721

to the animal or the part. To producethousand delicate intonations of the humanvoice, the highest degree of sensibility isgiven to the larynx; but incomparably lesswill suffice for the animal, the compass andintonations of whose voice are so limited.We can imagine that in the one the morbidirritability may be so great, that no fluidcan pass over the membrane without excit-

ing the mo3t horrible spasm ; that even thevery thought of it shall produce the spasm,md even a current of air, in increased

quantity, or of altered temperature, passingthrough the glottis, shall be followed by thesame horrible consequence, while in theother, no marked ettect shall be producedby the same agents. This will be more

fully discussed, when, under the sensorialsystem, I trat of rabies. It is now men-tioned incidentally as satisfactorily account-ing for the fact, that the principal distin-guishing symptom of rabies in the humanbeing is wanting in the quadruped.

LONDON HOSPITAL.

CLINICAL LECTUREDELIVERED BY

DR. BILLING,PHYSICIAN TO THE HOSPITAL,

Dec. 31, 1831.

2TESV FEVER. -

Additional Cases of Petechial Synorha.SixcE last lecture, Gentlemen, I have

admitted three more cases of the petechialsynocha. The two remaining of the formerpatients, F. W. and J. ’1’., are now alsoperfectly convalescent ; there is nothingwoith mentioning’ in the reports, exceptthat J. T. continued to have troublesomecough and headach, which were removedby a blister to the che-;t, and leeches to thetemples two or three times, and ipecac. gr. i,ter die as an expectorant, added to the qui-nine. In those cases where you find deli-rium, or even headach, continue after the

eruption has come out fully, you must applyleeches to the temples, or the patient willbecome typhoid, and if you find that statecommencing, the leeches will relieve thehead, and make the pulse fuller.

Case 1.—J. H. æt. 32. Febris.

Dec. 29. One P.M. Complains of head-ach, weakness in his limbs, and cough;rhonchus sonorus gravis and sibilans; is in-coherent. His friends state that lie has Ibeen ill about a week. Tongue white;

! thirst, anorexia; pulse 120, strong, and! hard; skin and forehead hot and dry;, bowels confined. Had copious bleedingfrom the nose yesterday, and the day be-fore ; he has been bled from the arm, and

had some medicine ; he shows great morbid! anxiety, and objects to being bled.

V.S. ad 3xvi. statim. Abraso capillitio lo-tio frigida fronti. Capt. magnes. sulph.,3ss; Ex inf. sennœ, 3iss. statim; et posteamagnesiœ, sulph, 3j; Antimoniitart.g.1;Ex aquœ, 3ies, 4tis horis.

Five P.M. Pulse much softer ; tonguemoister.You had here an opportunity of seeing

the synocha in its full character, and par-ticularly the sensoi,ii J’anctio7zes pS)’MM tur-

batœ; for though incoherent, he was think-ing anxiously about his family and himself,and was offended because I referred to hisfriends to confirm his statement, and par-ticularly because I ordered him to be bledimmediately afterwards, thinking it impos-sible I should do so had 1 believed his ac-count of the quantity of blood lie had al-

ready lost; you do not see this activity ofmind in typhus, nor in synocha, when thebrain and viscera are oppiessed for want ofdepletion; compare, for instance, the caseof J. 1’. with this, or a case which I havenext to remark upon ; observe also the re-port of profuse bleeding from the nose,which kind of occurrence was one of the

things that formerly gave a hint to Syden-liam and others to relieve apparent debility,by taking off the load from the viscera,having observed spontaneous haemorrhageto afford relief, when they had not venturedto bleed.

30. Feels much better ; lies on his side ;still rather confused, and his manner hur-ried and anxious ; eyes more lively ; sayshe does not sleep petechiæ fading pulse120, soft, rather full; tongue whitish, nearlyclean ; thii-at; but little cough ; no headachbowels opened once. Perstet.

’, 31. Says he is very bad, very low ; feelsno better, and his head worse ; hopes weare not going to bleed him again. But the

petechiæ are gone ; he slept in the night;skin temperate ; is perfectly collected ;pulse 94, soft ; tongue clean, rather dry ;he has been purged six or seven times

to-day.Habt. tinct. opii, ltixv .Ex aq. menthœ,

3j. stutim; Capt. decocti hœmatoxyli,3iss. ter die. Omitt. cœtera.

