Imagens das páginas
PDF
ePub

lose their balance, and sometimes think that their lower extremities have lost power; the tactile sensibility of the sole of the foot becomes blunted or otherwise altered. They soon seem to be walking on saft substances when treading upon a pavement, or the ground appears to be elastic and to jerk them up. Subsequently they are unable to walk without throwing the legs forcibly forwards and striking the ground violently with the heel. These movements are at times so violent and sudden, that the body is shaken at every step, and that the patient loses the balance; this irregularity increases to such an extent as to rentier standing and walking almost im|ios.sible. It is then necessary to support the individual on both sides, and in attempting to make a few steps, their limbs are agitated in the most violent manner, without apparent object; the strength is speedily exhausted by these efforts, and the patient begs to be led back to his arm-chair. In this condition the patients pass their lite, sitting or lying down. At the same time, with all these symptoms of paralysis, there is great force in individual movements, a? shown by a dynamometer invented by Dr. Duchenne. The inquiry into the state of these movements must be made while the patient is sitting or standing; but it is more convenient to examine the lower extremities in the horizontal posture. The author first causes the patient to perform those movements whioh he proposes to study, then when the muscles which produce them are in a stateftof contraction and are maintained so by the patient, he acts upon the extremity of the member in question in the opposite sense to the movement performed, so as to support that part of the limb which serves as the attachment of the contracted muscles. For instance, in measuring the force of the extensors of the leg on the thifjh, the patient lying on the opposite side, Dr. Duchenne has the thigh held very firmly at its inferior extremity, and whilst the patient tries to extend his leg forcibly, the Dootor acts upon it in the opposite direction, and applying the force at the level of the ankles, until he has produced flexion of the limbs. This the patient can do without fatigue; the dynamometer determines the force of the movement of extension employed by the individual experimented upon. A drawing of the instrument is annexed, but the exact method of its action is not explained.

i

II. On, Acute Inflammation of the Parotid Gland. By Rud. Vihohow. (Annalen des Charite Krankenhauses Achter Jahrgang, 8 Heft.)

In this paper Professor Virchow combats the doctrine that the seat of the morbid action in parotitis is in the inter-glandular cellular tissue, and not in the gland-tissue itself. According to his experience it is the latter which is affected. He has never been able to make a cadaveric examination in a case of primary idiopathic parotitis, but has repeatedly investigated the secondary and metastatic forms in various stages in the dead body. The first change which the author has observed is a considerable hyperemia of the gland, causing it and tho inter-glandular cellular tissue to become more moist and swollen. The red acini become more and more isolated from the surrounding yellow tissue, and, on section, resemble groups of red grains. The secretion accumulates in the follicles and ducts; it soon beoomes purulent, and pus corpuscles are early detected mixed up with the large salivary corpuscles. If the morbid process continues, a sort of fusion takes place, and the follicles appear directly converted into small abscesses. The inter-glandular areolar tissue next suppurates, and diffuse phlegmonous inflammation may ensue. In this case, a portion of the gland tissue sloughs away.

Professor Virchow suggests that this description may not apply to ordinary mumps; as the metastasis which at times takes place to the testicles militates against the assumption of the gland being so seriously affected as just described, whereas a mere serous exudation might be readily absorbed and removed. He is himself of opinion that there is no essential anatomical difference between the various forms. He agrees, however with Bamberger, in establishing three nosological varieties:—1. The primary simple catarrh of the glands commonly occurs epidemically without tendency to suppuration and ulceration (cynanche parotidea, mumps). 2. The secondary purulent catarrh (blennorrhcea parotidea), readily leading to abscesses, commonly associated with catarrh of the oral cavity, alphthui, and the like; not unfrequently with affection of the labyrinth. 3. Specific, ichorrbmtaio catarrh (almost invariably leading to gangrene (verjauchung), and commonly associated with metastases. The author is of opinion that the disease results chiefly from circumstances that induce catarrhal and rheumatic influences, and an analysis of his cases shows that the majority of cases occurs in the months of March, April, and May. Some other remarks are added, for which the reader is referred to the original.

III. On Jerking Respiration (respiration saccadic.) By Dr. A. Bottrga.de. (Archives

Generales, November, 1858.)

