Clinical Lectures ON GOUT, RHEUMATISM, RHEUMATIC GOUT, AND SCIATICA.

APRIL 23, 1864. draughts and saline aperients will induce free watery evacuations from the prima2 vise, but will fail in removing old accumulations in the bowels, and in relieving the patient’s ON sufferings. The means by which this end must be attained are enemata of a stimulating character, opium followed by full doses RHEUMATIC of castor oil or croton oil, and the continued use of guaiacum. No purgative is more certain in its operation than guaiacum, AND and none can be more thoroughly relied upon for affording relief. Combined with in equal proportions, in the form BY HENRY WM. FULLER, M.D. CANTAB., F.R.C.P., of powder, it proves sulphur a never failing aperient if given in half PHYSICIAN TO ST. GEORGE’S HOSPITAL. drachm doses twice or three times daily; and if administered only in appropriate cases, it proves one of our most trustworthy (Concluded from p. 432.) allies. You have seen me employ it so often in this hospital that it is scarcely necessary to direct your attention to it more Tmn will not permit me to do more than allude very cursorily particularly, but I will even detain you a few minutes whilst I recall the symptoms of J. S-, aged fifty, who was admitted to many instances which have come before you in the hospital into the Fuller ward on the 5th of May. This man was attacked in which sciatica has been connected with gout or gonorrhoea with sciatica of both sides six months before admission, and The case of W. H-, aged fifty-nine, who was admitted into although the pain had varied in intensity from time to time, it the Hope ward on the 8th of February, was an excellent ex- had never ceased since the commencement of the attack. He described the pain as of a dull aching or gnawing character, ample of the agency of gout in exciting the disease, and that of slightly aggravated by motion. It did not increase in severity B. R-, aged twenty-seven, who was admitted into Cam. at night, and it had not been accompanied by pain in any other bridge ward on the 22nd of October, of the influence of gonor- part of the body. He had never suffered from gout or rheumarhoea in producing the same result. But I would take the tism, and his general health was good; his aspect was healthy; coated ; bowels reported open, though usually costive ; opportunity of urging upon you again the necessity of endeavour- tongue urine clear and acid ; pulse 76, soft. Here, then, was a case in before cause of the disease to discover the you which all the causes of sciatic exciting ing pain which we have hitherto decide upon a plan of treatment. If you fail to ascertain the considered appeared to be absent. There were no symptoms of source of the irritation which is causing the sciatic pain, you local mischief in the spinal cord, or in the sciatic nerves, or of must necessarily prescribe in the dark; your remedies will not hip disease, or of renal irritation ; no evidence of the existence be suited to the exigencies of the case, and you will seldom of gout or rheumatism, or venereal taint ; no mark of general sedatives for its subjugation. succeed in relieving your patient. An apt illustration of this nervous irritability, requiring The patient was not a weakly or a nervous man, and his pulse fact is afforded by the two cases just referred to. In the former was steady and quiet. To what, then, was the pain attributable ? a history of gout was elicited at my first interview with the What indications were there for treatment ? One, and one patient, and accordingly I prescribed colchicum with antacids only, could be discovered. His tongue was coated, and his and gentle tonics. The remedies were in strict relation to the bowels were usually costive. True, they had acted on the nature of the disease, and the consequence was that the pain morning of his admission, but when acrid or hardened faeces accumulate in the lower bowels, they do not necessarily was relieved within a few days, and the patient left the hosobstruct the passage so far as to prevent even a daily pital at the expiration of three weeks. In the latter I was at action of the bowels. Nay, rather they are apt to excite local a loss to account for the symptoms, for the patient was young, irritation, and a frequent desire to go to stool, which often his aspect was healthy, there was no apparent local mischief, leads the patient to imagine that he is suffering from diarrhoea. and no history or present evidence of general derangement of You have often noted cases in the wards of this hospital in which a excited and kept up by the cause the system. Under these circumstances I suspected a venereal under spurious diarrhoea, has resisted chalk mixture and various astrin discussion, taint, and should have treated the case accordingly, but that gents, and has yielded immediately to a dose of castor oil, the man firmly denied having ever suffered either from syphilis which has brought away a quantity of hardened fseees, or acrid or gonorrhoea. I was therefore induced to try the effect of unhealthy secretions. Therefore it was that in the case of active purgatives, and afterwards of opiates in full doses. But J. S———,Idid not allow the alleged action of the bowels to deter me from following out the plan of treatment I had rethe remedies were not suited to the case, and therefore were solved upon after a careful consideration of the symptoms of the given in vain. After more than a fortnight’s treatment the case. If the pain were not excited sympathetically with the sciatica remained unrelieved. Shortly, however, he began to presence of acrid irritating matter in the intestines, to what it be attributable? The closest inquiry had failed to complain of the occurrence of pain and tenderness on his shin could elicit the slightest evidence of the existence of the other causes attack as to venereal of his the bones. My suspicions origin and if the cause under discussion had not excited sciatica, were thus confirmed, and I at once prescribed ten grains of the pain, there was no indication for treatment. Accordingly iodide of potassium, with fifteen grains of acetate of potash, andl I determined to make trial of remedies which will usually get an ounce and a half of the cinchona draught, to be taken three! rid of faecal accumulations, and thus effect the object I had in times a day. The result was a speedy cessation of the symp- view. Whilst allowing the patient a full and generous diet, toms. Within a week the severity of the pain had greatlyrwith a pint of porter daily, I prescribed a powder, to be taken three times a consisting of two scruples of guaiacum and diminished, and at the expiration of a fortnight the patient leftttwo of sulphur.day,This treatment was commenced on the 5th of the hospital quite free from sciatica. May, and was continued until the lith. At that date the pain In another class of cases sciatica is connected with sym. was greatly relieved, and the bowels were acting so freely that irritation, excited by long-continued loading of the3 the powder was repeated only night and morning. From this bowels, or by the presence of crude irritating secretions in the3 time he took it usually twice, but sometimes once a day, acprimse viae. In many of thes instances the patients have never cording to the action of the bowels, until the 19th, when, as he Buffered from gout or rheumatism, and there is an absence off longer suffered from pain, he left the hospital, and returned symptoms indicative of hip disease, of renal irritation, or of,f to work. The instances I have hitherto brought before you have been general nervous irritation, as in the cases last mentioned. The skin is cool, the complexion is seldom pallid as in cases of rheu- examples of sciatica in which, the cause of the disease having matism, the urine is usually clear and often pale, there is no been correctly diagnosed, the treatment was adapted to the pain in, or retraction of the testicle, and no pain in the course of exigencies of the case, and relief was speedily obtained. But the ureter. Further, the pain is usually felt down the course although I have wished to bring prominently before you the of both sciatic nerves, instead of being confined to one side, the possibility-nay, the probability-of affording speedy relief, if tongue is furred, and the bowels are costive. In this class of an appropriate method of treatment is employed, and the equal cases the indications for treatment are obvious enough. It be- probability that failure will attend your efforts if you do not hoves us to act fully on the bowels, so as to rid them of all correctly ascertain the cause of the sciatic pain, and, therefore, irritating secretions and of the hardened faeces which are often cannot determine the class of remedies which are needed, I impacted in them. But ordinary purgatives are of little avail would caution you against putting a too favourable interpretafor this purpose. Experience proves that colocynth pills and tion on my remarks, and imagining that sciatica ought in all senna

