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absolute necessity. Neither do I haverecourse to violent purging, but simply pre-serve an open state of the bowels, and sub-due symptoms of local inflammation by thelocal removal of blood, blisters, and sina-pisms. I also endeavour to procure a moiststate of the mouth by means of mercury,either calomel or hydrarg. cum creta, insmall and frequent doses, which, if. notin a majority of cases necessary to a cure,in many cases are, and in most cases greatlyaccelerate the removal of the disease.You will recollect another patient who

was admitted the same dav into William’sward, who had been ill three weeks,whereas this man had been ill but eleven

days, and who was not by any meansso had as this man, but who had been bledin the arm before his admission, has re-

covered much more slowlv, and even nowis not able to leave his bed, nor will beforeten days to come, on account of a crop ofboils which appeared on the abdomen, andan abscess in one groin. I will not saythat this delay was owing’ to the venesection,but I only wish to urge to you that it is ingeneral unnecessary in the fevers we havein this hospital to use strong measures.

RHEUMATISM.

There was a case of rheumatism in a managed 40, who was admitted on the 21st ofOctober, on account of having pain in theside as well as the rheumatism, and wentout on the 4th of November perfectly well.He had been ill a fortnight. The jointswere swollen and hot and rather red, andhe sweated. I bled him to a pint, and hetook six grains of calomel that day and theday after, and cold water was applied to theparts affected. His bowels were openedand colchicum was given him in the dose ofhalf a drachm of the wine every six hours.He at once recovered without any compli-cation of medicines or any alteration ofplan.With respect to the cases admitted this

week, there were five amongst the women,viz. one of epilepsy, one of bronchitis, oneof lepra, one of eczema, and one whichturned out, as I suspected, to be itch. It issometimes difficult to decide upon cases ofitch, from persons scratching themselves sounmercifully as to destroy the real characterof the election ; but in general you may tellitch by its occurrence on the hands and ancles- at the roots of the thumbs especiallv, andat the wrists. I never knew an instance ofits affecting the face. Frurigo will occur inthe face.

Amongst the men was one case of bron-chitis, two of rheumatism, one of remittentfever, and one of aneurism of the abdominalaorta.

LONDON HOSPITAL.

CLINICAL LECTUREDELIVERED BY

DR. BILLING,PHYSICIAN TO THE HOSPITAL,

November 12, 1831.

BEFORE entering upon any new cases, Imust report upon the progress of those de.scribed in the last lecture.

AGUE.

Case 1.—C—— D--, Nov. 6th. Feelsbetter than yesterday (see page 237), butnot quite so well as an hour ago, havingmore confusion in his head; his appearanceis improved ; had some shivering this after.noon, and lips trembling now ; pulse 100,full and strong ; cough very troublesome ;tongue moist, but furred, yellowish white;appetite T)ad; thirst ; bowels confined.

Haust. cathart. statim.7th. Feels better in every respect, except

the noise in his head; bowels open once.8th. Feels better, and better appetite,

but still noise in head ; is almost constantlysweating, and has slight occasional chills inthe back, but no rigors ; cough better exceptat night; pulse 108, weak, full, but jerking;tongue nearly cleaiz, with a slight white fur.He mentions, that in his trade, he is

sometimes exposed to dense fumes from

burning wood, to which he attributes thecough and headach, as he found them in-duced on those occasions.

Capt. sulph. quinince, gr. vj.Opii, gr. i. 6tis horis.Omitt. haust. anod. h.s.

He has stated enough to account for his

having some cough and headach, but thecontinuance of dry cough, chiefly tronblesomeat night, with pulse generally above 100,makes me anticipate tubercular disease.There are some points in the right lungI where I think I observe a diminution of therespiratory murmur, without any extra reosonance upon percussion. Now the speci-men in this glass, of miliary tubercles, pro.ducing a diminution of the natural sponvi-ness of the lung, will at one view explain toyou how such symptoms as exist in the pre.sent case might arise. The ague may, not-

withstanding, still be cured. I discontinnedthe solutio arsenicalis, on account of the

bright white superficial fur on the tongue,resembling that produced by mercury. ThisI have observed to be one of the visrble ef-fects of this medicine, which it is not de-sirable to increase in this instance; I have

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therefore substituted a combination of bark iwidi opium, which has been found very efficacious in obstinate cases.

Gase 2.—J—— S--, Nov. 6. Has hadsome shivering this morning. (Seep. 237).