Dr. Bourgade is of opinion, and we think jnstly, that the profession have not paid sufficient attention to interrupted or jerking respiration, as one of the earliest symptoms of pulmonary tubercle. He details nine cases, and states that he has observed others, in which jerking respiration heard at the apex of one lung was the first auscultatory phenomenon indicating the deposition of tubercle subsequently proved by more palpable symptoms, and in part confirmed by post-mortem examination. In discussing the rationale of its production, he quotes one post-mortem examination, whioh absolutely disproves the views of Messrs. Barth and Roger on this point. They hold that it is due to the presence of the adhesions which are so frequently met with at the apex of the lungs in phthisieal subjects. In the case in question there were no adhesions at the apex or about the middle of the lung in which the jerking respiration had been heard. It is to be remembered that the symptom is most commonly met with at a time when no evidence exists of preceding or accompanying pleurisy; the character of the sound and the structure of the parts in which it is found has always seemed to us totjustify our attributing it to a partial constriction of the smaller bronchi owing to adjoining tubercles pressing mion them, the effort of inspiration causing the successive opening of the obstructed passages. We have met with cases in which spasm appeared to be the cause of the constriction; but we hold with Dr. Bourgade that, in the great majority of cases, jerking respiration is a sign of tubercular deposit.

We would endorse the following summary of observations made by Dr. Bourgade. Respiration is jerking when the respiratory murmur presents three or four brief intervals, and the auscnlting ear experiences the sensation of a certain difficulty in the expansion of the pulmonary tissue from the prolonged expiratory murmur. The respiratory murmur otherwise preserves its normal timbre, and the symptom is chiefly observed during inspiration; it occurs, but less frequently, during expiration. This change in the respiratory murmur does not persist beyond a limited period; a prolonged expiratory murmur follows, or, more rarely, progressive diminution of the respiratory sound. This fact probably explains the circumstance of the symptom having been overlooked by many hospital physicians, who, seeing phthisis chiefly in its more advanced forms, do not meet with jerking respiration here as frequently as in private or extra-hospital practice. Jerking respiration is commonly limited to the apices of the lungs, which we should explain by the greater resistance of the parietes of these parts favouring the pressure of tubercle upon the adjoining bronchial tubes. When the patient is made to breathe more fully, the symptom is not rendered more palpable, but commonly disappears altogether. Jerking respiration is not always continuous, but at times presents regular intermissions; it may occur at every second, third, or fourth inspiration, sometimes even at greater intervals. It is chiefly at its first appearance that it presents this character, but when well marked it is commonly continuous; like other auscultatory phenomena, it may vary in strength and precision from day to day.

In concluding his paper, the author, though attributing much more importance to jerking respiration as an early sign of pulmonary tubercle, states that he does not regard it as an absolute evidence of the deposit having taken plaoe; for this purpose he justly requires tie presence of collateral, general, or local symptoms.

IV. On the Treatment of Croup. By M. Malqaiqxe. (L'Union Me'dicale, Dec. 9th, 1859.)

In a letter addressed to the Academy of Medicine, d propos of a long discussion on the treatment 6f croup, M. Malgaigne complains of the erroneous manner in which his doctrines as to the employment of tracheotomy in this disease have been represented, and sums up the views he entertains thus: he regards the operation as a sad but imperative duty, justified only by the absence of all other chance for the patient, and he distinctly opposes the doctrine of M. Trousseau, who inculcates that the operation should be had recourse to as soon as false membranes make their appearance in the larynx. M. Malgaigne considers that the time for the surgeon to interfere is when the physician states himself to be unable to do anything more.

V. On Perityphlitis: a Clinical Lecture. By Professor Oppolzer. (Allg. Wien. Med. Ztg., 20, 21, 1858, and Schmidt's Jahrbucher, 1858, No. 9.)