You have in this day’s report, Gentlemen,the disTinction between complaint and dis-ease ; his disease is gone, but he is full of

complaints. The reason is that, in the firstplace, besides his own feebleness, he hasmuch cause for domestic anxiety, and hisfeeling of weakness makes him dread being

722

bled again the purging also, though neces-sary, makes him feet low, and we may withsafety give him the tinct. opii to soothe hisnerves, which ladies take for the same pur-pose, very much to their detriment, whendone unadvisedly. After that he requiresnothing more than the decoct. hœmatoxyli,which will act as a mild tonic on the mu-cous membrane of the primse v ix.

Case 2.-L. S., aet. 22. Febris.

Dec. 29. Has heaviness in his head,pains in his back, abdomen, and limbs, withweakne-s; he lies supine ; has been thusaffected for about a fortnight, has had seve.ral restless nights, and been delirious; isincoherent, and speaks thick ; skin dry, nothot; some cough he says at night ; pulse120, small, and soft ; ronchus sonorus gra-vis and sibilans in various parts of chest,and crepitans posteriorly ; tongue brownand dry in the centre, with a margin ofmoist white fur; anorexia ; thirst ; bowels

quite confined for several days; abdomentender on pressure; urine said to be natural.

VS. ad zxvi, et capt. haust. lilf. senrtce,ziss. c. Magnesice sulph., a tss. statim etpostea, antim. tart., g; Magnes. sulph.,;i ; Ex aq., xiss. 4tis horis.

This man was admitted in a state of greatoppression, from the duration of his dis-ease, and its being unchecked by any reme-dies ; the state of the pulse, &c., showedthat he was beginning to sink ; but thosewho do not avail themselves of ausculta-tion would not have been led to suspectthat this proceeded from inflammation ofthe lungs, as he merely reported that hecoughed at night, and made no complaint ofpain in his chest. I should not haveblamed any man much who had mistakenthis case for typhus fever, if he did notunderstand auscultation, but I should blamehim very much for not being an auscultatorin the present day. I remarked to those

gentlemen who were with me at the time, ithat this case would teach them not to fearthe bugbear debility, and when you seewhat was the effect of V.S. and salineantimonial medicine, you may judge whatmight have been the effect of wine and

brandv.30. Nine A.M. Answers distinctly, and

sits up in bed; skin hotter than natural;bowels not relieved.

Rep. haust. cath.Two P.M. Has relapsed into stupor since

morning ; lies supine, but does not seemweak when roused ; bowels not yet opened ;abdomen tender on pressure, and muchflatus in the epigastrium; skin dry, andrather hotter than natural; some petechiaeon the chest; he coughs, but does not ex-pectorate ; pulse 84, full; tongue dry.

V.S. ad zxvj statim ; Rep, haust. cath.statim; lpjec. enema puog. c. ol. tere.

birctlz. ij statim.I need scarcely add any observation to

this r port, which showed the tendency tocoma, instead of typomania, and the neces-sity for active depletion. The ol. terebinth.was added as a carminative on account ofthe flatus.

To-day (31st) he is a little relieved, butstilt comatose, and shows no sign of debilityafter a second bleeding and being freelypurged. He was delirious in the night; heis now drowsy and inclined to snore, butwhen roused answers better than yesterday,and says he is thirsty, showing therebymore sensibility ; he says he has no head--,ch nor pain in the abdomen, except whenit is pressed ; he still coughs ; the petechiasare less abundant than in the other cases;pulse 92, of natural force; skin softer;tongue still dry. 1 consider him going onwell, and have ordered him hirndines x tem-paribus, and to continue the saline antimonialmedicine.

Pathological Remarks.I have now to show you a specimen of

the pathological state which is indicated bythe auscultatory signs in this epidemic, thelungs gorged with blood, but particularly,as you see, the mucous membrane of thetrachea and bronchial tubes, of a bright red,with a sponginess, or thickened state. This

specimen was obtained from the body of theold woman E. G., who died a few days afteradmission, though she had, in fact, less ofthe symptoms of fever than the others, butthis congestion of the lungs and inflamma-tion of the bronchial tubes required deple-tion, which she could not bear like theothers, in consequence of the cartilaginousstate of the mitral valve, and the heart andthe pericardium being loaded with fat; and

she died much more from suffocation thanfever. The brain and meninges were

healthy, and also the peritoneum and intes-tines, though the abdomen had been tenderon pressure, but that is often the case fromflatus and other causes besides inflamma-tion. She had the pulse of synocha at

admission, and but little delirium ; she wascovered with red petechise ; she had at thesame time subsultus tendinum, and uponthe application of twelve leeches the pulsebecame irregular and weak.

