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CLINICAL REPORTS, LECTURES, ETC.
CLINICAL MEDICINE.-PROFESSOR ALISON. OBSERVATIONS MADE ON SOME OF THE CASES IN THE CLINICAL WARDS OF THE ROYAL INFIRMARY, EDINBURGH, NOVEMBER 1850. ABRIDGED FROM LECTURES.
Although much has been said, and very properly said, as to different modes of conducting clinical instruction, yet a little attention to the subject will show, that more depends on the exertions and attention of the student, than on the mode taken of communicating information to him. It is, however, of the greatest importance, as regards the advantage of the student, that he should have, from the first, a clear understanding of the different objects to which his attention is to be directed, and with which it is wished that he should make himself familiar, in the course of his attendance here; and the following may be pointed out as the main objects for his observation and reflection.
1. The different classes of symptoms,—uneasy sensations,-disordered functions, -and altered sensible qualities of different parts of the body, by means of which diseases are recognised during life ;-the kind of information given by those different kinds of symptoms being considerably different and a combination and succession of symptoms being almost always requisite, to characterise any well-marked disease.
2. The observations which may be made on many patients, which indicate, not the specific disease under which they may labour, but some peculiarity of their condition or constitution, sometimes of old-standing, sometimes recently acquired, which may be common to many different diseases, and often regulates both the prognosis and the practice, at least as much as the diagnostic symptoms of disease,-€.g., the indications of the scrofulous diathesis, of the typhoid tendency, of general failure of the vis vitæ, &c.
3. The observation of the changes which diseases undergo from day to day, making us familiar with the usual course of diseases, both in the cases that terminate favourably and in those that are fatal, the examination after death forming, of course, a most essential part of the history thus impressed on the mind, and that whether any distinct traces are or are not found, to correspond with the symptoms.
4. The observation of the effects of remedies on disease, for which we are in fact only well prepared when we have pretty clear ideas as to the course to be expected independently of such remedies; but of which we are capable of judging, in most instances, more satisfactorily by watching the progress of individual cases, than by making statistical comparisons of different sets of cases and modes of treatment ;—the evidence of Statistics, being in fact, for reasons which it is not difficult to assign, much more generally applicable with good effect in inquiries regarding the causes of diseases, than in those which relate to their treatment.
5. Another inquiry presents itself for consideration, in regard to the diseases here, and the practice employed in our hospital, which requires more previous experience, but is equally important,- viz., how far, when we have recognised diseases, we can observe their symptoms, course, and the action of remedies on them, to be similar to, or different from, what we have seen or heard of the same diseases at other times or places. It is generally admitted, as to the epidemic and endemic diseases excited by specific poisons, that they vary remarkably in different seasons; and I have repeatedly stated my conviction, and find it to be the general belief of practitioners in this country, that an equally striking difference has taken place, although more gradually, in regard to sporadic diseases, especially inflammations. Since I expressed this opinion in this place in June last, I have had several communications from experienced practitioners in confirmation of it, and showing that more caution is requisite than has been generally acknowledged, in applying the experience of one time or place to the practice in another; affording likewise another illustration of the general danger of practising merely for the names of diseases; and of the general importance of fixing in our minds principles, in regard to the modes of fatal termination to be apprehended in the course of disease, of more extensive application than the histories of individual diseases. One of these communications is from a friend in Aberdeen, who is one of the professors of medicine, and one of the physicians to the hospital, and who says-“ The unusually large number of cases of pneumonia and pleurisy has been observed this season with us, as well as at Edinburgh, both in the infirmary and private practice; and with regard generally to the use of bloodletting in inflammatory disorders, it has long been a common remark among the profession, in this district as elsewhere, that that remedy is neither required nor borne, to the extent that formerly seemed necessary. About the time your lectures appeared, I had under my care a middle-aged woman with well-marked pneumonia, whose symptoms, from the very first, were such as to forbid the abstraction of a single drop of blood, and to demand wine, ammonia, and beef-tea, and who under these, with blisters and stimulating expectorants, recovered perfectly, although slowly.”
