« AnteriorContinuar »
fluid blood, and appeared quite healthy. The popliteal artery contained a mottled coagulum an inch and a half in length, firmly adherent to the inner surface of the vessel, and completely blocking up its canal. Below this again the vessel was contracted. Its lining membrane was very red, and had attached to it shreds of fibrin. The popliteal vein at this point was obstructed by a clot, and the surrounding tissues were infiltrated and condensed. The coagulum was so firmly adherent to the lining membrane of the popliteal artery, that a stream of water allowed to fall upon it from a common jug, at the distance of from eight to twelve inches, did not in the least detach it. The preparation is preserved in the Museum of King's College.”
If, then, we find, as in the foregoing cases, that fibrin deposited in the heart may undergo a process of softening, and may then be conveyed in the course of the circulation to arteries of the smallest as well as of the largest diameter, and may there lodge, producing softening of the surrounding tissues, or even mortification, what must we suppose to be the result of similar changes when they originate in the arteries themselves ?
Fibrinous deposits not unfrequently form in diseased arteries, and may here, as elsewhere, undergo the process of softening. The product of this softening then, together with the débris of the internal coat of the artery, and the softened atheromatous deposit, are carried along the course of the circulation, until arrested in the smaller tubes, or in the actual substance of organs. Wherever they stop, other changes occur. In some cases the fibrin, still retaining some consistency, and adhering in its new bed, may become absorbed, and cause a puckering and contraction of surrounding parts. Nearly all arteries that have thus been obstructed have been found contracted after a certain time. This is so generally the case, that Professor Tiedemann, in describing this disease, has assumed for his title, Arctation, and closure of the arteries. In general, however, post-mortem examinations reveal that softening, accompanied by cell-development, has taken place in portions of fibrin that have been stopped in their course. When this occurs in a bloodvessel, it produces inflammation of its outer coats and neighbouring tissues ; when in the structure of organs, it is accompanied by softening of the surrounding parts. If we find, then, as the result of discase of the arteries, that morbid materials find their way into the blood, and produce a separation of fibro-albuminous deposits which in their ulterior changes are liable to poison the different organs to which they are conveyed in the acute forms now noticed, we are led farther to inquire whether there are any chronic forms of the same affection. In cases of long-standing disease of the arteries, the products of morbid deposits between their coats, which have undergone the process of softening, must constantly pass into the circulation, as must also aby portions of liquefied fibrin which have temporarily adhered to those parts where the lining membrave bas given way. If the quantity of morbid deposit or of liquefied fibrin be small, it is probably disposed of without any great inconvenience, but when larger, it would appear that the contaminated blood has a tendency to lodge in the substance of the first organ to which it is conveyed. In parts where the circulation is vigorous, the impediment may probably he readily overcome, but in those parts in which the circulation is
more languid (although perhaps they may contain a large quantity of blood), there we find the injurious effects producel. Now, these are exactly the conditions in which senile gangrene ordinarily occurs. A diseased artery gradually but constantly pours the product of fatty degeneration into the blood which is conveyed to the most distant and dependant part of the circulation. The excessive pain coincides with that which experiment proves to be the result of the injection of arteries with fluids which do not readily pass into the veins. The skin, which contains the largest ainount of blood, and therefore the largest quantity of the morbid material, perishes first; and in succession the cellular membrane, bone, tendon, and ligament. If this be the true pathology of dry gangrene, it explains at once how futile amputation is likely to be while the original source of disease remains in the form of fatty degeneration of the artery supplying the limb. It explains also why opium and tonics are found to agree so much better than the antiphlogistic plan formerly recommended by Dupuytren. Finally, it explains how, when the morbid material which produces the gangrene ceases to be supplied, the patient may recover, as in case No. III.
The following case, which lately came under the care of my friend Mr. Bowman, at King's College Hospital, shows the tendency there is to the formation of fibrinous deposits in those situations where the inner coat of the arteries has been removed by disease.
