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We have now concluded the consideration of difficult labours, once daily.-Evening: only six or seven ounces of blood were so far as their causes, symptoms, and general treatment, are con- obtained by cupping, and it was buffy; pain continues on the cerned. We have directed your attention to cases where the aid left side; friction-sound over the cardiac region increased; pulse of the vectis, the forceps, or the perforator, is called for. It re- 130, rather full; countenance very anxious; joints swelled and mains to us, therefore, to consider the mode of applying these painfuL Ordered venesection to twenty-four ounces, which did instruments. The application of instruments shall be the next not produce fainting ; to take three-quarters of a grain of muriate subject of our attention. of morphia immediately, two more doses of calomel in the course to a the left side of Erratum.-In p. 31, note, at foot of second column, for Ramsbotham’s of the night, and have blister upon the chest, Obstetric Midwifery and Surgery, read Ramsbotham’s Obstetric liledicine and another over the heart. and Surgery. October 1 st.- The blisters have acted well; friction-sound continues ; face very pale; pulse still rather full. Has had three doses of calomel, and the mouth is very sore. At noon, Dr. CONTRIBUTIONS TO CLINICAL MEDICINE. Thomson saw her, and ordered one grain of calomel and two BY JOHN TAYLOR, M.D., grains of tartarized antimony, in a pill, to be taken every four still some 120, rather hard and PROFESSOR OF CLINICAL MEDICINE IN UNIVERSITY COLLEGE, AND hours.-Evening: pain; pulse PHYSICIAN TO UNIVERSITY COLLEGE HOSPITAL, LONDON. full; the sogophony behind approaches nearer to bronchophony; none but bronchial respiration audible. in PERICARDITIS. 2nd.-The pulse has fallen much force and volume, but not in This took last soon after the CASE 5.-Rheumatismus sub-acutus-Acute without frequency. change place night, pericarditis, tartar emetic was taken. Has been sick and a deal metastasis-Feeble and very good impulse sounds-Friction-sound-Ex- face has had no friction-sound not dimi- tended and variable purged; anxious ; sleep; dulness-Subsequently, pleurisy and pneumonia nished. To have three-quarters of a grain of muriate of morphia of both sides-Endocarditis about the mitral valve-Enlargement at bedtime. heart-Pneumonia in the of the right lung preceded by signs of 3rd.-Passed a good night and feels better ; pulse 120; double congestion.-Treatment : Copious bleeding, general and local, rubbing sound much rougher, being quite rasping, about the base mercury, tartarized antimony, and blisters-Cure-Remarks- of the heart, but not about the apex; bronchial Direction the serum into the bronchophony; of pel’icardial dulness-Effusion of respiration and crepitant rhonchus over the posterior part of the exist with a and without or- pericardium may friction-sound any left lung, and friction-sound over the posterior part of’ the right. thopnaea- Respiratory murmur may co-exist with effusion of serum Had in the side for which ten leeches were in ’ pain right yesterday, into the p7eura-Physical conditions pleurisy producing cego- It is now better. To have two of tartarized and the and applied. grains phony bronchophony-Complications of pericarditis and one grain of blue pill every six hours, and three- their duration the antimony causes-Long of friction-sound-Pneumonia quarters of a of muriate of morphia at bedtime. and whilst the is under the grain pleurisy may supervene system influencefluence 4th.-Feels better; pulse 120, not full, easily compressed; a of mercury. little sharp rough sound about the base of the heart undiminished, ELLEN P-, aged twenty-six, admitted September 28th, 1838. and in the rest of the cardiac region much rougher and louder Servant of all-work, of ordinary conformation and lymphatic tem- than yesterday. No murmur in the arteries of the neck; no perament ; has never been ill, except with occasional headach; bruit de diable; external jugular vein of each side very large, but never had rheumatism-*oefore; has had a hard situation, and lived no distinct pulsation.- Lungs : left, posteriorly bronchophony in a damp kitchen with a stone floor. A fortnight ago began to and crepitation; right, posteriorly bronchophony, bronchial re- have pains and swelling in the joints ; has had pain in the region spiration, and crepitation; friction-sound with expiration, but no of the heart the whole time, but more particularly during the longer any with inspiration. Mouth and throat very sore; no last seven days. Has had no medicine, except a dose of Epsom sickness or purging; tongue pale, and furred; countenance less salts. anxious; rheumatism better. On admission, pains in most joints, with swelling and redness5th.-Dr. Thomson omitted the antimony and blue pill, and in some; countenance rather anxious; headach ; throat rather’ ordered solution of potash with tincture of hyoscyamus; also a sore; tongue white and furred ; bowels opened daily; respirationspint of beef-tea daily. short and frequent; a sharp pain in the region of the heart on 8th.-To have eight leeches on the right side of the chest. inspiring deeply; pain also on pressure about the left breast, much10th.