ERYSIPELAS AND CARBUNCLE. (Continued.)W. A., whose case I explained to you on

the 10th (page 583), has gone on well,though he has suffered much pain, as mighthave been expected from the severity of thedisease, similar ones sometimes terminating.fatally. The calomel after a few doses

723

made his mouth sore; but this did not

appear beneficial, on the contrary, just asthe mouth became aifected, there was a

slight spread of the erysipelas towards thesternum, upon which part a blister was

applied, and the spreading was arrested,but leeches gave most ease, ten of whichwere applied six or seven times before he

got nd of the rigors, or could swallow withanv facilitv. On the 19th the core sloughedfrnm the carbuncle ; on the 23rd somehealthy pus was evacuated from the anterior

part of the neck; after the slough separated,the parts remained exquisitely tender,which you saw were immediately relievedbv the oil-of-turpemine dressing; the

quinine was increased to gr. v, and hasbeen continued with opening medicine oc-casionally, and he is now quite convales-cent.

We had another case of combination of

erysipelas with carbuncle in the old manW. B., who was convalescent from chronicmeningitis, when he was attacked with

erysipelas of the face, and as that subsidedhe got a carbuncle swelling, about fiveinches in diameter, below the left scapula,which was checked by leeches and poul-tices, though not sufficiently to prevent thenecessity for making’ a deep incision intoit, to discharge the core. He is gettingwell rapidlv, with taking quininæ sulph.,gr. iij 8vis horis, and decoct. aloes coinp.to keep the bowels regular.

CASES OF APOPLEXY AND PARALYSIS.

Value of Depletion in cases of long standing.Case 1.—The case of J. C. is instructive,

as showing you a man on the totter of apo-plexy, without becoming actually comatose.On admission he could not take two stepsforward unsupported.

Dec. 8. J. C., ast. 40, complains of gid-diness in his head, preventing him fromwalking ; was first attacked ten days ago,after intoxication, which he acknowledgesto be habitual. He feels drowsy : pulse92, hard; bowels open from medicine;says he has no other complaint, but that h(-coughs a little usually of a morning, and issubject to colic pains; he has been cuppedwith relief.

V.S. ud zxvj ; puiu. cat. c. jal. co.

alternis auro’ts ; antirn. tai-tariz. g. 193magnes. sulph.zj, ex aquœ ziss ter die.

This is one of those cases, which I havementioned to you, of acute inflammatorycongestion on the surface of the brain, pro-duced by excesses, or other causes, and

terminating in apoplexy, as this would havedone, had not the fit’ been kept off by hisbeing cupped and purged. This man hasno weakness, or paralytic tendency of either

side, and when apoplexy does take place ittthese cases, it sometimes passes off likeexcessive intoxication, without leaving thathemipleg’ia which remains when there is

rupture of a vessel, or other injury withinthe substance of the brain, or somethingwhich depresses its sutface, and which wiltexist also in these cases, if the inflamma-tion penetrate deeply, even without pres-sure. The treatment was simply and ac-tively antiphlogistic ; besides the openingmedicines, he has been bleed three timesto zxvj, and had a dozen leeches twice tohis temples. On the 16th, as he was get-ting th n, and had previously been out ofcondition from his digestion being injuredby intemperance, I ordered him quininae,gr. ij, in addition, ter die; he graduallyacquired steadiness in walking, and yes-terday went home well. I fear very much,however, we may have him return likeJ. T., whose case is in a former journal,and will interest you both from the analogyand on account of the pathological exami-nation.

Case 2. J. T., ast. 40, brought by hisfriends in a state of phrenitis, restless, in-coherent, and noisy; he is in the habit ofintoxication, and yesterday, going up- stairs,he was seized with pain in the head, andweakness of left leg and arm, but did notfall or have any fit. Pulse hard, skin hotand dry, bowels costive. He was treatedin the same way as J. C., and left the hos.pital well in a month ; he had regained thefull power of his limbs within the first week.When dismissed, he was cautioned of thedanger he ran by indulging in fermentedliquors ; but in less than a month, afterhaving made too free, he was brought backin a state of apoplexy, of which he died.

