« AnteriorContinuar »
all over the kingdom-1542, hot agues and fluxes-1545, the great plague 1552, the sweating sickness again, and very general-1557, hot burning agues, seven aldermen in London died-1563, 21,500 died of the plague in London -1593, the plague again, of which 17,890 died in London 1603, the plague carried off 30,000 in London. The bills of mortality, or "display of the diseases and mortality," as they are called, commences from the latter date. When we examine the table (page 66) shewing the proportion of deaths from plague, in each week, from 1593 to 1665, we find that it prevailed 20 years out of that time, during some of which, viz. in 1603 and 1625, it nearly equalled in mortality the great plague of 1665. Thus, in the months of July, August, and September, 1625, it killed from one to four thousand weekly in London. In 1665, it presented itself in the last week of April-rose gradually to seven thousand a week, and fell in December to 281. In that fatal Summer, it carried off 68,506 souls!
When we contemplate the bills of mortality in this book, and compare the devastations of former epidemics with those of our own times, we have reason to be thankful for the improved state of health enjoyed by the inhabitants of this great metropolis.
We recommend this volume to the patronage of the profession-a patronage which, we are sorry to say, has been denied it, in one, at least, of those great corporate bodies where patronage ought to be found!
CYCLOPEDIA OF PRACTICAL MEDICINE, Parts III., IV., and V.
(Continued from last Number.) THIS work goes on prosperously-indeed its success is now beyond doubt. We shall not attempt to notice all the articles in this vast assemblage, especially in an analytical manner. Nevertheless, we shall glance at those which are most adapted for comment or quotation.
1. AUSCULTATION. This, of course, is from the pen of Dr. Forbes, and we need hardly say that it is well executed, seeing the great pains taken by the author in translating Laennec, and in prosecuting the subject of auscultation in his own practice. We can only give the following extract from this condensed article.
AUSCULTATION OF THE HEART IN THE FETUS-DIAGNOSIS OF PREGNANCY. "M. Mayer, of Geneva, appears to have been the first who applied the tests afforded by auscultation to discover the existence of the fœtus in utero. In the Bibliothéque Universelle for November, 1818, it was stated that this gentleman had ascertained that the sounds of the fœtal heart are readily perceptible by applying the ear to the abdomen of the mother. The subject was afterwards prosecuted, with the aid of the stethoscope, by M. Kergaradec, and with additional results indicative of its importance; and the following facts, verified by numerous auscultators in this country and on the Continent, are now as well ascertained as any detailed in former parts of this article.
There are two auscultatory signs of the presence of a living foetus in the womb-1. the double sound of the heart; and, 2. the existence of the bellows-sound in the placental arteries, or rather, in the uterine arteries immediately connected with the placenta.
1. The pulsations of the foetal heart may be perceived as early as the fifth month, or between that and the sixth. They are characterised by the double sound of the adult heart, and by the peculiar rhythm of this, which can never be mistaken for any other sound. The sounds, when compared with those of the adult heart, examined in the cardiac region, are extremely feeble; but they are, when at all perceptible, perfectly distinct. They are distinguished from all arterial pulsation of the mother by the duplex rhythm, and by the extreme frequency of their recurrence. The foetal pulsations are generally more than double that of the mother. The sounds are found to be much more distinct at one time than another, in the
same place, and in different places at different times. These variations no doubt result from the varying position of the fœtus, and from its relation to the uterine parietes.
