Imagens das páginas

bral hemorrhage-is the most frequent cause of sudden deaths as entirely erroneous for in one only out of the forty cases, all of which he examined with much care, did he discover un seul foyer apoplectique; and, even in this case, the lateral ventricles contained a considerable quantity of serum. M. Devergie is of opinion that, in almost all cases of sudden death from cerebral apoplexy, the congestion is not confined to one spot, but is exercised over a considerable extent of the brain. He relates the following case in confirmation of his views.

A woman was seized with the pains of labour; the uterine contractions were soon accompanied with very troublesome fits of vomiting. At the end of four hours she expired. On dissection it was found that a hæmorrhage had taken place from a blood-vessel adjoining to the left lateral ventricle of the brain, and that the blood had gradually filled the four cerebral ventricles to complete distention. The common idea, that sudden death is often occasioned by a very limited or circumscribed local lesion, has arisen from pathologists being apt to examine the organs separately and by themselves, and not in connexion with each other. Hence the great importance of the anatomist making a general inspection of the cerebral and thoracic viscera, before he divides or detaches any of them from their natural position.

Each of the three modes of sudden death—according as the brain, the lungs, or the heart, has first ceased to act-leaves certain pathological changes, which to the experienced eye are, in some degree at least, characteristic.

Thus, when the death proceeds from some interruption of the pulmonary functions, the circulation is primarily arrested in the lungs :-hence the pulmo nary arteries, the right cavities of the heart, and the venæ cavæ are gorged with blood; while the pulmonary veins, the left cavities of the heart, and the aorta are altogether or nearly empty of blood.

Again; if the death has been owing to a sudden cessation of the brain's influence, the meningeal veins will be found extremely congested, the lungs will be similarly affected, and the cavities of the heart on both sides will probably contain blood, although more certainly may exist in the right than in the left cavities. These pathological phenomena are just what we might expect, when we call to mind that, in sudden death from a cerebral cause, the lungs are oppressed before the heart ceases to act.

Lastly; if the death has debuté from the heart, the cavities of this organ, on both sides, will be found on dissection to contain blood; the veins are not more loaded than the arteries, and neither the lungs nor the brain exhibit the signs of genuine congestion.

It thus appears that it is quite possible to distinguish, or at least to form a probble coujecture of, the three modes of sudden death, provided we examine the state of the brain, lungs, and heart with sufficient care, and without detaching them from their connexions.

Having thus briefly alluded to the leading pathological characters of sudden death, whether it proceeds from syncope, or from pulmonary, or from cerebral, asphyxia-we shall now arrange the forty cases, to which we have already alluded, in a tabular view, so as to exhibit more exactly the nature of the disease which proved fatal.

Apoplexy, with a circumscribed effusion or foyer in the tuber annulare 1 Apoplexy, meningeal ..

Apoplexy, serous, and accompanied with pulmonary congestion

Congestion, cerebro-rachidian

Congestion, pulmonary

[ocr errors]

Congestion, pulmonary and cerebral



Rupture of the heart

Rupture of the pulmonary artery









(M. Devergie here enters into a minute anatomical description of the postmortem phenomena in each of the three sorts of sudden death; but, as we have already alluded to the general pathognomonic characters of these, we deem it unnecessary to do more than recommend our readers to peruse the memoir for themselves.)-Rev.

As to the determining causes of sudden death, it is almost impossible to give any satisfactory account of these. One sixth of the bodies, which are brought to the Morgue at Paris, is never claimed; and in very many cases of the remaining number no precise information can ever be obtained. In fourteen however out of the forty, M. Devergie satisfied himself that the sudden death was owing to excessive intoxication; which will account for the frequency of pulmonary and cerebral congestion, as a post-mortem phenomenon in his researches.

With respect to the age of the deceased, this was ascertained in 35 out of the forty cases :



From 20 to 30 years 2 cases.
From 30 to 40
From 40 to 50
From 50 to 60
From 60 to 70
From 70 to 80



As might be expected, the frequency of sudden death among men is very much greater than among women. The ratio in M. Devergie's practice has been about one to eight or nine.

[ocr errors]
[ocr errors]


[ocr errors]

The author sums up his observations in the following propositions:

1. The most frequent immediate cause of sudden death is pulmonary congestion; either simple, or complicated with cerebral congestion.

2. Sudden death from apoplexy is of much less frequent occurrence than has been generally supposed.

3. In most cases, the sanguineous congestion of any of the three vital organs is usually extensive or diffused, and not confined to a single or very circumscribed spot.

4. Sudden deaths are greatly more frequent among men than among women; and the periods of life, at which they are most common, are between 40 and 50, and between 60 and 70 years of age.