-Rubbing sound over the heart undiminished; crepitant more under the left hypochondrium, and some on the left side ofrhonchus and bronchophony posteriorly on the left side, and the abdomen; can lie on either side. slight friction-sound on the right. Pulse 120; some pain in the Physical signs.-Heart: impulse scarcely if at all perceptible, back on respiration. Venesection to eight ounces; tartarized either by the eye, hand, or ear; natural sounds very feeble; a antimony, two grains, and calomel, one grain, every six hours. double friction-sound over the greater part of the cardiac region; Omit the beef-tea. that with the systole the louder and more prolonged of the two. lith.-Blood much buffed and more cupped; pulse 120; has They are most distinct upon the sternum, but do not vary much been sick. in intensity over different parts of the heart; no bellows-murmur 15th.-To omit the tartarized antimony, and resume the beef- at the apex, top of the sternum, or in the neck. tea. Lungs.-Respiratory murmur rather feeble, but otherwise i 20th.-Cardiac double friction-sound is now almost confined to healthy ; no cagophony. Percussion : dulness in the cardiac a point on the sternum, opposite to the second rib. No murmur region much too extended, being vertically four inches and a in the arteries of the neck; crepitation in both sides behind. half, commencing superiorly at the third rib, and transversely Pulse 108, smaller and weaker. four inches from the middle line of the sternum. Pulse 116, not 22nd.-Cardiac friction-sound now very faint and limited. No very full or strong; no irregularity. Ordered, venesection to murmur in the neck; a faint deep-seated bellows-murmur with sixteen ounces; to take five grains of calomel and ten grains of the first sound at the apex of the heart. Pulse 112. Dover’s powder immediately, and four grains of calomel every November 12th.-Over the second rib a slight double sound of three hours ; low diet. roughish character, heard less distinctly in receding from that 29th.-The sharp pain on deep inspiration has diminished, but point, and not heard in the neck; at the apex a deep-seated not ceased, since the bleeding; pulse 116, not less full, slightly bellows-sound. Impulse too strong and too extended; no crepi- jerking ; impulse and natural sounds as before; friction-sound tation ; no pleural friction-sound. feebler; dulness on percussion now reaches as high as the second 25th.-Slight sound, as before, about the second rib; soft faint rib, but is not increased in extent transversely. Venesection to murmur at the apex; nothing morbid in the lungs or pleura. Is twelve ounces.-Evening: blood much buffed and cupped; has much improved in strength. now acute pain further towards the left side, just below the Discharged about this time, having pains in the abdomen, axilla ; respiration audible, but feeble ; percussion duller; sego- thought to be rheumatic. phony about the lower angle of the left scapula; cardiac friction- Remarks.-Synaptoms and Diagnosis.-Nothing could be clearer sound less, but still distinct; pulse 120, rather full. Repeat vene- than the proof of acute pericarditis in this case, and at first it was section to twelve ounces. probably uncomplicated with pleurisy, although this is not a 30th.-The blood last taken is much less buffed; rather less matter of certainty. The general symptoms indicated the exist- pain in the chest, but the joints are even more painful ; sleeps ence of pericarditis or of pleuritis of the left side, but were quite none; friction-sound rather increased; no bellows-murmur; useless as a means of distinguishing between the two. The respiration still too feeble on the left side, and there is some habitually short and frequent inspirations, and sharp pain on in- bronchial respiration ; segophony ; dulness on percussion. Right spiring deeply, would be supposed, a priori, more likely to arise side: percussion less clear posteriorly than it was; respiratory from pleurisy than from pericarditis; and the absence of palpita- murmur unchanged; ptyalism has supervened. To be cupped on tions and of all irregularity in the pulse would be calculated to the left side to ten ounces, and to have four grains of calomel confirm this view. The diagnosis, therefore, rested almost ex- 62 elusively upon the ph3-sical signs, the indications of which, how- part of the right lung, shown by dull sound on percussion, with- ever, were quite unequivocal. out appreciable change in the respiration. Did this arise from 1. The enfeebled impulse and natural sounds of the heart, and congestion, which subsequently passed into inflammation ? On the extent and direction of the dull sound on percussion, especially the sixth day, also, we have pleurisy on the right side, announced considered in connexion with the other signs and symptoms, by friction-sound and pain in the right side; and on the seventh proved the presence of a rather considerable amount of liquid day, bronchial respiration, bronchophony, and crepitation, indi- effusion into the pericardium. The dull sound alone, reaching up cating the addition of pneumonia. On the fourteenth day the to the third rib, (probably its upper margin,) would have war- pneumonia and pleurisy of both sides had ceased. ranted a strong’ suspicion, if no more, of the existence of this Causes and complications.