Imagens das páginas
PDF
ePub

except at advanced ages. The vigorous action of the heart helps to remove the pain, as is evidenced by the improvement which generally occurs after dinner. In a case where there was great pain and stiffness in the arms, hands. and deltoid muscles, the immersion of the arms in very warm water removed the pain for the time. Many rheumatic patients felt quite well in a warm bath; though often worse after it, from increased susceptibility. The influence of temperature on the local circulation has much power over rheumatism. Patients take cold often through sitting near cold walls, &c. The cause of the pain is probably, primarily, the contraction of the pale muscular fibres of the skin, the stagnation of blood in their capillaries; the hot aching pain which succeeds being due to reaction and dilatation of the vessels; the one efficient cause of rheumatic pain in general being deficient flow of blood through the affected parts. With regard to treatment, the author thought that no satisfactory results could be ascribed to colchicum, in large or small doses. Warm baths are useful in some cases. Nitrate of potash had proved useful in the hands of some, but he thought the iodide of potassium had a stronger claim to efficiency. Guaiacum, aconite, opium, steel, and cod-liver oil, all prove useful in some cases; and the local application of heat by packing in wet sheets, blisters, sinapisms, heated irons, red flannel, and red merino, also. The indication appears to be, to restore the strength of the individual and the vigor of his circulation. In the most troublesome form, pain in the plantar fascia was removed by perfect rest and galvanism.

ART. 21.-On the Difficult Breathing of Scorbutus. By M, PERRIN.

(L'Union Méd., Nos. 103 and 104, 1857.)

The following remarks are from a paper on scorbutus, as observed in the French army in the Crimea.

Difficult breathing was a constant symptom of scorbutus; but it sometimes assumed the form of such a serious complication as to constitute one of the most dangerous accidents of the disease. The scorbutic patients of the Crimean army were rapidly transported to Constantinople before the disease could compromise their lives. One circumstance alone defied all precautions, viz., the sudden outbreak of an affection of the chest, which proved promptly fatal. In a single night three scorbutic patients of the author's regiment died in this manner, and in a few days he himself nearly underwent the same fate. The invasion of this symptom was quite sudden. To the ordinary difficulty of breaking of the disease, there succeeded, generally in the course of one night, the extremest anxiety and an almost absolute impossibility of breathing. The thorax seemed as if compressed by an iron hoop, while the severest pains traversed the base of the chest in every direction, and compelled an immovability which only yielded to imminent asphyxia. No one can picture the anguish of an unfortunate patient thus surprised, who amidst comparative health, without fever or any cerebral reaction, finds himself suddenly condemned to absolute immovability either in the standing or sitting position, scarcely able to articulate a syllable, and obtaining a little air only at the expense of the most violent muscular efforts. In contrast with this the pulse is small, but irregular; the heart beats feebly; the respiratory murmur, though more indistinct, is unaccompanied by rule; percussion detects no effusion or notable congestion; and the skin, though dry, is devoid of febrile heat.

Once produced, this accident persists until death or change of place, manifesting regular alternations of better and worse, according to the hygrometric conditions by which the patient is surrounded. The appearance of this complication is not peculiar to any special stage of the scorbutus, and it sometimes even precedes all organic manifestations of the disease. M. Perrin believes that the thoracic pains spoken of by Lind and Boerhaave are of the same nature as these here described; but he has never found them, as described by Lind, confined to one side, or modifying the piercing pains of the limbs. He is disposed to attribute their production to contraction of the diaphragm, all the muscles of relation being liable to become scorbutic, i. e., to acquire the painful engorgement so commonly seen in the muscles of the thigh and calf.

In such a condition a muscle cannot contract, or impart the slightest movement, but at the expense of the most vivid pain; and if we supposed the diaphragm so affected, we should have a ready explanation of the excessive difficulty of breathing, unconnected with pulmonary lesion and of the relief derived from bringing into play the great thoracic inspiratory muscles.

ART. 22.-On the Coexistence of Elephantiasis and Leprosy.
By Mr. WARING, of the Madras Medical Service.