Another letter, from an experienced practitioner at York, expresses “mueh interest in finding that the medical men in Edinburgh entertain the same views on the character of disease, as have been gaining ground with us for some time past.” He adds: “I am making some inquiries with regard to the diseases of cattle, and learn, what indeed I already knew in part, that the diseases incident both to horned cattle and horses, have of late years assumed an adynamic character, and that bleeding is not employed to anything like the same extent as formerly.
One remarkable fact in the practice of the clinical wards this month, has been the number of cases of Erysipelas, which, from some cause unknown to us, has been unusually prevalent in the town. Eight cases have been treated in No. 2 (the small men's ward, now appropriated to diseases of the skin), and two in the women's ward, No. 11. Of these one only had originated in the house, --SO that we have hardly had to consider the question, always demanding attention when erysipelas shows itself in an hospital, how may its extension be restrained? All that I can say on that point is, that, so far as I have ever seen, there is one expedient worth all others put together, for that purpose, - viz., isolating the cases of erysipelas that are either brought into the house or originate in it, and preventing their communicating with patients ill of other diseases, especially with such as require any incisions, bloodletting, leeching, even blistering, on the surface of their bodies ; for I am sure you will find it to be the usual mode of extension of the disease in an hospital, that in some of the patients in whom the skin is thus broke, the erythematic inflammation shows itself, at the spots thus laid open to the influence of its cause; even although the eruptive fever, consequent, I presume, on the absorption of the poison, may precede the inflammation by several days;—but that this happens only when there are already in the ward other patients, affected with this specific form of inflammation. And knowing, as we do (and as I have repeatedly seen), that a person may be inoculated with the erythematic inflammation and its attendant fever, by receiving on a cut or prick on the finger a very minute quantity of matter which has formed part of the exudation from an erysipelatous inflammation in another, we advance no extravagant theory in supposing, that effluvia from the erysipelatous patients in a ward find their way into the various openings in the cuticle above-mentioned, and inoculate the patients, who become affected with the disease ; and that where no patients in erysipelas are treated
in the same wards with others, there is little or no chance of this kind of communication.
As to the pathology of this disease, we can hardly go farther than this,—that although rightly arranged as a form of inflammation, it is clearly an inflammation of peculiar or specific character,-shown by its tendency to spread along the surface-by its tending to vesication or effusion of serum, much more than to the effusion of lymph, on whatever texture it takes place,-farther, by the general symptoms attending it being remarkably various, and often strictly typhoid, and by its often prevailing to a certain degree epidemically, although from unknown causes, and undoubtedly in some instances, extending itself by contagion or inoculation. Judging by these marks, we are very sure (and can show by reference to various authors) that this form of inflammation occasionally attacks, and even affects epidemically, various internal textures, as well as the integuments; especially the cellular or areolar membrane, the mucous membrane of the fauces and air passages, the peritoneum, and the inner membrane of the veins.
In regard to the proper practice in this form of inflammation, there has been such a difference of statement by experienced practitioners, at different times and places, as must naturally appear very perplexing to a young practitioner, unless he is master of the principle above stated, that probably all diseases,certainly all those diseases which at times prevail epidemically-show themselves, not only in different individuals, but in different districts and seasons, under a very considerable variety of forms, particularly as regards the constitutional fever attending them,--and may therefore be fatal in different modes, and require that they may be most successfully treated, very different kinds of practice, i. e., different kinds of aid to the natural process of decline, to which all modes of practice must be regarded as auxiliary. This has been, to a certain degree, exemplified here. We had one fatal case, Briggs—a man past seventy, of intemperate habits, admitted 3d November, on the fifth day of erysipelas of the head and face, closing the eyelids, and which had gone on to partial vesication on the face. His pulse was from the first small, and soon became feeble, and tongue dry, with typhoid delirium and drowsiness, as usual in severe cases in such subjects. We tried to arrest the inflammation on the face by a number of small punctures on the eyelids, the first night he was in the house, but this had no good effect on him. Afterwards the erythema spread rather slowly over the face, and neck, and back, causing no great swelling, and neither vesication nor suppuration. Besides laxatives, he had only wine and spirits, gradually increased to 3x. and ziv.; and, for some days, I thought we should have pulled him through ; but the whole typhoid symptoms then increased, and he died on the 17th day, rather by asthenia than coma, because, although very drowsy, he could be roused so as to answer questions, even when his pulse was hardly perceptible, and his skin cold and clammy.
