SIR,
The ROYAL SOCIETY’S, and
_Your_ most obedient Servant,
William Mountaine.
ADDENDA _to Mr._ Murdoch_’s Paper_, Nº. LXXIII.
IF it is required “to draw a map, in which the superficies of a given
zone shall be equal to the zone on the sphere, while at the same time
the projection from the center is strictly geometrical;” _Take_ Cx
_to_ CM _as a geometrical mean between_ CM _and_ Nn, _is to the like
mean between the cosine of the middle latitude, and twice the tangent
of the semidifference of latitudes_; and project on the conic surface
generated by _xt_. But here the degrees of latitude towards the
middle will fall short of their just quantity, and at the extremities
exceed it: which hurts the eye. Artists may use either rule: or, in
most cases, they need only make C_x_ to CM as the arc ML is to its
tangent, and finish the map; either by a projection, or, as in the
first method, by dividing that part of _xt_ which is intercepted by
the secants thro’ L and _l_, into equal degrees of latitude.
Mr. Mountaine justly observes, “that my rule does not admit of a
zone containing N. and S. latitudes.” But the remedy is, _to extend
the lesser latitudes to an equality with the greater; that the cone
may be changed into a cylinder, and the rumbs into straight lines_.
LXXV. _Cases of the remarkable Effects of Blisters in lessening the
Quickness of the Pulse in Coughs, attended with Infarction of the
Lungs and Fever: By_ Robert Whytt, _M. D. F.R.S. Fellow of the Royal
College of Physicians, and Professor of Medicine in the University of_
Edinburgh.
[Read Feb. 16, 1758.]
ONE of the most natural effects of blistering plaisters, when applied
to the human body, is to quicken the pulse, and increase the force
of the circulation. This effect they produce, not only by means of
the pain and inflammation they raise in the parts to which they are
applied, but also because the finer particles of the _cantharides_,
which enter the blood, render it more apt to stimulate the heart and
vascular system.
The apprehension, that blisters must in every case accelerate the
motion of the blood, seems to have been the reason, why some eminent
physicians have been unwilling to use them in feverish and inflammatory
disorders, till after the force of the disease was a good deal abated,
and the pulse beginning to sink. However, an attentive observation
of the effects, which follow the application of blisters in those
diseases, will shew, that instead of increasing, they often remarkably
lessen the frequency of the pulse. This I had occasion formerly to take
notice of[31], and shall now evince more fully by the following cases.
I. A widow lady, aged about 50, was seized (December 1755) with a bad
cough, oppression about her stomach and breast, and a pain in her
right side, tho’ not very acute. Her pulse being quick, and skin hot,
some blood was taken away, which was a good deal sizy: attenuating and
expectorating medicines were also prescribed. But as her complaints
did not yield to these remedies, I was called on December 26th, after
she had been ill about ten days; at which time her pulse beat from 96
to 100 times in a minute, but was not fuller than natural. I ordered
her to lose seven or eight ounces more of blood, which, like the
former, was sizy; and next day, finding no abatement of her complaints,
I advised a blister to be applied, in the evening, to that part of
her right side which was pained. Next morning, when the blister was
removed, the pain of her side was gone, and her pulse beat only 88
times in a minute, and in two days more it came down to 78. However,
after the blistered part became dry, the pulse rose in one day’s time
to 96, and continued between that number and 90 for four days; after
which I ordered a large blister to be put between her shoulders. When
this plaister was taken off, her pulse beat under 90 times in a minute;
and next day it fell to 76, and the day after to 72. The cough and
other symptoms, which were relieved by the first blister, were quite
cured by the second.
II. John Graham, bookbinder, in Edinburgh, aged 37, of a thin habit
of body, formerly subject to coughs, and thought to be in danger of
a _phthisis pulmonalis_, having exposed himself unwarily to cold
in the night time, was, about the end of January 1756, seized with
a bad cough and feverishness; for which he was blooded, and had a
diaphoretic julep, a pectoral decoction, and a mixture with _gum.
ammoniacum_ and _acetum scilliticum_, given him by Mr. James Russell,
surgeon-apothecary in this place. On the 12th of February, after he
had been ill above a fortnight, I was desired to visit him. He seemed
to be a good deal emaciated; his eyes were hollow, and cheeks fallen
in: he was almost constantly in a sweat; coughed frequently, and spit
up a great quantity of tough phlegm, somewhat resembling _pus_: his
pulse beat from 112 to 116 times in a minute. In this condition I
ordered immediately a blister to be applied between his shoulders,
which lessened in some degree his cough and spitting, as well as the
frequency of his pulse; but the blistered part no sooner began to
heal, than he became as ill as before, and continued in this bad way
nine or ten days, gradually wasting, with continued sweats, and a
great spitting of a thick _mucus_. During this time he used _tinctura
rosarum_, and the mixture with _gum. ammon._ and _acet. scillit._
without any sensible benefit, and had six ounces of blood taken away,
which was very watery, and the _crassamentum_ was of a lax texture.