(Indian Annals of Medical Science, Jan., 1858.)

The following remarks are taken from an excellent paper on elephantiasis as it exists in Travancore-a paper in which the whole subject is thoroughly investigated. Personally, and with the aid of his medical subordinates in the various out-stations, Mr. Waring investigated no less than 815 cases.

"Nothing perhaps has tended more to retard our attaining a correct knowledge of the nature and treatment of the disease now under consideration, than the unfortunate confusion which has so long existed between elephantiasis Græcorum and elephantiasis Arabum, the former being that fearful constitutional malady, tubercular leprosy, the latter being the comparatively mild and local affection, elephantia, elephantiasis, or Cochin leg.

"Many well informed and experienced medical men, even in India, still regard them as allied diseases, but from such an opinion I must, with diffidence, be allowed to express my dissent; they present no features in common; in their origin, progress, and termination, they differ essentially. The distinction between them is well insisted upon by Dr. Copland, in his admirable ‘Dictionary of Practical Medicine' (vol. ii. p. 701, et seq.); he speaks of the distinction between them being 'very wide,' and adds that it (elephantiasis Arabum) is not a tubercular malady,' which true leprosy undoubtedly is.

"In 919 cases in which the conjunction or otherwise of these diseases is noticed, we find

"No symptoms of leprosy present
Leprosy coexistent

867 or 94.35
52"
5.65

919 100.00

"As a doubt might be entertained as to the accuracy of the returns from the out stations, I may add that, in the 273 cases examined by myself, 255, or 93.40 per cent., were undoubtedly free from any symptom of leprosy, 12, or 4.39 per cent., were thus affected; and 6, or 2.18 per cent., presented ulcerations which some might have regarded as leprous, but which appeared to me to be decidedly syphilitic; these, therefore, I entered as doubtful.

"In the out-station list of 542 cases, 491, or 90.59, were free from leprosy ; 33, or 6.09, were affected; and 18, or 3.50, are entered as doubtful. În Dr. Pringle's Cochin list of 130 cases, 121, or 93.07 per cent., were free; 7, or 5.39, were affected; and 2, or 1.53, were doubtful. The uniformity exhibited by these three series of observations, conducted entirely independently of each other, is not a little remarkable."

ART. 23.-On the Connection between Elephantiasis and Fever.

By Mr. WARING.

(Indian Annals of Med. Science, Jan., 1858.)

In the paper to which reference was made in the last article are facts which show very clearly the intimate connection which exists between elephantiasis and fever. This fever, Mr. Waring tells us, differs comparatively little from ordinary intermittent fever, excepting that, generally speaking, the paroxysms are more prolonged and severe in their character, mostly extending over a period of three days, and even sometimes longer. Most cases are attended with marked headache; and of the three stages, the cold is the most marked and severe. The distinguishing characteristic of the fever, however, is the erysipelatous enlargement of one or more of the extremities, from which a red

PART XXVII.

4

line of inflammation may be traced along the line of the lymphatic vessels, extending to an enlarged and painful gland in the inguinal or axillary region, according as the upper or lower extremity is affected; great pain is experienced in these glands, especially on pressure, and there is much uneasiness in all the neighboring parts. Though so enlarged and painful, they rarely take on a suppurative action; but their tumefied condition may remain for several days after the fever has subsided. The enlargement of the extremity attains its maximum towards the termination of the febrile paroxysm, and after this has passed off some days, the extremity decreases considerably in size, though it remains larger than it was before the febrile attack occurred. The resulting swelling or enlargement is, in mild cases, uniform, not pitting on pressure, and of rather lower temperature than the upper part of the limb. In some cases, a little bulla appears near the ankle, and, after each attack, a large amount of serum exudes; in such instances, the enlargement is generally inconsiderable. In the intervals between the paroxysms the health appears to be in no ways impaired.

Of 226 cases examined by Mr. Waring-

Fever had existed in 224 or in 99.11 per cent.