The author observes, with reference to the diagnosis of perityphlitis, that the site of the tumefaction is either under the iliac fascia, immediately upon the subjacent muscles, nerves, and vessels, or above them in that portion of the cellular tissue of the iliac fossa which is in immediate contact with the peritonaeum and caecum. In the former case the swelling is sli-ht and caases bat a trifling projection of the anterior abdominal parietes; bat the symptoms are much more argent owin- to the pressure of the rigid fascia, and the pain on moving the right foot intense from the iliac muscle being involved. In the second case the tumoar is larger, more distinctly visible and tangible; the symptoms are less urgent. Perityphlitis may be confounded with partial peritonitis, perforation of the vermiform process, accumulation of faeces (this we have found associated with perityphlitis so as to act as an exciting cause), congestive abscesses, new growths in the neighbourhood of the Ciecum. The history and progress of the disease must in each case determine the diagnosis, which however is not always easy. The second variety of perityphlitis is the most favourable of the two, and when caused by catarrhal influences, generally ends in resolution; the first form generally terminates in suppuration, and the pus makes its exit in various directions. The treatment is to be directed to diminishing the pain and arresting peristaltic action; hence leeches, warm fomentations, and opium are indicated, followed by alteratives and warm baths after the inflammation has subsided. In the case of suppuration an early opening should be effected.

VI. Notes on Pigment in the Urine. By A. J. Paine, M.D., Bengal Medical Service. (Indian Aimals of Medical Science, July, 1858.)

Dr. Paine has made it a rule to examine the urine of his hospital patients with reference to the amount of pigmentary matter contained in it, and he arrives at the conclusion that it is invariably a test of the presence or absence of hepatio disease; the intensity of the colour produced by heat and the slow addition of nitric acid, being in the exact ratio of the amount of disease in the liver. He has found the test of especial advantage in determining the diagnosis of hepatic from other forms of dyspepsia. Dr. Paine carefully distinguishes between the iridescence produced by nitric acid in urines which contain bile, and the more or less deep-red colour caused by tho same acid after heating the liquid to he tested; it is the latter to which the present paper is devoted. He establishes seven shades, varying from a pale sherry colour, the reaction of pale healthy urine with heat and nitrio acid, to a colour which is so deep as not to allow the transmission of light. Five cases, with autopsies, are given; other cases in which recovery resulted are also recorded by the author, who sums up the evidence, proving that excess of pigment in tho urine is proof of liver disorder, thus—" In all the cases of organic disease of the organ, that have afforded opportunity of post-mortem inspection, the connexion has been established; in a wide range of cases, where experience teaches us that functional disorder prevails, pigment is found; in others, where structural disease is known to be present during life, it is found; where it is assumed to be an indication, even in opposition to other evidence, and practice is based upon it, such practice is successful; pigment does not occur under any circumstances which preclude hepatic affection; and lastly, in functional disorder, the quantity of pigment varies from time to time, iu the same manner as the state of the function may naturally be supposed to vary."

VII. The Diagnosis of Melanotic Cancer by the Urine. By Dr. Eiselt. (Vierteljahraschrift fur die praotische Heilkunde, xv. Jahrgang, 1858, Dritter Band.

Dr. Eiselt reports 3 cases which appear to show that the urine offers a means of diagnosis in melanotic cancer. The first is that of a man, aged sixty, who, in 1856, came under observation with symptoms of hepatic cancer, and with cancer of the left eye. There was no icterus, but the urine exhibited a remarkable peculiarity; when passed it was perfectly clear, but on standing it became as dark as porter without losing its transparency. A portion was drawn by the catheter; it was found to contain copious uric acid, and a normal quantity of urea; when exposed to air and light it became dark in a few hours, but concentrated nitrio aoid caused the change instantly; other oxidising substances, especially chromic acid, produced th« same effect, and the black matter was regarded as melanin, which induced the opinion that the cancer was melanotic, a diagnosis confirmed by the autopsy. A year later a man, aged sixtyeight, was admitted into the Prague Hospital with cutaneous melanotic, canoer. The urine at first exhibited the peculiarity shown in the last case feebly, but as the disease spread to the internal organs, and especially as the liver became affected, the reaction of the urine became as characteristic as in the former case. A third case occurred in May, 1858, in which there was hepatic cancer, and cancer of one eye. The urine again induced the attending physician to diagnose melanotic cancer; some nrine of May 8th -was closed hermetically and kept in the dark; some that was passed on Way 9th was also closed hermetically and placed in the shade. On May 25th Dr. Eiselt exhibited both specimens to the College of Physicians of Prague; the urine of May 8th was slightly turbid, pale yeltow, and had deposited phosphates; the urine of May 9th was black with reflected, and dark-brown with transmitted light. On opening the first specimen, nitric acid and chromic acid at once induced the black colour. The autopsy confirmed the diaguosis of melanotic cancer, for which there had been no other indication.

