mental anxiety. The immediate cause of the acute rheumatic affection had been a long walk, during which she had felt repeated shiverings when taking rest, a week previously. All the joints were swollen and painful; the patient was unable to make the least movement. The affected parts were red, and inflamed lymphatics could be traced along the skin. There was slight jaundice and enlarged liver; an impetiginoid eruption was seen on the legs. The aortic and mitral valves each presented a systolic souffle; pulse 130, full and strong. No albumen in the urine. She was treated with quinine, one gramme (gr. xv.) during the day, in three doses, to which a small quantity of opium was added on the 3rd July. On the 4th, the first symptoms of cerebral excitement occurred. There was sub-delirium; speech short and anxious; the face flushed; the eyes brilliant; the pupils contracted; pulse 136. The souffle very loud and harsh; the joints the same. A venæsection, a blister to one leg, an "antispasmodic potion without opium," were ordered. Diarrhoea and delirium occurred during the day. The blood was much cupped and buffed; the serum yellow, coloured green on the addition of nitric acid. Twenty leeches were placed behind the ear. During the ensuing night the delirium and agitation were extreme. There were no irritable convulsions and no vomiting. The patient expired at six a.m. We must refer the reader to the original for the interesting details of the examination of the joints and the external parts affected, which are given with much minuteness. In the chest, satisfactory evidence was found of endocarditis affecting especially the valvular tissues on the left side of the breast. Within the cranium, on the anterior part of the convex surface of the brain, a vivid redness was found, which was not removed by washing; the arachnoid and the pia mater at this point were strongly injected. The subjacent grey matter was softened, of a rose tint; under a stream of water it presented a velvety appearance. The lateral ventricles contained a reddish sanguinolent serum; the ventricular parietes were not softened. The choroid plexuses were infiltrated, and presented a large number of minute transparent vesicles. The liver was found enormously enlarged, "of the colour of beeswax, of firm consistency; when cut, the fibrous tissue was found hypertrophied. The microscope showed the parenchyma to consist of hepatic cells, distended and deformed by oil-globules; there was also free fat." The spleen was also enlarged to nearly double its normal size. Professor Gubler terms the above morbid condition of the liver, “ wax liver des Anglais;" and informs us at the same time that he has only once seen it among his compatriots. Our readers will probably agree with us that the above description in no way tallies with the microscopic features which we regard as constituting waxy liver. Dr. Gubler reports two other cases of articular rheumatism, in which cephalic symptoms were manifested; but as one recovered, and the other, although fatal, exhibited no trace of cerebral lesion, they only tend to confirm the prevailing opinion relative to the purely symptomatic character of the cephalic symptoms accompanying rheumatic fever. On Partial Paralysis of the Extremities induced by the continued Use of Snuff containing Lead. By Dr. MORITZ MEYER, of Berlin. (Virchow's Archiv, Band xi. Heft 3.) Four interesting cases observed by the author are given in detail, in which the history and the symptoms justify the diagnosis of lead poisoning. The features characterizing the cases were-1. A more or less advanced paralysis of the extensors of the fore-arm; 2. A projection of the metacarpal bones; 3. A yellowish sallow complexion. In three of the cases, repeated attacks of colic had preceded the appearance of the paralysis; in one, it was absent. In three cases, the extensores digitorum communes, and in one, the deltoid muscles, had suffered chiefly. The presence of lead in the tobacco used by each patient was proved chemically. A large number of other kinds of snuff besides those used by the above-named patients were analysed, and all that had been packed in lead were found to be more or less impregnated with lead or oxide of lead, the amount of impregnation varying from 0.78 to 178 per cent. II. AFFECTIONS OF THE THORACIC VISCERA. Memoranda of a New Method of Measuring the Thorax. By Dr. WOILLEZ. (Archives Générales, p. 583, May, 1857.) The author has presented to the Academy of Medicine a new instrument for measuring the thorax, which he terms a cyrtometre, with which he avers that he can at once determine the modifications of certain diameters, and of the circular outline of the thorax. He is of opinion that the method of mensuration hitherto pursued is erroneous, because based upon two false principles; the one being the supposition that the healthy side presents an uniform capacity, while the diseased side alone is regarded as susceptible of modification, the other being the opinion that mensuration is a means of diagnosis in the strict sense of the word. The instrument consists of joints of whalebone of two centimetres each, moveable in such a way that when applied to any surface the whole may take and retain the curve of that part. The outline of the curve of the thorax thus obtained being transferred to paper, the com. parison of curves, taken at different periods of the malady, aids to determine the successive changes in the affected part. Without diagrams, it would be useless to go more into detail. On Redness of the Cheeks as a Symptom of Pneumonia. By ADOLphe Gubler. (L'Union Médicale, No. 23, April 28, and May 2, 1857.) Dr. Gubler takes up the old doctrine that the redness of a check in a case of pneumonia indicates the side on which the disease lies. Modern authors have paid little attention to the subject, but Dr. Gubler has satisfied himself, by extensive observation in the Salpétrières, that the general law is true. The author has guarded against the fallacy which might result from the patient lying on the cheek presenting the greater redness, and has measured the relative femperature of the two sides of the face with the thermometer. Numerous cases are detailed, and the following is the summary of his observations: 1. The redness of the cheeks which commonly coincides with pulmonary inflammation, is not, as is commonly thought, a fortuitous circumstance, but a functional disturbance bearing a definite relation to the disturbance of the respiratory passages. 