On dissection in him, no appearance that could be distinctly pronounced morbid was detected, except a serous effusion into the ventricles of the brain, and on its surface beneath the arachnoid, distending those parts slightly, but not exceeding half an ounce in all. This is exactly the same appearance as in the most common lesion after typhus fever, and on which I think the most valuable observations are those of the late Dr J. Reid, long pathologist here, shewing that its amount is most generally proportioned, not to any affection of the brain during life, but simply to the age of the patient.
“ We have seen cerebral derangement (before death) as strongly narked, in cases where no increased effusion of serum was found in the cranium after death, as in those where this was observed. Besides, it is not unusual to find increased serous effusion within the cranium in old people, or when the patient has been emaciated by other diseases, in quantities equal to what we have found so frequently in fever. The average age of the cases in which an increased effusion was found within the cranium (in fever) was 423 years,
NEW SERIES.-N0. XIII. JANUARY 1851.
while the average age of those in whom no increased effusion was found was 2614 years. The average age of the four patients in whom Zvij or more of serum was found in the lateral ventricles, was 574 years,—the youngest being 48, and the oldest 68 years of age.”—Report on the Epidemic Fever of Edinburgh, in Physiological Researches. By Dr J. Reid. P. 460.
When we remember, in addition to these facts, that many patients, although advanced in life, recover from typhoid fever, under the use of stimuli, in whom the affection of the functions of the brain during life had been very much the same as in this man, but that the recovery of the functions of the brain is usually, in such cases, very slow and gradual, we must regard it as highly probable, that some degree of effusion of this kind is frequently recovered from; and we cannot consider such effusions as we found here, as either an appearance peculiar to typhoid fever, or necessarily connected with its fatal event.
In one case only, that of J. Wood, æt. 22, admitted on the 3d day of erysipelas in the face, which had already produced slight vesication on the eyelids, the state of the circulation was such (pulse 100, and firm, with sense of heat, and uneasy throbbing, as well as pain of head) that I thought bleeding at the arm justified. He was bled immediately to zxij ; the blood was sizy, and this was one of the cases, the mere watching of which I take to be more satisfactory than the counting of many would be, in evidence of the power of that remedy over some circumstances of the disease ; for he expressed himself much relieved as to all his uneasy feelings immediately after the bleeding-his pulse was never above 90 after it, and there was positively no extension of the inflammation, either on his forehead or down his neck, after that night-i. e., the first night he was in the house, or fifth of his disease.
A more singular circumstance connected with these cases of erysipelas was, that in two of the ten, it was complicated with Phlebitis, although in circumstances very different. Janet Duff, æt. 36, delivered ten days before she came to hospital, was admitted with a broad patch of erythematic inflammation over the sacrum, the whole of the left leg and thigh swelled, tense, and painful, and several superficial veins on the inner side of the thigh much distended and tender a little above the knee, and circumscribed tenderness, likewise distinct, though slight, in the situation of the femoral vein at the groin ; and M'Naughton, a man, æt. 36, admitted on the 5th day of distinct erysipelas ædematodes occupying the left foot, extending to the ankle, and attended with ædematous swelling of the whole leg and thigh,-just such as we see in the phlegmasia dolens after delivery, or in the swelled leg after fever -although less tense and elastic than that swelling often is—and in like manner attended with distinct swelling and tenderness along the line of the femoral vein at the groin. In these cases, however, the febrile symptoms were less severe than might have been expected, and all the symptoms subsided remarkably well after two applications of leeches in each, over the affected veins, with very little additional treatment except absolute rest of the limbs. In the case of Duff, however, the erysipelas on the nates ended in pretty extensive suppuration. Comparing the case of M‘Naughton with various others, of swelled legs going along with symptoms of phlebitis at the groin, I could not doubt that he was thus saved a tedious and troublesome, if not dangerous, affection of the limb. But in neither of these cases was there any indication of the dangerous secondary inflammation of internal parts, against which we must always be on our guard when we distinctly recognise phlebitis ;- which we may apprehend especially when we have it complicated with erysipelatous inflammation externally; but which, so far as I have seen, is much less frequent, and of a less malignant character, in cases that lead to obvious obstruction of a vein, than in cases where the effusion into the vein is of a less plastic character.