8th. Has had a slight but regular fit ofaaue to-day, and is now (3 P.M.) perspir- Iing; tongue furred, white ; uneasiness infauces, and complains of want of the senseof tasting.

Capt. sulph. quiizino3, gr. v. ter. die. BThe evidence of the effect of the medi.cine on his mouth rendered it necessary to

’Bresort to the quinine, although bark had be-fore disagreed with his stomach. His hav- I-ing had a regular fit of ague I do not consi-1

der unfavourable. It is not unusual for pa-tients who come here from aguish districtsto say, they have "the dead ague," or"abue in their bones," and that they woulddo well if they could " shake out ;" and,in fact, the ague does frequently assume aregular type, under medicine, before theyrecover.

These two cases in the hospital are muchmore interesting than the common routinecases which are treated as out-patients.

llth. No return of ague or pain, but hashad diarrhœa since the medicine was

changed; 7 or 8 motions in the 24 hours ;tongue clean and pale ; appetite not sogood.

Capt. opii, gr. i. cum sinaulis dos. qui-niæ sulph. urgente diarrhœa.

You perceive that cinchona still disagreeswith his digestive organs, producing diar-rhœa, which however may be controlled byopium so as to enable him to perseverewith it.

SIMPLE FEVER.

I have now to point out to you three well-characterised cases of diseases differingfrom each other, which may prove as in-structive by being thus grouped and com-pared, as when affections of the same kindare brought together ; but we have not al-ways this opportunity. One is a case ofsimple fever, another simple inflammationof the lungs, the third a case of fever com-plicated with inflammation of the lungs.The first case is an example of mild ty.’

phus, for there are instances of mild typhusfever, as well as of mild small-pox ; this isone of those cases which confirm the wordsof Armstrong, that typhus is not merely anaggravated degree of fever, but that it istyphus ab initio. I recommend you to studyArmstrong’s writings on fevers, and thoughI ditfer from him on some subjects, I liketo give honour where it is due, and to pointout now, as I have done whilst he was liv-iug, that he was the first, in this country,

to introduce the proper mode of lecturing onthe practice of medicine,—demonstratingthe pathology by specimens and drawings.

B’ F-- H--, stat 22, sugar baker’slabourer. Febris.

Oct. 27th. His friends state, that lie hasbeen ill seven days, after, as they say,catching cold; that he complained first ofpain in his chest and limbs, and afterwardsof his head ; he lies supine, and presents amarked appearance of sensorial oppression,stupor, not coma nor drowsiness, and is ra- ther deaf, eyes sunk and dull ; complains

now only of pains in his limbs, and weak-ness ; skin dry ; pulse 80, weak ; tonguedry; thirst; no appetite ; bowels openedabout four times a day since 24th, on which

i day he had a dose of salts.Capt. magnesiæ sulph. 3i.Ex inf. i-os6c comp. iss. ter. die.Milk diet.

The disease here was fully formed, behad complained of his chest at first, but youmust recollect that there is another organthere besides the lungs ; he has had no

cough ; the uneasiness was in the praecor-dia, the febrile " anxietas," the distressabout the heart which the Irish complainof so constantly in acute diseases ; it is thelabouring heart which in vain seeks rest,

" otium divos rogat," whilst the poison of ,

the fever is in the nervous system. Whenonce the morbid poison of fever has injuredthe nervous system, time must be allowed

for it to recover its energv, bv means of theblood circulated through it; you cannotstop the disease at once, you cannot makethe patient take up his bed and walk, yourduty is to relieve or assist the natural ope-rations of repair, and, if any organ be over-loaded, to deplete, but to recollect not to

waste too much of that blood which is tonourish and restore ; and on the other handto bear in mind, that if there be too muchof it, in proportion to the strength of thelanguid heart, it cannot be sent to the partslanguid heart, it cannot be sent to the partsacquiring it, nor through the lungs to bepurified; and that in such circumstances, itwill be better by venesection to send a

scanty supply than none.There was no indication of active treat-

ment here. The magnesiæ sulph. was givenin just sufficient doses to keep up slight ac-tion of the bowels, and like the other salinesit promotes the secretion of the kidneys andskin. The vehicle chosen was the infoiloste co., containing t11vi. Acidi sulph. dil.in the i, which acts as the mildest possibletonic on the relaxed vessels of the mucousmembranes, and diminishes thirst.

28. Feels no better, but answers morereadily; eyes rather more suffused ; head.ach; had some sleep ; skin warm, dry ;

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pulse 74, soft ; tongae moister, and furred ;thirst.