“CASE V.-Philip Shaw, aged fifty-six, a porter, was admitted into Fisk Ward on the 4th of February, 1857, with gangrene of the left foot. On the 31st of January, after having been exposed to cold during the day, he felt in the evening some numbness and stiffness in the left foot. He subsequently experienced considerable pain, and the skin of the toes became of a dark bluish colour. When admitted into the hospital, his countenance was pinched and congested, as if from habitual intemperance. The pulse intermitted at every seven or eight beats, and there was a distinct bellows sound at the apex of the heart. In the beginning of March, the whole of the metatarsal bones had become exposed by the separation of the sloughs, and on the 23rd of the same month he died. The body was examined thirty-four hours after death. A distinct arcus senilis presented itself in each eye. On opening the chest, the lungs were found healthy, and everywhere crepitant. The cavities of the heart were empty; there was some thickening of the mitral valve; the arch of the aorta presented numerous atheromatous patches. In the abdomen the liver, spleen, kidneys, and intestines were found perfectly healthy. The aorta here presented similar deposits to those already noticed. Near the origin of the inferior mesenteric were some fibrinous flakes adhering to the posterior part of the vessel, and connected with a coagulum which extended some three or four inches down the vessel. The common and external iliac arteries on both sides were much more diseased, the atheromatous deposit here having undergone various degrees both of hardening and softening. The femoral artery of the left side was almost obstructed in its lower part by white fibrinous coagula. Between this deposit and the wall of the artery a channel appeared to have been formed, through which the blood had passed. In the popliteal space the vein and the artery had become firmly adherent, and were both obstructed. The left posterior tibial artery was almost closed by fibrinous coagula. In the anterior tibial artery no disease was discovered. The axillary, brachial, radial, and ulnar arteries on both sides
were apparently healthy. The arteries at the base of the brain showed some distinct patches of atheromatous deposit. A preparation of the arteries containing the fibrinous deposits is preserved in the museum of King's College."
The practical idea which suggests itself from the foregoing observations and cases is, that a diseased or partially obstructed artery may be more dangerous to a patient's welfare than one which is completely closed. The blood, in the case of the obliteration of the main trunk, would probably be conveyed to the extremity in diminished quantity, but flowing through collateral and comparatively undiseased channels, it would be more free from the admixture of any morbid matter which it might receive in its passage through the limb.
A greater danger may therefore arise to a limb from the principal artery being partially or temporarily obstructed, than from its complete and permanent obliteration. This point is illustrated by the following case, taken from Dr. Oldham's notes, and for which I am indebted to Mr. Birkett, of Guy's Hospital :
“Case VI.—A very tall, healthy, muscular, and robust Scotch peasant, thirty years of age, was admitted into Guy's Hospital on the 15th of August, 1856, for a popliteal aneurism. On the 17th of August a 'temporary ligature' was applied to the femoral artery. The ligature was removed at the expiration of seventy-two hours. For the next four days everything appeared satisfactory, when on the morning of the 25th of August a small dusky spot was observed by Mr. Birkett on the dorsum of the foot. This spot increased, and it was evident that mortification had commenced. During the course of the day some hæmorrhage took place from the situation of the temporary ligature. This again recurred on the following day, August 26th, when amputation of the thigh was performed.”
Whether the partial and temporary obstruction to arteries by pressure in cases of aneurism is liable to be followed by any similar accidents to those attending upon the temporary ligature, experience has yet to decide. Three instances have lately come under the author's notice in which mortification of the leg followed the treatment of a popliteal aneurism by pressure. In two of these cases the femoral artery was at length tied, and before the mortification had apparently commenced.
Chronicle of Medical Science.
HALF-YEARLY REPORT ON MATERIA MEDICA AND
By ROBERT HUNTER SEMPLE, M.D., Licentiate of the Royal College of Physicians, and Physician to the Northern Dispensary. I. On Indian Febrifuges. By Assistant-Surgeon W. R. CORNISH. (Indian
Annals of Medical Science, October, 1856.) Among the indigenous febrifuge plants of India, the margosa or neem tree has long enjoyed a considerable reputation. This tree belongs to the natural order of Meliacee, and to the genus Azadirachta. The important part of the margosa tree, considered as a febrifuge, is the bark, which varies in thickness from a quarter of an inch to an inch, according to the size of the tree. On making a section of the bark, the outer layer is found to be of a bright purple colour, while the inner is almost white; these separate readily from each other, the inner being the thicker of the two. If a small portion of the latter be chewed in the recent state, it has at first a sweetish taste, followed quickly by a powerful and lasting bitter. The author of the paper remarks upon the curious fact, that although the margosa bark has long been recommended as a febrifuge, yet it has hitherto been very rarely used by European practitioners in India; and he points out the necessity of searching for some cheap and efficient substitute for quinine at the