who had died gular while awake, was so much more

thus unexpectedly, without being able to enfeebled during sleep, as to be in factdiscover any morbid appearances ; and they almost suspended, and thus to occasionconfessed that they were equally ignorant alarming faintings and siiikings ; so that itof the cause, the mode of prevention, or the became necessary, notwithstanding the ex-method of treating, that state of the system treme drowsiness which had succeeded thewhich immediately preceded the fatal ter- long-continued watchfulness, to interruptmination. the sleep at the expiration of two minutes,"As the object of my inquiry was of con- by which time, or even sooner, the sinking

siderable importance, I gave a constant and of the pulse and countenance indicated theminute attention to the operation of mer- approaching languor."cury on the constitution in general, as well « To prevent the dangerous consequencesas to its effects on the disease for which it of this diseased state, the patient ought towas administered ; and, after some time had discontinue the use of mercury ; nor is thiselapsed, I ascertained that these sinister rule to be deviated from, whatever may beevents are to be ascribed to mercury acting the stage, or extent, or violence of the vene-as a poison on the system, quite unconnected real symptoms. The impending destructionwith its agency as a remedy ; and that its of the patient forms an argument paramountdeleterious qualities were neither in pro- to all others; it may not be, indeed, super-portion to the inflammation of the mouth, fluous to add, that a perseverance in thenor to the actual quantity of the mineral mercurial course, under these circumstances,absorbed into the body." will seldom restrain the progress of the dis-The erethismus mercurialis may come on ease, or be productive of any advantage.

at any period of the use of mercurial reme- The patient must be expressly directed todies. In Dr. Bateman the first symptom expose himself freely to a dry and cool air,occurred on the ninth day of mercurial in- in such a manner as shall be attended withunction, with languor, fever, and, on the the least fatigue. It will not be sufficientnext morning, with violent and irregular to sit in a room with the windows open; hebeating of the heart. must be taken into a garden, or a field, and

Mr. Pearson observes-«The gradual live as much as possible in the open air,approach of this diseased state, is com- until the forementioned symptoms be con-monly indicated by paleness of the counte- siderably abated. The good effects of thisnance, a state of general inquietude, and mode of treatment, conjoined with a gene-frequent sighing; the respiration becomes rous course of diet, will be soon manifested;more frequent, sometimes accompanied with and I have frequently seen patients so fara sense of constriction across the thorax ; recovered in the space of from ten to four-the pulse is small, frequent, and often inter- teen days, that they could safely resumemitting, and there is a sense of fluttering the use of mercury ; and, what may appearabout the prsecordia. In this early stage, remarkable, they can very often employthe farther progress of the mercurial ere- that specific efficiently afterwards, withoutthismus may be frequently prevented, by suffering any inconvenience."giving the camphor mixture with large To show how little this affection is under-doses of volatile alkali, at the same time stood, even now, I quote the following shortsuspending the use of mercury." And account, which may be compared with thatfurther,-« the erethismus is characterised given by Dr. Bateman:—" Mr.-, sur-by great depression of strength, a sense of geon, and a West Indian, called upon me toanxiety about the praecordia, irregular ac- hold some conversation on his own case.tion of the heart, frequent sighing, trembling, He attributed his unhappy condition to apartial or universal, a small, quick, and malignant fever, with erysipelas, duringsometimes an intermitting pulse, occasional which there had been exhibited a great dealvomiting, a pale contracted countenance, a of calomel, as much as thirty grains at onesense of coldness ; but the tongue is seldom dose, which cured him; but he thought it

furred, nor are the vital or natural functions left him subject to a gastric affection, withmuch disordered. When these, or the chronic inflammation.greater part of these symptoms are present, " However that may be, this is his presentn sudden and violent exertion of the animal condition: on falling asleep, just at the mo-powers will sometimes prove fatal ; for in- ment when volition and sensibility cease,

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the involuntary motions also stop, with asensation of death, under which he awakesgenerally convulsed.