Lotio frioida capillitio abraso.Hlrud. viij temporibus 2espere si opusfuerit.

The only indication here was, to relievethe distended vessels of the head by theastringent action of cold, or if that shouldfail, by emptying the vessels by leeches;but the latter was left conditional for thedecision of the apothecary, because, though,as you may have seen, 1 do not hesitate toabstract xx or xxx at once, if plainlyrequisite, I never, willingly, waste a dropof blood.

-

29. Feels better; less headach (leechesnot required) ; eyes less suffused; pulse 96,soft; tongue inclined to dryness ; bowelsopen twice.

30. Thinks himself better; tongue moist;pulse 90, full and soft ; bowels open twice ; Iless deaf.

31. Is out of bed, slept well ; pulse 90,weak ; skin soft ; some. appetite.

Nov.l. Much better; no thirst, appe-tite improving ; pulse 90, soft; tongueclean ; bowels free.

2. Convalescent.-8th. Discharged.

PLEURO-PERIPNEUMONY.

G— H-, aetat. 16, labourer.Nov. 8. (Extra case, 8 P.M.) Says be

was seized five days ago with pain of rightside of chest, " of a pricking character, andas if there were a hole in his side," withdyspnoea and cough; he passed a restlessngght, from pain, and next morning began toexpectorate, as he still. does, but scantily;crepitation extensively in right side ; respi-ration puerile in the left ; headach; com-plexion livid ; skin cool, from exposure toweather, being ill clothed; pulse 120,weak ; tongue neatly natural ; thirst; noappetite.

l’o be placed in a warm bed; V.S. ad xiv circiter.

Capt. antim. tartariz., gr. , ex aquip.Omni hora. Milk diet.

This is one of the numerous cases whichshows you the advantages of auscultation,even without which it was clear enoughthat pleurisy existed ; but the puerile respi-ration on the sound side, and crepitation onthe affected side, told us that the substance’also of the lung was in a sate of engoue-’’,ment, approaching to hepatisation, such asyou see in these specimens. Contrast thesensorii functiones plurimum turbate, thestupor of the case of idiopathic fever, withthe unembarrassed intellect of symptomaticfever (pyrexia) here, though so much in-jury, and of so important an organ as thelungs, existed.

The indications of cure here were, to

equalize the circulation by warming theskin and extremities, which were shrunkwith cold, to relieve the lungs of partoftheir load bv venesection, and, this done, topromote the secretions and excretions, bvrepeated small doses of antim. tartariz.,which also has the effect of preventing thepulse from getting hard.

9. At midnight he was very sick, hadrejected much greenish matter, and theantim. tartariz. was suspended by the apo-thecary.Nine A.M. Felt comfortable, having slept

several hours ; respiration easy ; less cough,less pain in side.Two P.M. Not so well ; dyspnœa and

pain in side increased ; pulse 130, full ;bowels confined ; has not resumed his medi.cine.

Capt. haustum caihart. statim.Himdines xx lateri qua dolet.Contin. autim. tartar. sicut antea.

The first day I thought the venesectionwould afford more immediate relief, and b.less fatiguing- in the state he presentedhimself. The pleuritic affection requiredleeching on this day, but in such a case afew leeches would make very little impres-sion.

10. Much better, only weak ; no pain,but cough troublesome ; expectoration morefree ; pulse 90, soft; tongue clean; bowelsopen, skin soft.

11. Much better; pulse 84; skin natu-ral, expectoration free ; tongue nearly clean;crepitation has ceased ; but there is slightbronchial respiration. Complains of w,ntof appetite.

Omitt. mist. antim. tartar.

Capt. magnesiœ sulph. zj.Antim. tartar., gr. 8.Ex aquce, iss ter. die.

By referring again to the pathologicalspecimens, you can better understand thenature of the stethoscopic signs; the crapita-tion has ceased, because the inflammationbeing subdued, the inflammatory thicken-ing (engouement) has subsided ; for the

crepitation is produced by just so much

congestion as, without excluding the airfrom the cells, closes the entrance to them,so that the air in forcing a passage, makesaslight click ; and this takes place in otherstates besides peripneumonv, as where

dropsical fluid congests the lung withoutinflammation, also when tubercles, havingincreased from the miliary size, are ea-

larged and ripening, their presence becomesa source of irritation, producing an entoue-ment around them, and crepitation is heard.But in this case, though the inflamina-

tion is removed, the effect of it is not; thebronchial respiration indicates, that part oi