In this almost desperate condition, another blister, larger than the
former, was put between his shoulders, which remarkably lessened his
cough and spitting, and in two or three days reduced his pulse to
96 strokes in a minute. After this he continued to recover slowly,
without the assistance of any other medicine, except the _tinctura
rosarum_ and the mixture with _gum. ammon._ and _acet. scillit._ and at
present he enjoys good health.
III. Mrs.----, aged upwards of 40, who had for several years been
subject to a cough and spitting in the winter months, was, in October
1756, seized with those complaints in a much greater degree than
usual; to remove which, she was blooded, and got some attenuating and
pectoral medicines from Mr. John Balfour, surgeon-apothecary in Leith.
I was called on November 11th, after she had been ill several weeks,
and found her in a very unpromising condition. She had a frequent
and severe cough, with great shortness of breath and a wheezing; her
lungs seemed to be quite stuffed with phlegm, of which she spit a vast
quantity every day, and of such an appearance, that I was apprehensive
it was, in part at least, truly purulent. When she sat up in a chair,
her pulse beat above 130 times in a minute. She had a considerable
thirst, and her tongue was of a deep red colour, with a beginning
aphthous crust on some parts of it. She was so weak, and her pulse so
feeble, that there was no place for further bleeding: a blister was
therefore applied to her back, November 11th, which somewhat lowered
her pulse, and lessened the shortness of breathing and quantity of
phlegm in her lungs. November 16th, a second blister was laid to her
side, which gave her still more sensible relief than the former, and
reduced her pulse to 114 strokes in a minute. November 25th, a third
blister was applied to her back; by which her cough and wheezing were
rendered considerably easier, and the phlegm, which she spit up, lost
its purulent appearance, became thinner, more frothy, and was much
less in quantity. Her pulse beat now only 104 times in a minute. After
this, her cough and spitting increasing again, she had, on the 20th of
December, a fourth blister applied to her back, which, like the former,
did her great service. Her stomach being extremely delicate, I scarce
ordered any medicines for her all this time, except a cordial julep,
with _spir. volat. oleos._ tincture of rhubarb as a laxative, and a
julep of _aqu. rosar. acet. vin. alb._ and _syr. balsam._ of which last
she took two table spoonfuls twice or thrice a day in a quarter of a
pint of lintseed tea. After the fourth blister, she drank for some time
a cupful of _infusum amarum_ twice a day, and continued to recover
slowly: and tho’ during the remaining part of the winter she was, as
usually, a good deal troubled with a cough, yet in the spring she got
free from it, and is now in her ordinary health.
IV. Christian Mʿewen, aged 21, had laboured under a cough, thick
spitting, pain of her breast, and pains in her sides affecting her
breathing, for about a twelvemonth: and after getting, by proper
remedies, in a good measure free from those complaints, her cough, from
catching a fresh cold, increased to a greater degree than ever, became
hard and dry, and was attended with a constant difficulty of breathing,
pain in her left side, and head-ach. After having been seven or eight
days in this condition, she was admitted into the Royal Infirmary,
January 9th, 1757. As her pulse was small, tho’ very quick, _viz._
beating 130 in a minute, I thought it unnecessary to bleed her, as
from former experience I did not doubt but that blistering alone would
relieve her: I ordered, therefore, a large blister to be applied to her
left side, where she complained of pain, and prescribed for her the
following julep:
℞ _Aqu. menth. simp. spirit. Minderer. ana_ ℥ iij. _acet. scillit._ ℥
i. _sacchar. alb._ ℥ ij. _misce; cap. coch._ ij. _ter in die_.
She was also desired to breathe frequently over the steam of hot water,
and to drink lintseed tea.
January 10th. Her pulse beat only 112 times in a minute, and was
somewhat fuller than on the 9th. The blister was not removed till late
in the evening, and made a plentiful discharge. The cough having been
so severe last night, as to keep her from sleep, I ordered her the
following anodyne draught:
℞ _Spirit. Minderer._ ℥ ss. _acet. scillit._ ȝ i. _syr. papav. alb._
ȝ vi. _misce; cap. hor. somni._
Jan. 11th. The cough easier last night; difficulty of breathing less;
pulse 108 in a minute. Ordered the anodyne draught to be repeated, and
the use of the julep, with _acet. scillit._ to be continued.
Jan. 12th. Pulse slower; cough and pain of the side easier; but still
complains of a head-ach.
Jan. 13th. Pulse 94 in a minute; cough continues easier in the night,
but is troublesome in the day-time.