2. This redness is not necessarily proportioned to the extent and degree of the anatomical lesion, but bears a relation to the intensity and progress of the inflammatory action. 3. A sensible, and sometimes considerable elevation of temperature (from 0-50° to 5:40° Cent., or nearly 1° to 10° F.) accompanies the hyperæmia, and gives it the character of active congestion. 4. The congested cheek corresponds to the lung which is the seat of phlegmasia, or the one which is most affected. 5. The flushed cheek is seen, not only in pneumonia, but also in the majority of other pulmonary inflammations-in those which accompany tuberculization, as in typhoid pneumonia, and even in capillary bronchitis. It appears to be most marked in pneumonia of the apices -a circumstance already pointed out by Bouillaud.* 6. The production Nosographie Médicale, tom. xi. p. 484. of other morbid conditions may be promoted by the habitual hyperemia of the face; thus a spot of erysipelas has been seen developed on the cheek of the affected side. 7. The redness of the cheeks in acute diseases of the lung may be explained by the stimulation of their nervous plexuses extending to the brain, and reflected upon the respiratory nerves of the face. 8. The phenomenon may be regarded as a manifest example of sympathy established between two distant regions by the agency of the nervous system. By On Extravasation of Blood in the Tissue of the Valves of the Heart. Prof. Luschka, in 1852,* discovered the existence of bloodvessels between the layers of the endocardium, or the valves. His researches led him to conclude, that "the exudations or fibrinous vegetations observed on the surface of the valves in endocarditis is dependent on an hyperemic condition of these vessels, accompanied by exudation of lymph from them." He now considers the formation of small extravasations which occur in the tissue of the valves in consequence of the rupture of these vessels. The Professor has but rarely met with such ecchymosis in the heart of adults; he found one near the free edge of the anterior curtain of the tricuspid in a man aged eighteen, and another in the same subject in the anterior flap of the aortic valves. A well-defined ecchymosis occurred in the left flap of the aortic valves near its insertion, and an extravasation was observed on one of the larger tendons of the mitral in a female who died of pneumonia. Dr. Reuss is quoted as having seen an ecchymosis within a fold of the pulmonary valve. Dr. Luschka has much more frequently met with hemorrhage in the tissues of the valves of new-born infants. The extravasations almost always occur in the vicinity of the free margin of the mitral and tricuspid valves. They are chiefly visible on the inner layer, and generally cause the surface to project somewhat. They are generally circular, and look like red granules scattered through the tissue, varying in size from that of a poppy seed to that of a millet seed. They are rarely solitary, but more frequently there are from three to six. Their colour is yellowish red, or blackish red, or even absolutely black. When quite recent, we may detect in them blood-corpuscles and debris of tissue. In those that offer a reddish yellow hue, amber-coloured molecules of pigment, decomposing blood-corpuscles, and oil-globules are never absent; and in the black spot, which is probably of older date, doubtless granular black pigment is found in considerable quantity. These extravasations appear to be of very frequent occurrence in the newborn infant. They were met with 41 times in 165 post-mortems-viz., Of the 165 children, 128 were born alive; 37 were stillborn. Of the former, 31, of the latter, 10, exhibited these ecchymoses. Archiv für Path. Anat., p. 182. 1852; and British and Foreign Medico-Chirurgical Review, p. 254. July, 1853. On the Relations of Bright's Disease and Cardiac Affections. By H. BAMBERGER, Professor of Medicine in Würzburg. (Archiv für Pathol. Anat. und Physiol., Band xi. Heft 1.) The well-known frequency of the complication of Bright's disease and valvular disease has been differently accounted for by different authors. An essential question regarding the etiology of the two classes of affections is, which of them precedes the other? Prof. Bamberger states that, with the exception of a small number of cases in which, during the course of Bright's disease, endocarditis took place, he has never seen a case in which the renal affection was the first; whereas he has observed many in which morbus Brightii was developed during the existence of valvular disease. He therefore concludes that valvular disease is a frequent cause of Bright's disease, but admits that the latter, under these circumstances, frequently does not pass beyond the first stages. The author next considers the relation of hypertrophy of the heart, unaccompanied by valvular affections, to Bright's disease. The ratio appears to be above 20 per cent. of the former; Dr. Bright himself estimated the frequency of cardiac hypertrophy at 23 per cent. Dr. Bamberger is of opinion that the mechanical explanation ordinarily offered, according to which the hypertrophy is produced by the physical influence of the derangement in the circulating fluid, is untenable. He admits that hypertrophy of the heart, in the majority of instances, is secondary to the renal affection; but he shows that it is found with large kidneys and contracted kidneys, and argues that a very different effect upon the momentum of the aortic current must be produced by each of these forms of renal disease. The Professor remarks, that if the obliteration