present day, when the cinchona forests of South America are gradually becoming extinct. Mr. Cornish's experience of the efficacy of the margosa bark extended over a period of six months, during which time nearly all the fever patients which came under his care while he was doing duty with a native troop of Horse Artillery at Secunderabad were treated with margosa decoction. He employed an emetic in all the cases as a preliminary measure, and afterwards prescribed a decoction of the margosa bark, prepared by boiling the dried bark in water for fifteen to twenty minutes, and straining it while hot through calico. The dose was an ounce and a half to three ounces, given repeatedly before the accession of the paroxysm. The physiological action of the bark can only be described negatively. A large dose of the decoction has no immediate action upon any of the animal functions, and continued doses are borne without any inconvenience to the system. It does not appear to be a very active remedy, and it rarely cuts short a paroxysm of fever. It does not produce any disagreeable effect upon the internal economy, and under its use the tongue becomes clean, the appetite generally improves, the febrile paroxysms become milder, and are soon worn out. The neem bark is unquestionably a tonic, but it is difficult to determine whether it can be regarded as an antiperiodic. The author thinks that the properties of the bark depend on the presence of a bitter alkaloid principle, to which he applies the term maryosine. This bitter principle is found in the greatest quantity in the inner bark, while the outer bark contains an astringent principle closely allied to the variety of tannin found in catechu. In addition to these principles, the bark yields an essential oil, a bitter resin, gum, starch, and sugar in considerable quantities. The results of his experience are such as to convince Mr. Cornish that the margosa is quite as effective in the treatment of intermittent fevers as cinchona and arsenic, and he found that the percentage of failures was even less under the margosa treatment.
Under the impression that the action of tonics and astringents is identical, Mr. Cornish has been induced to examine the effect of the latter class of medicines in the treatment of fevers, and the results have been somewhat favourable. He comes to the conclusion, -1st. That vegetable astringents may be substituted for quinine in the treatment of simple quotidian and tertian intermittent fevers. 2. That in the former, vegetable astringents will fail in from five to ten per cent. of the cases treated. 3. That in the latter, quinine has little or no advantage in breaking the febrile paroxysms or curing the patient. 4. That the double tertian intermittents do not readily yield to vegetable astringents, and in this type of fever quinine is superior. And 5. That vegetable astringents have failed in a smaller proportion of cases of all forms of fever, than the febrifuges, cinchona and arsenie.' The vegetable astringents which have been tested in hospital practice have been galls, catechu, and dibi divi, or Cæsalpinia coriaria. The seed-pods of the latter plant contain a large per-centage of astringent matter, and Mr. Cornish therefore employed them in the treatment of fever. He gave the dibi divi powder to nearly one hundred patients suffering from intermittent fever in its various forms, and with considerable success. The dose of the powder-pods commonly used was from forty to sixty grains three times a day. Constipation of the bowels was a very uncommon symptom, and in two cases the dibi divi even seemed to cause diarrhea. Cases of fever, complicated with anæmia and splenic enlargements, appeared to do best under this treatment.
The author remarks incidentally, that the amorphous quinine supplied to the Indian hospitals does not appear to possess any great advantage over some of the common native febrifuges, but that the sulphate of quinine is undoubtedly the best febrifuge in existence. He is accumulating evidence to show that the amorphous quinine is not of equal value as a febrifuge with the crystalline variety.
II. On Chloride of Gold and Sodium, employed as a Solvent in the Treatmeat of certain Tumours. By Dr. Rouault. (L'Union Médicale, Feb. 21st, 1857.)
The author of this.communication relates some cases observed by Dr. Debreque and himself, in which it was found that the preparations of gold possess a special elective action in the treatment of glandular tumours. In chronic adenitis in general, and particularly in cervical adenitis, the solvent properties of the preparation alluded to appeared even more energetie and certain than those of iodine. One of the circumstances favourable to its employment is the presence of several tumours, separated or united in the form of a chaplet, or of ganglionic knots. The author remarked that its efficacy was less evident when there existed only a single ganglion, the resolution of which then only takes place with extreme slowness, and often not at all. Gold is also useful in benignant tumours of the breast, such as simple engorgement, hypertrophy, and sub-inflammatory tumours; and it also appeared to Dr. Rouault to be undoubtedly efficacious in certain tumours which were evidently of a malignant nature. The chloride of gold and sodium was the preparation generally employed, being combined with starch and gum arabic, and made into pills. With one of these pills friction was made every evening on the tongue, the gums, and the inside of the cheeks. The friction should be employed for some minutes, and the patient ought not to spit, so as to swallow any remains of the matter which is rubbed in. This plan is to be followed for at least six weeks. Several cases are related in which this plan appears to bave been attended with success,