Jan. 14th. Every way better; pulse only 80 in a minute. As her cough
is still bound, ordered her, besides the medicines above-mentioned, a
pectoral decoction of _rad. alth._ &c.
Jan. 15th. Cough and other complaints in a great measure removed; pulse
65 in a minute.
From this time her cough gave her little trouble; but on the 18th she
complained of a pain in the _epigastrium_, with sickness at stomach,
want of apetite, and a giddiness in her head, which were considerably
relieved by a vomit, _infusum amarum_, and stomachic purges; and were
almost wholly cured by the return of her menses on the 5th of February,
after an interval of eight weeks.
V. A girl 21 months old, who had (December 1756) a great load of
the small-pox, and not of a good kind, with a cough and obstructed
breathing, was, on the seventh day from the eruption, blistered on the
back; by which the pulse was lessened from 200 to 156 strokes in a
minute. Next day her legs were also blistered, and the pulse thereby
fell to 136. But the child’s lungs being much oppressed, and her throat
being so full of pustules that she could scarce swallow any thing, she
died towards the end of the ninth day.
I could add several other cases of the remarkable effects of blisters
in lessening the quickness of the pulse in coughs attended with fever,
pain in the side, and pituitous infarction of the lungs: but those
above may be sufficient to put this matter out of doubt, as well as to
remove any prejudice, that may still remain against the free use of so
efficacious a remedy.
In a true peripneumony, especially where the inflammation is great,
repeated bleeding is the principal remedy, and blisters early applied
are not so proper. But when the peripneumony is of a mixed kind;
when the lungs are not so much inflamed as loaded with a pituitous
matter; when bleeding gives but little relief; when the pulse, tho’
quick, is small; when the patient is little able to bear evacuations,
and the disease has continued for a considerable time; in all these
cases blistering will produce remarkable good effects, and, far from
increasing, will generally lessen the frequency of the pulse, and
fever, more speedily than any other remedy.
On the other hand, when the fever and frequency of the pulse proceed
from a true inflammation of the lungs, from large obstructions tending
to suppuration, or from an open ulcer in them, blisters will be of less
use, nay, sometimes will do harm, except in the last case, where they,
as well as issues and setons, are often beneficial, tho’ seldom able
to compleat a cure. But as in pituitous infarctions of the lungs, with
cough and fever, repeated blisters applied to the back and sides are
far preferable to issues or setons, so these last seem most proper in
an open ulcer of the lungs. The former make a greater and more sudden
derivation, and are therefore adapted to acute cases; the latter act
more slowly, but for a much longer time, and are therefore best suited
to chronic diseases. Further, while blisters evacuate chiefly the
serous humours, issues and setons generally discharge true purulent
matter, and on this account may be of greatest service in internal
ulcers.
In what manner blisters may lessen the fever and frequency of the
pulse attending internal inflammations, I have elsewhere endeavoured
to explain[32]; and shall only add here, that in the cases above
recited, where the quick pulse and feverishness proceeded more from a
pituitous infarction than a true inflammation of the lungs, blisters,
by relieving this organ, in some measure, of the load of humours
oppressing it, would render the circulation through its vessels freer,
and consequently lessen the quickness of the pulse, and other feverish
symptoms.
It may not, however, be improper briefly to point out the reason,
why blisters, which have been observed to be remarkably efficacious,
even when early applied, in pleurisies[33], are less so in true
peripneumonies. This difference, I imagine, may be accounted for from
there being no immediate communication between the pulmonary vessels
and those of the sides and back, to which the blisters are applied;
whereas the _pleura_, and intercostal muscles, are furnished with
blood-vessels from the intercostal arteries, which also supply the
teguments of the _thorax_: so that while a greater flow of serous
humours, and also indeed of red blood, is derived into the vessels of
the external parts, to which the vesicatories are applied, the force
of the fluids in the vessels of the inflamed _pleura_, or intercostal
muscles, must be considerably lessened. Further, as the intercostal
muscles and _pleura_ are, as well as the teguments of the _thorax_,
supplied with nerves from the _true_ intercostals, blisters applied to
the back and sides may perhaps, on this account also, have a greater
effect in relieving inflammations there than in the lungs, which have
nerves from the eighth pair, and from the _intercostals_ improperly so
called.
Edinburgh, May 23d, 1757.
_Extract of a Letter from Dr._ Whytt, _Professor of Medicine in the
University of_ Edinburgh, _and F. R. S. to Dr._ Pringle, _F.R.S._
Edinburgh, 10 Nov. 1757.