VIII. On Hemorrhagic Measles. By Dr. Otto Veit. (Archiv. fur Pathologische Anatomie und Physiologic, Band xiv., Hefte 1 and 2.

The prevailing view that the hemorrhagic or petechial form of measles is of a malignant or septic character indicating great danger, is combated by Dr. Veit upon the strength of the experience which he has derived from the various epidemics that have occurred in Berlin, from 1847 to 1857. After quoting various authors from Huxham downwards, of whom Rilliet and Barthez alone coincide with the views advocated by Dr. Veit, he details his own observations. He met with the petechial form in 11 out of 160 cases; and although 9 of them lived in needy circumstances, they all passed through the disease without any peculiar disturbance or ill effects. The author does not deny in toto the occurrence of a septic form of measles, but is unwilling to admit that the petechiae in the cases observed by himself were due to decomposition of the blood, but that they must be regarded as a proof of the greater intensity of the jihysiological process, in the same way as the catarrhal affection of the respiratory organs may be converted into croup or bronchitis. In the baemorrhagic form the eruption, after the usual prodromata of fever and catarrh, on the second, third, or fourth day, instead of becoming paler, suddenly assumes a dark-red colour. These spots become still darker on the ensuing days, and even black; they are round or angular, but have a sharply-defined margin; they vary in size from a flea-bite to that of a pea or bean, and more. They do not disappear on pressure, but behave exactly like extravasations. These spots retain their intensity of colour for a day or two, and then pass through the various changes of colour observed in other extravasations, becoming purple, brown, and yellow before they disappear altogether. The desquamation of the epidermis is more marked over these spots than elsewhere. Dr. Veit has not met with cases in each epidemic of any intensity; sex appears to exert some influence on the occ urrence of the hemorrhagic form, seven having been mides and four females; while of the 160 cases of measles, 80 were males and 78 females, the sex of two children not having been noted. All the epidemics observed by the author had a benignant character, only 8 of his 160 patients having died.

IX. Anatomical and Clinical Researches on the Dropsy consequent -upon Typhoid Fever. By E. Leudet, Titular Professor of Clinical Medicine at Rouen, &o. (Archives Generates de Me"decine, October, 1858.)

During ten years of study in the hospitals of Paris, Dr. Leudet met with no coses of dropsy consequent upon typhoid fever; but during the four years that he has been chief medical officer at the Rouen Hospital, no less than seven instances have occurred to him, where the inferior extremities and the entire surface of the body became cedematous about the second or third week of the fever. All but one, who died of peritonitis, recovered; and none had albuminous urine, although this symptom was very frequently observed in other typhoid fever patients. The author regards oedema as a matter of no great consequenoe, exoept that it retards the recovery of the patient; several of Dr. Leudet's patients were more than two months before they recovered sufficiently to return to work, one even returned to the hospital on account of his debility. Dr. Leudet considers his treatment to have had no influence in the production of the oedema, as he never employed antiphlogistic remedies and abstained from repeated purgations and emetics, his treatment of the fever having been expectative and tonic rather than adynamising. His patients were all fed with bouillon, even from the commencement of the disease, and on the supervention of the oedema they received a more nutritious diet, with quinine, wine, or chalybeates. Dr. Leudet attributes the oedema to the feeble constitution of the inhabitants of Rouen, and of the same nature as the typhoid fever, which is more frequently complicated with stomatitis and pleurisy than elsewhere; he also states that the pyrexiae and phlegmasia} of his townsmen generally present an adynamic character.

X. On Intermittent Fever; the Remit of the Observationt made during, several Epidemiol. By Dr. Hetdeniiain in Marienwerder. (Archiv fur Pathologische Anatotnie, Band xiv., Hefto 5 and 6.)