Clinical Lectures

GOUT, RHEUMATISM, SCIATICA. GOUT,

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No. 2121.

460 to be got rid of within a few days of the commencement much unnecessary suffering. Rely upon it, gentlemen, the of treatment. Some cases there are, as you have already seen, success of treatment depends upon its adaptation to the requirewhich admit of relief in a very short time, but there are others, ments of the case, and that in sciatica the non-success of any and unfortunately a large proportion, in which the patient’s particular plan which may be adopted is in itself conclusive health is undermined, and cannot be so speedily restored, even evidence that the remedies are not in keeping with the nature removable cause, though the nature of the derangement be correctly diagnosed ; of the case. If the pain is referable to any and others, again, in which it is almost impossible at the outset and the remedies are calculated to subdue or get rid of it, relief of the attack to arrive at a correct conclusion respecting the will be experienced in the course of a few days, and the patient causation of the pain, and in which even if a correct judgment will thenceforward proceed steadily to recovery; and if you fail in any instance to afford relief in ten days or a fortnight, you were formed on this point, it would still be impossible to afford speedy relief. Let me instance the case of P. D-, aged will always do well to mistrust your diagnosis, and make a forty-eight, who was admitted into the Hope ward on the 11th fresh examination of your patient. In the case of P. D- I of December. This man, a " commissionaire" by occupation, deferred doing so until after the lapse of three weeks, under had suffered nine months from pain down the course of the the belief that my diagnosis was correct, and that a change of right sciatic nerve. It came on gradually, and he attributed it remedies might prove beneficial The result shows how wrong to the effect of exposure to wet and cold. The pain was con- I was in transgressing the rule which I have laid down for your stant, but was worse at night, and prevented his obtaining guidance; and if you require any further incentive to induce you quiet rest. A variety of external applications had been made to follow my precept, rather than the example which I set you Tise of prior to his admission to the hospital, but the pain had in this case, I may assure you that I have scarcely ever been steadily increased in severity. On admission his aspect was called to see a case in which this rule had been departed from healthy; his skin natural; pulse 84, of fair strength ; tongue without feeling how much better the patient would have fared rather coated; bowels reported regular; urine scanty, high- had his medical attendant been less confident in his diagnosis, coloured, and turbid ; appetite good. He had never suffered and more disposed to pay heed to the teachings of nature as from gout or rheumatism, or renal irritation, but he was ex- evidenced by the result of treatment. from his and from the -condition of his tongue and urine, I was led to regard his symptoms as attributable to rheumatic irritation of the nerve, aggravated SURGICAL OBSERVATIONS. by his nervous temperament. Acting upon this view, I prescribed a subcutaneous injection of half a grain of morphia at BY G. M. HUMPHRY, M.D., F.R.S., night, and a powder, three times a day, containing guaiacum, SURGEON TO ADDENBROOKE’S HOSPITAL, CAMBRIDGE. sulphur, and carbonate of soda. a scruple of each. This treatment was pursued until the 17th, when, as no relief had been LITHOTOMY. obtained, he was ordered five grains of iodide of potassium, half a drachm of bicarbonate of potash, and an ounce and a half of Mode of performing the operation; difficulty in cutting into the nitre draught, every six hours. On the 21st his pain remained bladder in child1’en, and caution against free use of the undiminished, and he complained of feeling weaker; and as his finger ficeraorrlaage; after-treatment ; " results of the operatongue had cleaned, and his urine had become clear, a drachm tion. of the sesquioxide of iron was administered three times daily, A ]PUPILAGE of three years at the Norwich Hospital gave me and the biniodide of mercury ointment was ordered to be rubbed in along the course of the nerve. So he went on until the 2nd an early interest in lithotomy; and the conversations and of January, when he complained of so much pain in the hip writings of Mr. Crosse, who had seen more of the dangers and that I was again induced to make a careful examination of the difficulties of the operation than most men, impressed me with joint. I then discovered considerable tumidity and general some anxiety respecting it. Accordingly, when