Examination of the B)-ain.-Upon exami-nation there was found a depression in thesurface of the brain, about the size of halfa hazel-nutshell, situated under the coronalsuture, an inch and a half from the longi-tudinal sinus, on the right side ; this hol-low contained recently-extravasated bloodunder the membrane. The surface of thebrain had a slight appearance of inflamma-tion, being more congested than the other,and the cortical surface more translucent,as far down as the petrous portion of thetemporal bone ; the brain and cerebellumwere in other respects healthy in appear-ance ; no effusion in the ventricles worthmentionmg ; perhaps two or three drachms.Remarks.-The quantity of actual mecha-

nical pressure here was not sufficient to

produce the symptoms, if it were not forthe inflammatory injury of the parts, andthe appearance of the extravasated blood,was too fresh for it to have been the causeof the first paralys s, three months before

724

death, besides which paralysis had existed from one to another. He had been ill ninebut a few days at that time. From these or ten months, and had been salivated, &c.cases you will learn the value of venesec- &c. After several visits I made up mytion, and other antiphlogistic treatment, in mind that the case, of however long stand-comatose diseases, connected with plethora ing, was still inflammatory, and recom-

andpyrexia, independent of actual pressure, mended bleeding again, to which he wasinasmuch as inflammation of a part impedes averse, having experienced no relief fromits functions, and of course an inflamed it before, and feeling weak. But I hadbrain, or part of a brain, may be as much succeeded in gaining his confidence and hedeprived of its function for the time by submitted ; the first free VS. gave himinflammation as by mechanical pressure, and slight relief, and he slept better that night,if you a low this inflammation to run on, he was bled many times, and with succes.disorganisation will commence, and as a sive improvement, and got well, and hascertain consequence of disorganisation, per- continued so now for some year, requiringmanent paralysis; whereas if you relieve VS. occasionally. His phrenological con-the inflammation of the part by antiphlo- volutions did not seem to be affect, d at any

. gistic means the paralysis will pass off; time, beyond the depression of spirits in.and in many instances you must persevere duced by confinement and continued pain.long with antiphlogistic treatment. The Having said so much of the value and

greatest difficulty in the practice of medi- necessity of antiphlogistic depletion incine is to gain that confidence or decision complaints of long standing, I must remindof action which depends on practical expe- you of what you have observed in the wards,rience, and which the witnessing a great that many paralytic cases also require tonicsnumber of cases alone can give. Hence and even stimulants, for when a part of thethe use of hospitals, for you might be seven brain is diseased with chronic inflammation,years practising before you would meet as well as any other part of the body, it re-with the same variety of cases which you quires some power of constitution to restoremav see here in seven weeks. it, and inflammation in an over-debilitated

Case in Illustration.—To illustrate the person is likely to degenerate, instead ofnecessity for long-continued active treat- improving; hence you may see two paraly-ment in old cases, and that old cases must tic patients of mine with their beds side bybe denominated acute, according to the side, the one having leeches and purgativessymptoms and not the duration, I may and antimonials ; the other little or no pur-mention oRe which occurred to me, which gatives, and taking bark, iron, sar,apanlla,is interesting on this account, and also ana- with animal food, and sometimes wiue.tomicaUy interesting. A gentleman con-

sulted me on account of distressing pain in Case 3.-The only other case of paralyticthe head, preventing sleep, and disturbing disease in the clinical journal exemplifiesappetite and other functions ; there was no that unfortunate waywardness which some-heat of skin, and very little alteration of times occurs in hemiplegiac patients, to

pulse except hardness, and I should have their great injury, by preventing their fol-considered the case neuralgic, had it not lowing up the advice which would ulti-been for a paralysis of the muscles of the mately restore them to health. It is one

right eye, and a numbness of that side of of those cases in which the paralytic strokethe face; there was also a diminution of precedes the apoplexy.heating on that side, with false sense of D. P. et. 33, Dec. 9th.-About sevennoise in the ear; the eye was always per- months ago he fell down and found himself

manerifly turned outwards, showing that the unable to rise, having lost the power of theabductor oculi alone was not paralysed, and left side; in six or seven hours he becameby looking at the base of this brain, you wilt quite senseless, and remained so for threebe able to judge how this happened ; there days, and for a week was speechless, andmust have been a stripe of inflammation of had great pain in the back of the head, somethe meninges or surface of the base of the of which continues. He has been bled, andbrain at one side, from front to back, affect- cupped several times. At the time of Lis

ing the neurilema of all the nerves in its admission he was able to walk, draggingcourse; the nerve of the sixth pair which the leg ; he could raise his hand to his head,goes to the abductor oculi, being on a pro- but not move the fingers (except, he said,jection as you see at the end of the corpus sometimes when warm in bed); the mus-pyramidale, out of the line, and hence the des of the face somewhat paralytic, allow-abductor not being paralysed, whilst its ing saliva to escape from the mouth, thoughantagonists were, kept the eye constantly less, he stated, than formerly. Sensationturned outwards. This gentleman had con- remained in the affected side. Pulse 75,suited several men of character in the pro- full ; tongue clean; appetite good ; bowelsfession without benefit, partly because he regular once a day without medicine. Ihad not given them fair play, as he went ordered him, however, antim. tart. gr. s