« His medical friends have sat by himand watched him, and they have found thatwhen sleep is overpowering him, the breath-ing becomes slower and weaker, the heartand pulse also fall low, and cease to beat assleep comes on, and, after a short time, heawakes in tremor." This gentleman is very naturally in

much apprehension that some of those at-tacks may terminate existence. But he isyoung, and I think the attack is essentiallydifferent from the case of angina pectoris.It presents to us a lively idea of what wouldresult, were the involuntary nerves sub-jected to the same law with the nerves ofsense and volition ; for then sleep, by over-powering both, would be death."

There is great similarity between theerethismus mercurialis and the effects ofloss of blood ; the extreme degree of chlo-rosis, and disease of the heart itself; in allthe peculiar effect of sleep, and the prone-ness to sudden dissolution, are the same.The erethismus described by Mr. Pearson

is not the only morbid effect of mercury,This remedy, instead of producing a kindlyeffect on the system and on the disease,sometimes induces a quickened pulse, withfeverishness and general inquietude, a

furred tongue, a harsh and intolerable feel-ing about the stomach and bowels, perhapswith sickness, perhaps with diarrhoea.Each dose and every form of the medicine

produces these painful and untoward effects,and we are frequently compelled to relin.

quish the use of our most important re-

medy.In two recent instances, the first of in-

flammation over the caput coli, the other ofinflammation of the right ovarium withascites, the progress of the treatment wasrepeatedly interrupted by this unkindlyaction of mercurials. Their form was chang-ed ; they were omitted, and resumed re-peatedly.In other cases a single dose of the pilula

hydrargyri, or of the hydrargyri submurias,induces a state of nausea and sickness, or oftormina with diarrhoea.There is still another morbid effect of

mercury, the erythema, or rather eczemamercuriale. This affection will be describedin another part oi’ these lectures. A similarrash is induced by opium, arsenic, and othersubstances, and by gastric irritation fromvarious causes.

In my next lecture I commence the detailof the results of a long-continued attentionto the PHYSIOLOGY, and especially the PA-THOLOGY of the NERVOUS SYSTEM, one of themost interesting subjects which can occupythe scientific physician, or the practitioner.I trust that I shall be enabled to excite in

you a deep interest iu this important subject.

LECTURESON

MATERTA MEDICA AND

THERAPEUTICS;NOW IN COURSE OF DELIVERY

AT THE

WINDMILL-STREET SCHOOL OF MEDICINE.BY

GEORGE G. SIGMOND, M.D.

GENTIANA.THE GENTIANÆ.—Characteristics of the fd-

mily ; its principal species. GENTIANALUTEA.-Description of the root and itsbark; preparations; doses. Gentianine;medicinal potvers of gentian. The Portland

gout-powder. CHIRAYITA GENTIANA.Great value cf this new bitter; directiorzsfor its use.—QUASSIA ExCELSA. Its pro-perties and preharations. Quassine. Useof quassia in diarrhœa.—QUASSIA Smtn-ROUBA. Its intense bitterness and medicalvirtues. Analysis of the bark. Its use inthe third stage of dysentery.GENTLEMEN :-The whole family of gen-

tians have for their great characteristic avery intense bitterness, without any degreeof acridity ; this property resides both inthe roots and in the stems. They are allquite innocuous, and some of them possessvery great power on the system, which theyinvigorate. They are particularly gratefulto the stomach, and administered alone, orproperly combined with medicines whichgive tone and strength, they add to the in-estimable treasures which are contained inthe catalogue of the materia medica. It istrue that their effects may neither be sostriking, nor so instantaneously produced,but still they are certain and efficacious re-medies in a vast number of chronic diseases.I cannot, of course, call upon you to devoteas much attention to the less powerful the-rapeutic agents which I am now describingto you, as you are required to do to thoseupon whose due and proper employment lifeand death must depend ; but you must bearin mind that owing to the vast improvementsin our science acute disease does not sooften come before you as it formerly did,and the necessity of early recourse to thehealing powers of medicine isnow so stronglyimpressed upon the minds of the great com-munity that it is quite as necessary youshould be familiar with the aid that youcan give by the less active remedies, or

those which take some time to produce theirdue influence, as that you should be tho-roughly acquainted with the properties ofarsenic, of mercury, of opium, or of hydro-cyanic acid. The principal species of gen-tianæ are the lutea, which is most commonly