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the lung continues in the solidified (hepa-tized) state, such as you see in that speci-men of hepati:ed pleitro-peripneuniony, andconducts the sound, making you hear thepassage of the air in the deep-seated bron-chial tubes, which you do not in the natu-ral state of the lung. Now there are dif-ferent gradations of this hepatization, someso firm, that the lung never recovers itsnatural state; in others, the extravasatedtvmph, &c., are gradually absorbed, andthe spongy texture is restored. As soon asa little air begins to get into the cells, cre-pitation is heard again (ronchus crepitansredux), so that here, if we find in a littletime that there is crepitation, you must notmistake it for renewal of inflammation, ifunaccompanied by other symptoms.Now as to the treatment :-He is well as

to pulse, tongue, slun, &c., but he is veryweak; his lungs are not in active inflam-mation, but in the state of a healing sore,and vou have plenty of opportunities in

your surgical practice of seeing, that a soredoes not heal well when the constitution isin a state of too great debility. Hence Ido not immediately apply more leeches tothe side ; but as his appetite is evidentlydeficient now, not form febrile anorexia,but on account of the tartar emetic, I haveleft it off, and hope that he will gain somestrength in a few days by mild nourishment.being at the same time kept perfectly quiet,and then we may attempt to assist naturein unloading the vessels, and the neiveswill help us if we support them a little. Topromote the secretions and excretions, heis to take just enough of medicine to be asubstitute for exercise, which he must notenjoy at present.

FEVER COIIPLICATED WITH PERIPNEUMONY.

In the next case you have an example ofidiopathic fever, complicated with visceralinflamation, as you find described byauthors. By ome the fever would be con-sidered as entirely symptomatic, or second-ary to the inflammation.

J- G-, astat. 16, sailor.(Extra case, 3 P.M.)

Nov. 1. Has been ill three days withheadach, pain in loins, and weakness, alsopain in his side and limbs ; pulse weak,fiequent; skin dry (cool at present fromexposure to the atmosphere) ; eyes very(hl1 and heavy; complexion purplishbrown-, bowels confined; tongue funed;no appetite ; thirst.

Balne. calid. statim; dein pulv. emet.;Flirod. x temjDor:6MS ;dntim. tartar. gr. T, ex aquœ SS 4tis

horis. Milk diet. -

You observe we were here, again, obligedto use artificial heat to the surface on ac-

count of the patient’s being chilled, but youwill find this circumstance often necessaryto attend to in private cases also, when thesurface is in a state of collapse. The tartaremetic was here given for the same reasonas in the preceding case ; but as he appear-ed in too great a state of collapse for V.S.,I gave an emetic of pulv, ipecac. 9j, antim.tartar gr.j,; and the solution of antimonyonly every four hours, and to be adminis-terednow, frequently, according to circum-stances, as might seem fit upon his beingvisited in the evening by the apothecary.

The leeches were applied to the head on

account of the predominance of the symp-toms of febrile sensorial oppression. Bichatwill inform you how this would tend to re-lieve the lungs.

Nov. 2. feels worse, though headachgone ; more pain in loins, and in the rightside of chest, increased by coughing ; chestoppressed ; has expectorated a little yellow-ish-grey mucus mixed with pituita; ronchuscrepitans at the back of the chest, and inright side near axilla; skin hot and dry;pulse 108, fuller and soft; tongue dry andbrown, anorexia ; thirst, urine high-colour-ed ; bowels relieved.Has been directed by the apothecary to

take the mixture every two hours, and havea blister between the shoulders. Thoughhis headach was gone, he "felt" worse,because, in fact, he felt or perceived hisillness more clearly on account of the reliefof the sensorium ; it is a bad symptom whenthe patient is so typhoid as to make no

complaint, and not even to be sensible ofithirst.

I must remind you that the whole of theronchus crepitans was not from inflammation,that sound being produced also by the con-gestive state, which takes place in the backof the lungs in fever, when the patient liessupine, as you will find described by Laen-nec ; had there been double peripneumony,to the amount which the single symptomof crepitation appeared to show, it mustsoon have proved fatal; the right side ofthe chest is the seat of the inflammation.You must not rely much on the expectora-

tion for negative signs ; the mucous appear-ance this day would have led to a supposi.tion that there was more resolution of theinflammation than was actually the case ;

tough, pituitous expectoration is a sign ofpositive inflammation tolerably certain.