725

magnesice sulph. zi, ex aquœ ziss ter die, to

assist in keeping’ down any inflammatorytendency, and to preserve regularity of thebowels, as exercise is injurious in thesecases, unttl pain and every suspicion of in-Bttmmation have been removed ; when thattime has arrived You mav exercise and rubthe muscles, and resort to electricity, to re-new nervous energy. He has been bledfrom the arm to §xvi, and leeched everyother day on the temples, it was also neces-sarv for him to take senna and salts, to

keep the bowels open, though he had re-ported them as regular without medicine.On the 27th he felt better and stronger, theheadach variable but palpably better aftereach application of the leeches, he couldmove his fingers, and grasp anything firm-1.; the muscles of the face recovered. Yetwith all this improvement he insisted upongoing home, feeling dissatisfied at being re-strained in his diet, and from walking out ofthe hospital when he pleased.

ST. THOMAS’S HOSPITAL.

CLINICAL LECTUREBY

JOHN ELLIOTSON, M.D., F.R.S.

PROFESSOR OF THE PRINCIPLES AND

PRACTICE OF MEDICINE

IN THE UNIVERSITY OF LONDON,

Delivered February 6th, 1832.*

* As a considerable portion of the present lecturerelates to a subject which is now under contro-versy in THE LANCET, it is transmitted for publica-tion a week out of its regular order.-REP.

I HAD intended, Gentlemen, to’ direct

your attention to some interesting specimensof morbid anatomy; at least, to lay beforeyou one specimen, taken from a man whodied of diseased heart; but after Dr. Da-vison and Mr. Nordblad had taken thetrouble of going a long’ way to inspect thebody, permission having been given by therelations, the undertaker would not allowthem to examine it, saying his liouse shouldnot be made a slaughter-house of, and I amtherefore disappointed, in consequence ofwhich I must advert to other cases, some ofwhich are now in the hospital.

CASES OF CONTINUED FEVER.

Free Admiraistration of Wine. Trial of SalineMedieines according to the Proposal of Dr.Stevens. Changes of late in the Characterof Fever.

Case 1.-The first case to which I am anxi-

ous to allude to-day, is one of continuedfever, pointing out the desoiption of prac-tice which is occasionally necessary in thisdisease. The case is that of HannahGell, aged about 26, who had been ill the

greater part of a fortnight with continuedfever. 1 could not discover that it arosefrom contagion. She was admitted in anadvanced stage of the complaint, lying uponher back, unable to move, almost unable tospeak, with extreme prostration of strength,the tongue dry and rough, and the teethcovered with sordes. She was delirious,and the pulse was extremely weak, at 130.

7’,reati)zeitt. -Before I saw her I foundthat ten leeches had been applied to thehead, and subsequently a cold wash, andalso a mustard poultice to the abdomen.The mustard poultice was applied on ac-count of pain felt in that situation. Thiswas a case of which, when I first saw

it, I feared the result, and I scarcely ven-tured to hope that the woman would re-cover. It was on the 6th of January thatI saw her, and there was then very littletenderness of the abdomen, so that themustard poultice appeared to have answer-ed the desired end. As to applying leechesagain to the head, that was out of the ques-tion, on account of the extreme debility.The indication appeared to be to supporther as much as possible. I therefore order-ed her two pints of beef tea as strong ascould be made, and two pints of miik, everyday. The bowels were confined, but Idared not venture to give her purgatives,and therefore merely ordered an injectionof barley water. I was afraid of addingany purgative to the injection. So extremewas her debility, that 1 intended to giveher wine the next day. It would havebeen injurious to begiez with stimulatingtreatment-to have given an abundance ofstrong beef tea, milk, and also wine, atthe onset, she having had, as 1 understood,nothing of that kind before she came in.On the following day she was allowed halfan ounce of wine every four hours, but asshe appeared sinking, it was soon found ne-cessary to give it her every three hours.She still however appeared to be sinking,and there was very little hope of her sur-

viving long,-indeed, even for twenty-fourhours,-and therefore the half ounce ofwine was given her every hour. From

that, on account of the extreme prostrationof strength, I was obliged to come to halfan ounce everv half hour, so that at last shetook twenty-four otiiiees of mine a day-aregular bottle. There was the greatest at-tention paid to her in my absence by Mr.Stone, who ’saw her two or three times a

day, and even in the middle of the night,

and regulated the quantity of wine till shetook what I have now stated-twenty- four