WHAT you remark with regard to blisters being freely used by the
physicians at London, in the cases mentioned in the paper I last sent
you, is very just, and indeed what I knew; but altho’ their efficacy
in such circumstances is now generally acknowleged both in England
and Scotland, yet I do not remember that their remarkable quality in
lessening the quickness of the pulse has been particularly attended to.
This, therefore, I thought it might not be amiss to ascertain by a few
careful observations.
I agree intirely with you, as to the use of blisters in fevers; being
of opinion, that when there is no particular part obstructed or
inflamed, they are of little service, and sometimes hurtful, unless
perhaps towards the end, when the pulse begins to sink. Nay, in fevers,
where the substance of the brain is affected, and not its membranes,
I have never found any sensible benefit from blisters: and I always
suspect the brain itself affected, when a fever and delirium come on
without any preceding head-ach, or redness in the _tunica albuginea_ of
the eyes. This kind of fever I have met with several times, and have
observed it to be generally fatal.
LXXVI. _A remarkable Instance of Four rough Stones, that were
discovered in an human urinary Bladder, contrary to the received
Opinion; and successfully extracted by the lateral Method of Cutting
for the Stone. By Mr._ Joseph Warner, _F. R. S. and Surgeon to_
Guy’s-Hospital.
[Read Feb. 23, 1758.]
THE favourable reception those few papers have met with from the Royal
Society, which I have done myself the honour of addressing to them,
encourages me to take the liberty of offering the following account to
their consideration: and I am the more immediately induced to submit
this paper to their perusal, as the fact hereafter related may possibly
be not esteemed a matter of mere curiosity; since it is probable,
that the inferences deduced from the history of the subsequent case,
when attended to, may prove of the greatest consequence to the future
ease and welfare of the patient, as well as be a means of preventing
the operator from falling into such errors, as cannot fail of drawing
an imputation upon his character, in the practice of one of the most
capital and difficult undertakings in his profession.
It is a maxim laid down by the most judicious and best received writers
upon operations in surgery, that when the surface of a stone, which
has been extracted from the bladder, appears to be totally rough, it
amounts to a proof of its having been there alone. But notwithstanding
I admit it is from experience found, that the observation is in general
well grounded, it may nevertheless appear, from the following case,
that this rule is not unexceptionable: for which reason perhaps it may
be thought right, that we should not be determined from circumstances
only; but, on the contrary, that it is necessary for every surgeon to
take such methods during the operation, as will enable him to judge
with that degree of certainty, without which he cannot be enabled to do
so.
The methods I would recommend are these: That after the extraction of
a stone from the bladder, tho’ the whole of its surface be rough, the
operator should nevertheless introduce the forefinger of his left or
right hand thro’ the wound into the cavity of the bladder; by which
means, if the subject be under twelve years of age, he will be enabled
to come in contact with every internal part of the bladder with his
finger: but if the subject be an adult, and of a corpulent habit of
body, the finger, under these circumstances, not being found to be
sufficiently long for the purpose, he must have recourse to a female
catheter, or some other instrument that is nearly strait, quite smooth
and polished, and of about nine or ten inches long; which will serve
the purpose equally well, if of a proper form and thickness. This is
the method I have made use of upon the like occasions of late years,
without giving any great degree of pain to the patient, or considerably
retarding the operation.
Since I have had the opportunity of making the following observation,
as well as a prior observation something similar to this, where two
rough stones were extracted by me a few years ago from a young man’s
bladder of 15 years of age, I cannot help suspecting, that there may
have been instances of one or more stones being left behind in the
bladder at the time of operating, merely from the operator’s putting
too great a confidence in this general rule. Which suspicion I am led
into from having known people, who have undergone the operation of
cutting for the stone, relapse into the like disorder in a short time
after the healing of their wounds, attended with such symptoms, as have
obliged them to submit to a second operation; when the stone, upon
being extracted, has appeared of so considerable a size, as to make it
suspicious, that this stone must probably have been of a much longer
growth, than the short time betwixt the two operations could admit of.
The maxim laid down to us by authors, of a smooth and polished stone
in the bladder being never there alone, but always accompanied with
one or more stones of the same kind, I know no exception to. But if
this phænomenon should ever occur, the strict observance of that rule
(delivered to us by judicious writers in surgery) of always searching
the bladder under the like appearances, on presumption of one or more
stones being left behind, cannot be attended with any future mischief
to the patient, when carefully executed by the methods recommended
above, and undoubtedly should always be strictly attended to. The
smooth and polished appearances of the surfaces of human _calculi_ are
universally supposed to arise from their rubbing one against the other;
which may with reason be supposed to be the case: but I confess this
inference is not satisfactory to me; since it is probable, if this was
the sole cause of their smoothness, the same effect would probably be
always produced, when attended with the same degree of friction. But
as this may be considered as a matter of mere speculation, I refer the
decision of this point to those of superior abilities.