3d. Feels no better ; pain on inspirationand coughing ; 50 respirations per minutecough troublesome at times, and he cannotexpectorate much ; expectoration pituitous,tough ; crepitation in right lung and dull-ness ; answers sluggishly, and articulationindistinct; sordes on teeth; eyes dull;

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skin warm and dry; pulse 120, soft ; tonguedry and brown ; thirst; only one motionsince admission.

, Capt. hydrarg. submur, gr. iij.Pulu. jalapœ, gr. x.Pulv. zingiberis, gr. i. statim applicen-

tur hirudines xii lateri.On this day there appears to have been anaggravation of both local and febrile symp-toms. Circumstances occurred to preventmy seeing him on these two days, but thetreatment appears to be very orthodox.

4th, two P.M. Feels better; complains ojbeing purged, and of troublesome cough ,pain across chest, respiration frequent :expectoration, brownisli mucus, scanty, andsome pituita; crepitation continues neai

right axilla, and posteriorly on both sides;eyes less dull; skin on trunk warm anddry, but natural on extremities.

Hi1’Udines xij lateri statim.V.S.vesperesi op its fuerit.

Seven P.M. Pain, cough, and dyspnœacontinuing, Mr. Williams had him bled,but only to vi, as syncope came on.You see here again the fever relieved

without influencing the peripneumony,which was even worse until further deple-tion was resorted to, the decline of thE

fever, however, placing the patient in mudmore favourable circumstances.

5th. Feels a little better ; very weak ;less pain in the chest; respiration morefree; more cough in the night, but looser,and expectoration more copious ; skin natu-ral ; pulse 100, weak ; tongue more moist,still furred, brownish; less thirst ; more

appetite ; bowels open once. Perstet.This day the state of skin and return of

appetite show him to be more free fromfever; the chest also much relieved, butstill requiring the continuance of the me-dicine ; you may remark that the cough,though more frequent, is less troublesome,on account of the free expectoration.

. The reports on the 6th and 7th continuefavourable.

8th. Better ; eyes and lips natural;tongue clean ; pulse 84, very soft ; bowelsfree ; slight crepitation in right axilla withbronchial respiration; puerile respirationin left lung ; some pain in right side still.

Capt. mist. ant. tartar. 4tis horis.Emplast. rubefaciens lateui dextro.

10th. Convalescent, up and dressed;pulse 96.

This youth is difficult of restraint, andhis mother brought him articles of foodwhich are improper for him, so that I feareda relapse some time ago ; the erect position i

quickens the pulse. ’

llth. Pulse 96, weak; tongue clean,but too smooth and dry in the middle ;bowels free.

Omitt. antim. tartar.

Capt. magnesiœ sulph. zi.Antim. tart. gr. , ex aqure iss, ter. die.

The tongue has the appearance which isso common after fever, looking as if it hadbeen deprived of the papillæ, but they willgradually rise up again. It is unnecessaryfor me to repeat the observations made uponthe pulmonary symptoms and treatment in

the last case which apply to this.

WESTMINSTER HOSPITAL.

A FEW numbers back we published anelaborate address delivered by Mr. ED-WARDS, introductory to a course of clinical

lectures intended for the pupils of this hos-pital. It will be further recollected, thatMr. EDWARDS announced that be engagedin the undertaking, at the request, or underthe authority, of the physicians of the esta-blishment. What, then, are we to think ofthe following communication and "notice ?"However, as we are apprehensive that thereis a mistake in this business, we shall with-hold further comment until all the partiesconcerned have had full opportunity for

explanation.To the Editor of THE LANCET.

SIR,—The accompanying notice havingbeen stuck up, in the surgery of the West-minster Hospital, by Mr. Edwards the resi-dent apothecary, and as I think it a delicatespecimen of the liberality of the physicianof the hospital, I take the liberty of for-warding it to you pro bono publico. I have,however, to remark, that Mr. D. 0. Ed-wards is a gentleman of such acknowledgedtalent and liberality of sentiment, as per-fectly to negative the idea of his being theemanator of such an injunction, or being 0 inany way accessary to the further impove.rishing of us poor medical students.

I am, Sir, your humble servant,DIEGO CARIOS.

"AIr. D. 0. Edwards presents his com-pliments to the gentlemen who have ho-noured him by their attendance at the ch-nical demonstrations, and begs to acquaintthem, that the physicians of this hospital,not approsing of the gratuitous communica-tion of information to the pupils, have re-quested him to discontinue the course.

Air. Edwards begs to invite them, however,to a course of demonstrations on pathotogv,which he will shortly commence at No. 9,Duke-street." November 9, 1831."