5. Sudden deaths are more common in Winter than in Summer.

6. Intemperance is one of the most common exciting causes.—Annales d' Hygiene, Juillet, 1838.

Remarks. The preceding observations of M. Devergie are doubtless quite correct, as far as his own researches have gone; but we strongly suspect that if they were taken as illustrative of the question of sudden death in general, and not only among the lower orders, but also among the higher classes of society -among the latter, be it remembered, the accident is most frequent-many of his conclusions would be found to be erroneous. We are to remember that M. Devergie's data have been derived almost entirely from the examination of the bodies-found in the Seine, and in the streets and suburbs of Paris-at the Morgue. It is almost unnecessary to say that by far the greater number of these have been the victims rather of violent, than of sudden, death. If such be the case, we may at once explain the frequency of pulmonary and cerebral congestion found on dissection, and the rarity of cardiac disease. M. Devergie himself has mentioned intoxication as one of the most common exciting causes of sudden death; and yet we all know that life is very rarely extinguished, in less than the space of several hours, from this cause.

We have already stated our opinion that sudden deaths are of more frequent occurrence among the rich than the poor, among men of educated and sensitive feelings than among the humbler classes of the people. We have little doubt

that among the former the heart and brain-more especially the former-are the organs primarily affected in most cases.-Rev.


The ancient writers have confounded under the general term phrenzy various affections, which the moderns have discriminated, and which they have sometimes described as new and unnoticed diseases. Among these we may place that bizarre affection, which was well portrayed by the English physician Sutton under the name of delirium tremens, and which, he shewed, was in almost every case occasioned by the abuse of spirituous liquors.

In lately perusing the works of Stoll, I (Professor Forget of Strasburg) was much struck with the very exact and faithful delineation of this disease, in the Chapter on the Causes and Seat of Phrenzy.

The report of the following three cases will interest every medical reader, not only by the accuracy of the description, but also by the judicious therapeutical instructions recommended by the author.

Case 1. A middle-aged man, of a robust constitution, was admitted into the hospital at Vienna on the 13th of June 1778. For six days he had been distressed with extreme lassitude, loss of appetite, frequently-recurring chills, and subsequently with a great trembling or shaking of the body, as if he was in the cold stage of an ague. The pulse was but little affected; the speech was quite clear, and the mind was tranquil. Dr. Stoll regarded the case as one of incipient bilious fever, and prescribed some light aperient to act upon the bowels.

During the night, however, the patient was unexpectedly seized with furious delirium; and, from this time until the hour of the morning visit, he was in a constant state of violent excitement, screaming out, and tearing every thing that he could get hold of. The pulse at this time was vibratory; and the surface of the body was covered with a copious sweat.

Three grains of emetic tartar were administered immediately; but neither vomiting nor purging was induced. An hour afterwards a mixture, containing eight grains of the same salt, was prescribed: one half to be taken at a dose, and the other half in half an hour, if no effect was produced. The patient however, mistaking the medicine for wine, which he was continually desiring to have, swallowed nearly the whole of the mixture at once. He was vomited and purged briskly three times; and a copious perspiration broke out. The delirium soon subsided, and he fell asleep muttering to himself. On the following day, he awoke quite conscious, and almost entirely tranquillized in his mind.

Remark. The treatment adopted by Stoll in the preceding case deserves especial notice, as some late writers have claimed to themselves the credit of having first announced the efficacy of emetics in delirium tremens.

Case 2. In the Autumn of 1778, we received into the hospital a man-servant, who was at the time in a state of furious excitement, Four or five days previously he had drunk a large quantity of strong beer, while heated from running; and he was soon afterwards seized with intense headache, and frequently-returning chills. He was immediately bled from the arm; but, although the blood was buffy, no decided relief was procured. During the course of the evening, he fell into a state of delirium: his eyes seemed to be pushed forwards, and they were constantly rolling about; he screamed out in violent paroxysms of rage; the whole surface of the body was drenched in profuse perspiration; and the

pulse, though scarcely at all accelerated, was vibratory and jerking. A second venæsection was practised, but without benefit.

On the following day, however, he was much more composed, and then Stoll saw him for the first time. He advised a small quantity of blood to be taken again from the arm it proved to be not at all buffy now. Acidulated drinks and gentle aperients were also prescribed; and, along with these medicines, a fourounce mixture containing six grains of tartrate of antimony. These means produced three copious stools, and also vomited him freely thrice. He became, soon afterwards, very calm, and at length fell into a profound soothing sleep, which lasted for many hours. In the course of a few days he had completely recovered.

Remark. The inutility of sanguineous depletions was strongly manifested in the preceding case.-(Rev.)