appointed enlargement over the joint, which was painful on pressure, and to this hospital, where stone cases are often admitted, evidently much distended with fluid. He could move his leg surgeon I set about a careful study of the operation by reading and bear the could not head of the without but carefully pain, femur to be pressed upwards against its socket. Under these practising on the dead, so as to determine the best mode of circumstances 1 applied a blister to the hip, and had the blis- performing it, and laid down the plan which I have adhered to tered surface dressed with mercurial ointment; at the same in every instance. time I gave him a morphia draught at night, and ordered him There is nothing new in the plan. The chief features of it to take three times a day a nitre draught, containing six grains to cut as little as possible of the deep structures are-first, of iodide of potassium, and two drachms of the solution of btiohloride of mercury, forming a soluble biniodide of mercury. (a rule applicable to other operations as well as to lithotomy; Notwithstanding this treatment the pain became more con- secondly, to use all possible gentleness in every stage of the stant and severe, and on the 15th, as the mischief appeared to proceeding. The most successful operator I had seen was be purely local, and the occurrence of ulceration of the cartilages peculiarly gentle in his manipulations. So far as I could gather more than probable, he was transferred to the care of the surfrom those who had seenhimoperate, this was also the great secret rrPnnr_ Now I would have you remark in reference tG this case- of Martineau’s success. My impression, too, derived from the lst, that the nature of the disease was overlooked, not only by same source, is that he usually cut the neck of the bladder very those who had charge of the man prior to his admission to the sparingly, or not at all. I admit that free incisions make the ,hospital, but also by myself on his admission into the hospital, operation quicker and more easy, facilitating the introduction -and that it was not until after the lapse of three weeks, when the of the forceps and the seizing and extraction of the stone; bttt enlargement of the hip attracted my notice that I became aware ,of the serious mischief I had to combat. The result-the in- Iam confident that they make it more dangerous, increasing risk of haemorrhage and of diffuse suppuration in the pelvic evitable result of this non-appreciation of the nature and extent of the mischief-was want of success in affording relief, and a tissue. Free incisions are advocate because they diminish the ,steady progression of the disease. Probably the man was correct necessity for rough, forcible dragging at the stone, and consein his assertion, that the malady was originally of rheumatic origin, tearing and bruising of the structures; but it is surpris. ,for he was healthy in appearance, and had not experienced any ’local injury of a nature to set up disease in the hip-joint. It is ing how much the structures will yield, without tearing or quite conceivable, therefore, that if, when he was first attacked bruising, while the stone is being slowly and cautiously drawn by the pain, its rheumatic nature had been recognised, and he away. It may be a question which is the worst, free use of the had been subjected to treatment calculated to get rid of the knife or rough use of the forceps. The plan 1 advocate is that rheumatic tendency, instead of being merely treated by enibroof using the knife little and the forceps slowly. By far the cations, lotions, and other local applications, which ceuld have number of operations may be conducted on this plan;x and little the effect in subgreater cause of ’%B0 influence on the disease, ,duing its local consequences, he might have escaped the injury and I never depart from it unless compelled by the size of the -to the joint, which, doubtless, was commencing at the time of stone or other unusual circumstance. his admission into the hospital. In like manner, if the true I the common lateral operation, using a cnrved st:a9, extent and character of the local mischief had been discovered withperform on its convexity, not to one side,* and a common the groove when he first presented himself to my notice, and those mea. -;Oln as proportion the groove is placed on one side it presents less width to sures had been at that time adopted to which I was ultimately the operator, is less easily found, and the scalpel or gorget is more likely to to have obliged recourse, he might even then have been saved slip out of it. It offers no advantage, for it is just- as easy to lateralize te cases

tremely nervous. Judging

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