-The rheumatism was complicated effusion, and on the next day, when found to have extended to the with pericarditis at the time of the patient’s admission. The second rib, it was of itself perfectly distinctive. In this case, as rheumatic affection neither ceased nor diminished, as far as the effusion increased, we find the dulness extended upwards could be learnt, when disease of the heart appeared. In fact, only, and not transversely. the pain in the left side had existed from the first. The next 2. The double morbid sound had all the characters of the fric- complication was with pleuritis of the left side. This may have tion-sound of pericarditis. It was almost equally distinct in every been caused in the same way as the pericarditis, or it may have part of the cardiac region, and was not limited to the situation of originated in an extension of the inflammation by the contiguity any of the valves. There was no sign of valvular disease co- of the two membranes. From the subsequent occurrence of existing ; no murmur at the apex, at the top of the sternum, or in pneumonia and pleurisy on the right side, however, it seems more the neck. probable that all the internal inflammations were due to one 3. This case proves, beyond all doubt, that’a double rubbing cause-.viz., the rheumatic diathesis ; and the case affords an sound in the pericardium may co-exist with a considerable additional illustration of the tendency of pericarditis to become amount of serous effusion. The report on Sept. 29th proves the complicated with endocarditis, pleurisy, and pneumonia. presence of both, but the friction-sound had decreased as the Duration.-The duration of the rubbing sound in the pericar- effusion of serum had increased. dium was at least two months, and probably from one to two 4. Tracing the progress. of the cardiac disease, we find, on the weeks longer. Rheumatism existed fourteen days before, and 30th, the friction-sound increased again, probably from a diminu- six days after admission. Pleurisy of the left side continued tion in the quantity of effused serum; but this was not ascertained about a fortnight; and pleurisy of the right side, with pneumonia by percussion. Oct. 3rd.-Probably a further diminution of of both, about seven or eight days. serum, for the rubbing sound was increased, and was much Treatment.-I. Eighty-four ounces of blood were taken by rougher at the base but not about the apex. On the 4th, a still bleeding and cupping, besides the application of eighteen leeches,. further absorption of serum was indicated by the increase of the yet the patient was lymphatic, and not remarkable for strength. rubbing sound over the body of the ventricle. On the 20th, we No fainting was produced, nor bruit de diable, but considerable find evidence of adhesion of a great part of the pericardium, or of paleness of the face. absorption of the coagulable lymph previously effused; the morbid 2. The mouth was made sore by calomel, yet the rheumatism,. sound was now limited to a very small space on the sternum, pericarditis, and pleuritis, continued after ptyalism came on;.y, opposite to the second rib. On the 22nd, the morbid sound at the and pneumonia of both sides, with pleurisy of the right, first ap- base of the heart was still less, but now there was evidence of peared, whilst the mouth was sore. Aboutthe time the gums be- disease in the mitral valve having supervened-viz., a deep- came tender, however, (Sept. 30th,) and for two or three days> seated systolic bellows-murmur at the apex of the heart, not heard after, (Oct. 3rd and 4th,) the quantity of serum in the pericardium at the base or in the neck, and not existing on the 20th. decreased. 5. On November 12th and 25th the characters of the sound at 3. A considerable quantity of tartarized antimony was taken the base of the heart were such that it might have arisen either in two-grain doses. It was prescribed October 1st, and the from some slight remains of the pericarditis, or from a trifling following day there was a marked change in the force and amount of inflammation supervening in the aortic valves. If the volume, but not in the frequency of the pulse. The first day it: cause last named were the true one, then it is worthy of remark produced a good deal of sickness and purging: a dose of muriate. that the sound was not (probably on account of its feeble intensity) of morphia was given, and these symptoms ceased. propagated into the arteries of the neck. 6. Although there was considerable effusion into the pericar- no mention is made of dium, any orthopnoea. DEPARTMENT. 7. When the patient was discharged, there remained a mur- FOREIGN mur in the mitral valve, a trifling morbid sound at the base of the and some with dilatation of the left heart, hypertrophy, ACADEMIE DE MEDECINE, PARIS. ventricle, indicated by the increased force and extent of the impulse. ’ (MARCH, APRIL, MAY, JUNE.) 8. A bellows-murmur in the mitral valve, which must have (Concluded from our last number.) arisen from endocarditis, first October 22nd. This was appeared A NEw MODE OF TREATING SPERMATORRIHEA. long after the mouth had been made sore. There was no other symptom of this inflammation in the interior of the heart. M. BRACHET, of Lyons, stated that he had been induced, acci- Lungs and .PMy