Case 3. A young man, who had been long addicted to excess in drinking, was seized with shivering, severe headache, frequent vomiting, and general weakAt times, all his limbs trembled or shook, as if he was in an ague-fit. The pulse was quickened, hard, and full. He was bled and purged with cooling aperients the blood was buffy. During the course of the night, however, he fell into a state of delirium and excessive restlessness. On the following day, there were frequent attacks of convulsions; and the delirium was almost constant. Next day he was conveyed to the hospital: he was then more tranquil, and could give some account of his illness.

While engaged however in speaking, his looks and whole demeanour indicated an excited and wavering state of the mind. He had no sooner finished his tale, than he was seized with furious delirium.

Five grains of the tartrate of antimony were given at once, and smaller doses were given at short intervals. After the emetic and purgative action of the medicine was freely induced, the state of the patient became much more composed. Although sleep did not come on for some time, his health gradually improved and was ultimately quite restored.

General Remarks. These three cases, reported by a most experienced physician of the last century, before the term delirium tremens had been heard of, will be read with interest and advantage. The efficacy of the antimonial treatment is most satisfactorily proved by the result of each case; and the recommendations of it by some recent writers are thus very beautifully confirmed. We are induced to append the following case, as it was one of extreme severity. It occurred in Dr. Forget's practice.

A healthy robust man, who confessed his propensity to intemperance, was admitted into the Hospital at Strasbourg on the 24th of June, 1837. His whole frame was agitated and shaking; he complained of acute headache, and general restlessness; the pulse was normal, the heat of the surface moderate, the bowels regular, and his ideas seemed to be clear and but little disturbed. He was bled from the arm; but the coagulum was soft and not at all buffy. As the patient said that, some years ago, he had had an attack of ague, the present ailment was regarded in the same light; and accordingly quinine was administered. During the course of the night, however, he became vehemently excited, and at length quite ferocious, so as to require the application of a straight jacket.

Next day he was in a constant state of delirium, screaming and shouting out, his whole frame convulsed with a trembling agitation; the eyes sparkled and rolled about incessantly; every now and then, he made violent efforts to disengage himself from the jacket: the pulse however was not much excited, and the skin was moist.

During the visit, he was seized with a most severe epileptiform convulsion; the whole body became stiff and immoveable, the head was thrown back, the face livid, the jaws and fingers clenched, and the breathing convulsive. This paroxysm lasted for two or three minutes. Twenty leeches were applied to the temples, and one grain of the extract of opium was ordered to be given every two hours: mustard poultices were applied to the legs. The agitation continued more or less during the whole day: the opiate treatment however was steadily persevered in ; and by midnight, when he had already taken nine grains in all, he fell into a deep sleep.

Next day, he was calm, spoke rationally, and had lost all the trembling agitation of his body and limbs-the pulse was eighty, and rather small in volume. This day he took three grains of opium, and had an aperient enema. The quantity of opium was gradually diminished each day; and by the end of the week he was discharged quite recovered.

Remarks. This case is especially interesting in a diagnostic point of view; its characters having successively assumed those of intermittent fever, meningitis, and epilepsy. It will often require great tact to avoid such mistakes; and, on the correctness of a right discrimination, will depend the appropriate management of the disease. The reader will observe that the paroxysms of delirium tremens are almost always aggravated after venæsection; whereas they are often cut short, almost immediately, by a full dose of opium. The delirium, which not unfrequently supervenes after a severe accident, such as fractures of the limbs, &c. (this is the delire traumatique of Dupuytren, and by him was always treated with opium), is of the same nature essentially as idiopathic delirium tremens, and requires the same mode of medication.-Bulletin General de Therapeutique.


The medical reader is well aware that, within the last few years, great attention has been paid in some of the German States to the question, how far vaccination has proved a preservative against the contagion of small-pox. It has been made an object of government enquiry; and the statistical reports, which have been derived not only from military, but also from many civil physicians, now constitute a mass of most valuable documents.

From these it most unquestionably appears, that the small-pox has of late years been progressively on the increase. According to Dr. Heim, of Wurtem burg, the author of an important work on the subject, nearly 180 out of every 1,000, who have been vaccinated, have suffered from variolous or varioloid contagion.

The results of re-vaccination also may be appealed to in confirmation of the same fact the diminution of the protecting influence of the cow-pox.

Out of 44,000 cases of re-vaccination, 20,000 exhibited the genuine, and 9,000 the modified cow-pox vesicle; and in the remaining 15,000 no effects were produced by the experiment.

The state of the cicatrices on the arms of the re-vaccinated has been examined with particular care. Out of 1,322 persons, who presented normal cicatrices, the re-vaccination took in about 65 per cent. ; in 25 per cent. it exhibited the modified vesicle; and in 9 per cent. it failed altogether.

Out of 1,134 re-vaccinated persons, in whom the cicatrices on the arms were

« AnteriorContinuar »