of some renal capillaries could exert so palpable an influence upon the heart as that observed to accompany many cases of contracted and granular kidneys, the obliteration or application of a ligature to any larger artery ought to produce the same result. He points out that granular liver is analogous to granular kidney, and yet is not productive of cardiac hypertrophy. In order to arrive at a solution of the question as to the efficient cause of the cardiac hypertrophy in these cases, he carefully tabulates and analyses 48 cases of Bright's disease observed by himself during life, in which postmortem examinations were made. In these 48 cases there were 25 in which there were marked alterations in the heart; in 15 there was either recent, or traces of former, pericarditis; in 10, fatty degeneration; in 4, degeneration of the aorta; in 3, the remains of endocarditis. Hypertrophy and dilatation of one or more cardiac divisions were met with 19 times. In 28 cases there was serious disease in the lungs; 11 times tubercle, 10 times pneumonia, pleurisy 9 times, emphysema 3 times; the spleen was enlarged in 24 cases; the liver was cirrhosed 3 times, in a state of adipose or bacony enlargement 16 times. It is manifest that serious derangement occurs in most of the vital organs as a complication of Bright's disease. The author concludes that the hypertrophy of the heart is therefore not explicable on purely physical grounds; but that it must be regarded as a purely "vital phenomenon," belonging to the same category as so many other derangements of nutrition which are developed in the course of Bright's disease. Contribution to the Pathology of Heart Disease. By W. O. MARKHAM, M.D. (British Medical Journal, April 4th, 1857.) An interesting case is detailed by the author, of a child aged four years, who during life had presented "a rough, loud, systolic bruit, which was audible all • Willigk (Prager Vierteljahrsschrift, Band xxxviii. p. 44) shows that in 209 cases of Bright's disease, valvular disease was present in 31, or about 15 per cent. See also Chambers, Decennium Pathologicum, who establishes a much higher ratio. 39-xx. 17 along the base of the heart, and in the whole of the left subclavicular region; it was indistinctly heard below the nipple, and was scarcely audible at the heart's apex; its point of greatest intensity was to the left of the upper part of the sternum; it was not audible up the right edge of the sternum, along the course of the aorta." There were slight traces of cyanosis before death, when febrile symptoms, with chronic twitchings of the arms, strong beatings of the heart, drowsiness, and other indications of cerebral disturbance, supervened. Although at one time pulmonary tubercle was suspected, the auscul tatory evidence of its presence was unsatisfactory. All the symptoms before death indicated an acute affection of the heart. This organ, however, presented "neither externally nor internally the slightest trace of inflammation, nor was there, as far as the eye could judge, any deviation from their normal condition observable in any of the valves, or of the orifices of the organ. There was neither constriction of the orifices, nor of the roots of the great vessels, nor any defect in the valvular apparatus. In all respects the heart appeared healthy and normal, excepting one, and this was in an open condition of the foramen ovale. The foramen ovale, though largely open, so as to permit the point of a finger to pass from the right into the left auricle, was partially closed on the left side of the septum by a peculiar adjustment of the membranous valve;" the membrane being attached above and below, so as to present two narrow semilunar slits, one on either side of the valve. Both lungs were studded with miliary tubercles. It is stated that the heart, having been submitted at the Pathological Society to some of our most distinguished cardiac pathologists, who were unable to detect any other lesion than the open foramen ovale, it is a fair inference that the bruit was due to the latter condition. The case is an important contribution to our knowledge of heart disease, and to the auscultation of the organ, inasmuch as it meets the chief objection to the production of a bruit by an open foramen ovale, that hitherto where a murmur has been found in connexion with this lesion, there has also been a constriction of the pulmonary orifices. A Peculiar Cavernous Degeneration of the Muscular Tissue of the Heart. By Dr. C. SKRZECZKA. (Archiv für Pathol. Anat. und Physiol., Band xi. Heft 2.) A strong-built man, aged twenty-one, who had always enjoyed good health, was pursued by a boy of twelve, seized, and thrown down. At the same moment he breathed hard once or twice, and expired. The heart was found of average size. The parietal and visceral layer of the pericardium entirely adherent, chalky deposits intervening between them in the form of hard laminæ. A section of the left ventricle, at the left margin of the heart, presented the appearance of the section of a fine sponge. Small cavities, varying in size from a pin's head to a small bean, lay closely aggregated together, yellowishbrown muscular tissue intervening. The larger ones lay externally, the largest immediately beneath the pericardium. Some of the latter were subdivided into several compartments by fine membranous or thready expansions, stretched across from one side to the other. When the heart was examined by Dr. Skrzeczka, it had lain in spirit some time. The cavities were found full of spirit, excepting one, which lay immediately under the pericardium, and contained some coagulated blood. The cavities had no lining membrane, but appeared to be mere lacunæ in the muscular texture. The whole left ventricle exhibited the same degeneration, as did also the septum. The right ventricle was partly affected in the same way, and the papillary muscles of the left yentricle showed traces of the same condition. The valves were all normal; the arteries showed no atheroma, and the coronary arteries were normal. |