Another remarkable fact here has been a fatal case, at one time somewhat resembling erysipelas and attended with very typhoid fever, but which I have no doubt was an example of Glanders in the human subject-closely resembling. those described by Dr Elliotson in the Medico-Chirurgical Transactions." (Vol. xvi.) This was John Turnbull, æt. 41, admitted evening of 18th November, having been complaining for a fortnight of febrile symptoms and pains of joints, and almost entirely disabled for work. When I saw this man on the evening of admission, finding he had been so long ill and was of intemperate habits, with a pustular eruption on the face, and had delirium, spectral illusions, and subsultus tendinum, with a pulse at 120, small and feeble, his tongue furred and dry, his breathing hurried, with cough, bronchial râles, and frequent vomiting, I thought it a bad case of bronchitis and rheumatic pains, complicated with delirium tremens, and gave directions for his reception, if necessary, into the ward appropriated for deranged patients; ordering likewise a blister, repeated small doses of aloes, calomel and opium, and a little wine. Next day we found that he had not become violent as expected, but had fallen into deep sleep with copious sweating, and although he could be roused to answer questions, and his bowels had been moved, was nearly comatose. The eruption on his face was now perceived to be attended with an erythematic flush on the forehead and closing of the left eye. His aspect immediately brought to my recollection the only other decided case of glanders in the human subject I had ever seen, which was traced to infection from the horse, and one of the gentlemen acting as assistants in the ward, who had seen a case in England last year, made the same remark ; and then finding on inquiry that he was a cab-driver, I had little doubt of the nature of the case. We now found that the same kind of eruption which we saw on the face, consisting of small hard pustules (or tubercles, for they were almost solid), each surrounded with a patch of erythematic inflammation, existed on different parts of the body, chiefly at the wrists and knee-joints, which had previously been the seat of the pains. There was no running from the nostrils, although the left side of the nose was much swollen as in erysipelas. The vomiting had abated, but the cough and hurried breathing and bronchial râles continued; his pulse was more frequent, and very feeble, and his tongue dry. After this, we attempted nothing more than the stimulating treatment, by increased doses of wine, carbonate of ammonia, and two doses of quinine, which had no obvious effect, and he died at four o'clock next morning, -having been only 36 hours in the house.
If there could be any doubt as to the nature of this case during life, I think there could be none when it was found, on examination of the body, that within the larynx there was a pustule, similar to those on the skin, a little above the chordæ vocales on the right side, and several smaller pustules of the same kind in the trachea ; the bronchi contained muco-purulent matter of little tenacity, these membranes being moderately injected ; the lungs presented several ecchymosed circular patches, scattered through various parts of their substance, each of which contained a central yellow granular deposit, gradually breaking down into pus. These, when near the surface, had the appearance of circular pustules, surrounded by a border of ecchymosis, very similar to those on the skin. On opening the nasal cavities, a line of small circular ulcerations was observed between the inferior and middle turbinated bone on the left side, which were infiltrated with pus. There was no such appearances on the opposite side ; nor was any disease found in the liver, nor in any of the veins or lymphatics which were examined.
We could not ascertain anything farther as to the history of this patient, than that he had been employed, up to the time of his illness, in a stable, in which a veterinary surgeon, who attended the examination of the body, said he knew there had been several cases of glanders. I learnt from Mr Dick, Professor of Veterinary Surgery, that he was aware of there having been cases of glanders recently in some of the stables for hackney coach horses, although he had not himself seen any.
I can say with certainty, that the appearances on the face, nose, and eye here, were exactly similar to those I saw in the one case, likewise fatal, some years ago in the hospital, which was traced to infection from a stable some