66

had not existed in

2" 0.89

[blocks in formation]

66

Of the two cases in which fever was stated not to have coexisted with the elephantiasis, one (No. 85) was a Brahmin, æt. 34, whose leg was very slightly enlarged, and in whom the symptom had only existed for one month. The other was a Syrian Christian female (No. 35), æt. 30, who had had enlargement of the right leg for twelve years; the circumference at the ankle, twelve inches. She stated that she never had any accompanying fever; simply pain, and swelling of the part periodically.

Mr. Waring proceeds:

These are the only two exceptions I had met with in 226 cases; the remaining 224 had periodical returns of fever in the following proportions:

[merged small][merged small][ocr errors][merged small][merged small][merged small][merged small][ocr errors][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][ocr errors][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][merged small][merged small][ocr errors][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small]

"The above table is highly valuable, as illustrating the intimate connection which exists between fever and elephantiasis. The question which naturally presents itself, on perusing it, is, In what light are we to regard this fever? which is cause, and which is effect? Are we simply to look upon the fever as one of the attendant symptoms of elephantiasis, and merely as symptomatic of inflammation of the lymphatic vessels and glands; or, are we justified in regard

ing the inflammation of the lymphatics, the local pain and erysipelatous swelling, and the subsequent deposition of albuminous matter constituting the disease known as elephantiasis, as a sequence or result of fever?

"The former opinion has been upheld by Hendy and most other writers, the latter by Dr. Hillary and Dr. Musgrave; and though it stands opposed to the opinion at present generally entertained by the profession, yet, after giving the subject the most earnest consideration, the conviction on my mind undoubtedly is, that fever is the primary disease, and that the albuminous deposit and enlargement constituting elephantiasis are a secondary affection.

The regular periodicity of the attacks tends to establish a belief in the febrile origin of the disease. However diversified may be the interval between the attacks, varying from a paroxysm every sixth day, or five times monthly, to one in a twelvemonth, or every two years, yet, in the majority of instances, the febrile paroxysm is stated to recur in the same individual with great regularity. In the preceding table it will be seen that, out of 224 cases, the fever is said to have been irregular in only 43; in the remainder it occurred with great regularity, at stated periods. Whenever a disease, especially one of a febrile nature, exhibits a distinct periodicity, most medical men incline to the belief that it is of malarious origin. Periodicity is one of the most distinctive symptoms or signs of the operation of a malarious poison on the system. Now we have no knowledge of any disease analogous to malarious or periodic affection of the lymphatics, attended by fever and the subsequent deposition of lymph; under these circumstances, it seems more rational to regard the fever which precedes any local lymphatic disturbance as the fons et origo mali, and to look upon the deposition of albuminous matter in the extremities as one of the sequences of the febrile action, and of the secondary inflammation of the lymphatics.

"The succession of symptoms would also tend to establish the same belief in the origin of elephantiasis. As a general rule, the febrile paroxysm precedes the local symptoms. This has been particularly noticed at the invasion of the disease. In subsequent attacks, the enlargement of the lymphatic glands in the groin or axilla may be observed concomitant with the cold stage of the fever; but this is of comparatively rare occurrence, the fever in most cases preceding the local disturbance.

"The statements of the patients themselves tend to establish a belief in the febrile origin of the disease. Thus, of 652 persons who ascribed the invasion of the disease to some specific cause, no less than 458, or 70 per cent., attributed it to fever; and what more natural than that they should do so, seeing that a febrile attack had been the immediate precursor of the enlargement of the limb? With the two exceptions previously mentioned, every patient afflicted wite elephantiasis, who has detailed his case to me, agreed in one point, no fever, no enlargement.' In the interval between the febrile paroxysms, no enlargement of the limbs takes place; and if, from any cause, such as removal to an uninfected site, &c., the fever become checked, so likewise proportionally is the enlargement of the affected part also checked.

"My note-book supplies me with many illustrations of the last observation. "Eetedah, Syrian Christian, male, æt. 42, merchant, both legs affected; disease commenced at the age of 26, no relations affected. He used formerly to have fever with rigors once a month. For a whole year he has now had no fever, and during this period there has not only been no increase, but rather a decrease in the size of the legs. (No. 20 in Sharetullay List.)