This paper is one of interest, as bearing npon the question of the change of type of disease generally, as well as on account of the special matter to which the author devotes his attention. Marienwerder, a town of western Prussia, not far from the delta of the Vistula, is the seat of intermittent fever and its congeners; and Dr. Heidenhain, having been in practice in that town and its vicinity for twenty-eight years, gives us the results of his experience during that period. He commenced his practice in 1831, shortly after cholera had claimed its first victims in the district surrounding Marienwerder. This town and the immediate vicinity had been spared, but instead of cholera there was an epidemic of gastric or bilious febrile conditions, with a remittent, or, more frequently, intermittent type. Gastric, bilious, and intermittent fevers almost disappeared when the cholera actually invaded Marienwerder; but the cholera itself assumed an intermittent character of the tertian type in some cases. On the cessation of cholera in 1881, intermittents ceased entirely in Marienwerder, and did not occur in the epidemic form until 1849. Even in the August of 1844, when the valley at the foot of the heights upon which Marienweder is built, was flooded by the Vistula, and after the subsidence of the waters the atmosphere was poisoned with effluvia of decomposing vegetable matter, intermittent* did not make their appearance. During these eighteen years febrile intermittents only occurred sporadically; the paroxysm was not ushered in by a severe rigor, but merely by a passing sense of cold, and the other symptoms of fever were not strongly marked. These affections were cured by large doses of quinine. In the place of genuine intermittents, intermittent neuralgic affections made their frequent appearance; the nerves affected were almost exclusively the first and second division of the fifth pair; the patients were affected with severe hemicrania for throe or more hours; the forehead, the orbital region, the cheek, half the nose and lip were the seat of the affection; the face was pale, at times slightly swollen, the eye dull, the pulse small, no trace of fever, the hands cool; the type was quotidian or tertian. The paroxysms commonly occurred in the morning, without premonitory symptoms, and ceased almost as suddenly. Twice the author observed similar neuralgic affections in the*nape of the neck, and once in the right tibial nerve; in the last instance the subject affected was a multipara, in whom the neuralgia took the place of the after pains immediately after confinement; the neuralgia lasted eight hours, then put on the tertian type. In addition to these neuralgic intermittents, the doctor observed a convulsive intermittent disease in children. It occurred between the years of two and nine, and the affection was at times difficult to distinguish from an apoplectic condition, unless reference was had to the intermittent type. Dr. Heidenhain's description is briefly this:—The child loses consciousness, the eyes • are closed, the pupil enlarged and sluggish, the head hot, the facial muscles are distorted by oonvulsive movements, the hps quiver or are drawn on one side, permitting the passage of frothy saliva, at times tinged with blood; it is almost impossible to effect deglutition. The extremities are violently thrown about; breathing is short and intermittent; there are suffocative attacks; profuse perspiration breaks out over the body. After four, six, or eight hours the symptoms abate, and the child appears to wake up exhausted, but otherwise in comparative health.

In the antnmn of 1849, with the cholera, all the forms of intermittent fever returned with greater frequency; but in 1850 and 1851 they increased still more; and in 1852, the bad year of the cholera, they were at their maximum, but did not, as in 1831, disappear with the cholera, but remained the prominent form of disease until the autumn of 1856, since which time they have diminished. The paroxysms were not characterized by severe rigors, and the cold stage was uniformly short, compared with the length of the hot and sweating stages. The affection attacked all ranks and ages, and however favourable the circumstances and healthy the dwellings of the individuals. A- characteristic feature during this period was the severe pain which, in the fever, often affected the lumbar and sacral regions, and the tenderness of the last cervical and first dorsal vertebra. This "spinal irritation" disappeared on the curative effect of the treatment being manifested.

During the period last spoken of, in addition to the neuralgic affection, neuroses of the motor nerves have made their appearance. Intermittent affections of the vaso-motor system of nerves have also been observed, such as intermittent ophthalmia with a tertian type; the pain was unusually severe in these cases, and out of proportion to the severity of the inflammatory symptoms.

Enlargement of the spleen and anasarca are the chief sequelae which the author has met with. Of the latter he says, that it used, previous to 1854, never to be associated with albuminuria, but that since that time the majority of cases exhibited albuminous urine; these cases commonly proved fatal.

With regard to the treatment of all these various conditions, Dr. Heidenhain recommends

« AnteriorContinuar »