44

Popanjan, Congany, male, æt. 61, merchant, left leg affected; disease commenced at the age of 39, only son affected. Had fever regularly for nineteen years, when it ceased; and from that time, a period of three years, there has been neither fever nor any increase in the size of the leg, which remains in statu quo-says it stopped spontaneously; took no remedies to check the fever. (No. 156.)

"Mythen, Mussulman, æt. 24, merchant, right leg affected; enlargement commenced at the age of 18, brother affected; used formerly to have fever twice or three times a month. He took a large quantity of black pepper to cbeck the fever, and now, for two years, he has had no return of fever, nor

has there been any increase in the size of the leg; it remains in statu quo. (No. 180.)

"Jyepen, Illoover, male, æt. 20, coolie, right leg affected; swelling commenced one year since, had a severe attack of fever once only, when the enlargement first appeared. No fever since, nor has there been any increase in the size of the limb. (No. 22.)

"Chaco, Syrian Christian, male, æt. 48, right leg affected; swelling commenced at the age of 30, mother and brother affected; for the first three years he used to get fever three times a month, but, for the last fifteen years, he has taken opium, and during the whole of this period he has had no fever, only slight shivering and perspiration, and there has been no increase whatever in the size of the leg. (No. 213.)

"These cases have an important practical bearing, not only as illustrating the intimate connection between elephantiasis and fever, but as showing that, in order to check and control the former, we must first adopt measures to subdue and eradicate the latter."

SECT. II. SPECIAL QUESTIONS IN MEDICINE.

(A) CONCERNING THE NERVOUS SYSTEM.

ART. 24.-The Legal Doctrine of Responsibility in cases of Insanity connected with alleged Criminal Acts. By Dr. FORBES WINSLOW, D. C. L.

(Juridical Society's Papers, Part vi., 1858.)

Dr. Winslow divides this essay (which was read before the Juridical Society, 15th December, 1857) into five principal parts: 1. The nature of insanity in its medico-legal relation. 2. The legal doctrine of responsibility in connection with insanity, associated with alleged criminal acts. 3. The doctrine of partial insanity, or monomania. 4. The existence of homicidal insanity and insane irresistible impulses. 5. Anomalous or mixed cases of mental disorder, involving the question of modified responsibility and the propriety of punishment. In discussing his subject under the first four aspects, he dwells principally on the oneness of the mind; and that psychological principle forms the basis of the opinions to which he gives expression. He combats the doctrine that the elementary and essential features of insanity consist in a disorder of the intellectual, as contradistinguished from a derangement of the moral, faculties of the mind, there being no such thing as separate and distinct faculties of that which is in nature one and the same; and, therefore, the courts of law were wrong in laying peculiar stress upon the presence or absence of delusions, as these might arise from sanitary causes. The important point, however, for consideration is, what might be the state of the effective or motive powers, what is the state of the volition, and to what degree has the mental diseases destroyed the healthy power of self-control over the thoughts and actions? Here arises the second branch of the inquiry; and after noticing the distinction which Mr. Fitzjames Stephens draws between tests of insanity and tests of responsibility, Dr. Winslow lays down the following as criteria of insanity propounded in the courts of justice: 1st, the presence of delusion; 2d, of delusions directly associated with the criminal act; and, 3d, a capability of distinguishing between what is lawful and unlawful, the capacity of knowing right from wrong, good from evil. These tests he holds to be erroneous, as their absence does not necessarily establish in the offender the mala animus, mala conscientia, which are the ingredients of criminal guilt. The tests of responsibility, however, upon which the courts acted, might be gathered from the opinions of the judges, delivered in the House of Lords in 1843. First, a person laboring under partial delusions only, and who is not in other respects insane, notwithstanding he committed a crime under the influence of the insane delusion that he is redressing or revenging some supposed grievance or injury, or producing some public benefit, is liable to punishment, if he knew at the time of committing such crime that he was acting contrary to the law of the

« AnteriorContinuar »