The sounds will be much more distinct when the trunk of the foetus is in direct contact with the uterus, and, most of all, when the anterior part of its chest is applied opposite to the spot on which the stethoscope rests. When the whole body of the child is removed from that side of the uterus over which the instrument rests, it is doubtful if the action of the heart can be at all perceived. The more copious is the liquor amnii, the less perceptible, cæteris paribus, will be the fœtal sounds. The space over which the sounds may be heard is generally pretty extensive, being, indeed, frequently the greater portion of the region occupied by the uterus. It is, however, in general easy to discover the point which is nearest to the source of the sounds, by the decreasing and increasing intensity of these, as our examinations recede from or approach towards one particular spot. In general, the pulsations of the foetal heart vary from 120 to 160 in a minute. In one case noticed by Dr. Ferguson, the relative frequency of the mother's and child's pulse was singularly reversed; the former being 100, while the latter was only 20. We have met with no similar instance on record. 2. The second auscultatory sign of the presence of the foetus has been termed the placental sound, or placental bellows-sound, likewise the utero-placental soufflet. It was first noticed by M. Kergaradec, and although a less absolutely certain indication of pregnancy than the sound of the foetal heart, it is a sign of great importance. Although termed placental, there can be little doubt that the site of the sound is in the uterus, in the enlarged arteries which supply the placenta. The sound assumes, at different times, all the character of the
* Dublin Trans. vol. I. New Series. "A striking analogical instance is afforded by the thyroid arteries in bronchocele, noticed in a former part of this
bellows-sound of the heart. It becomes perceptible about the fourth month of gestation, and is then more distinct than at a later period. Dr. Ferguson says that he has not observed any variety of the sounds to be peculiar to particular stages of pregnancy. In the early stages, Laennec describes the sound as resembling that which is produced by discharging a blast from a pair of bellows into an empty bottle. At a later period, the sound is duller, more diffused, and no longer conveying the impression of being limited to the caliber of a single artery. It assumes all the varieties of the valvular sounds of the heart, from the simple bellowssound to the sound of the rasp or saw. Dr. Ferguson says that the most constant variety is a combination of the bellows or the sawing with the hissing sound, commencing with one of the former and terminating with the latter.' These sounds are confined to a much smaller space than those of the foetal heart. The point where they are most audible is always fixed in the same person, but varies in each individual. In some, the sound can only be detected in a single spot a few inches square. There is no particular part of the uterine tumour in which the sound may not be found; but Dr. Ferguson says that he has found it most frequently in the iliac regions. The placental sound is always isochronous with the pulse of the mother, and is unaccompanied by any degree of impulse.
Whatever be the precise mode of production of this sound, there can be no doubt that it has its seat in the enlarged vessels of the uterus in that portion of it immediately connected with the placenta. This is proved by the following facts :-1. The sound, as already stated, is confined to a fixed space in each individual. 2. This spot is ascertained, by examination after delivery, to be always that to which the placenta had been attached. 3. That the sound is not seated, at least exclusively, in
article. Query, will the same result be obtained in active hypertrophies of other parts of the system?"
the placenta, is proved by the fact that the sound is still audible for a short period after the placenta is detached. 4. It ceases immediately upon the contraction of the utero-placental arteries, as is proved in cases of death of the fœtus without delivery, and by its instantaneous cessation on the contraction of the uterus after delivery. 5. It is in all cases synchronous with the mother's pulse. There seems little ground for believing, with Dr. Kennedy, that the placental arteries themselves have a share in the production of the sound, any farther than by their action promoting that of the uterine arteries. The character of the sound is changed by the cessation of the foetal circulation, as by the removal of the placenta, the death of the foetus, or tying of the cord (Dr. Kennedy denies M. Ollivry's statement that it is immediately extinguished), the sound becomingabrupt, of short continuance, and wanting the lengthened terminating whiz observed in the perfect sound.' This may easily be explained by the change necessarily produced in the uterine circulation by the removal of the foetal circulation, without supposing that the placental arteries had any direct share in its production.
Great care and attention are requisite on the part of the auscultator in investigating these phenomena. The sounds being very feeble, perfect silence is necessary during our explorations, and we must be very careful not to confound the sounds with others which may exist at the same time, such as the sound of the mother's heart (which is often distinctly audible in the region of the uterus), of the intestinal movements, and the sound of muscular contraction produced in compressing the abdomen with the stethoscope. As the phenomena are sometimes intermittent, or, at least, not always perceptible, we must not deny their existence because they are not discovered on the first examination. The sounds may be heard almost as well by the naked ear as the stethoscope; but to all who are accustomed to use this instrument, there are nume
* Dublin Trans.
As the talented author has paid great attention to these subjects (especially the latter) and written, ex professo, on one of them, we may consider this article as a resumé of the writer's more extended work. He divides his remarks into two sections-the first treating of the natural, the second of the morbid state of the vital fluid. On the natural condition of the blood we shall not dwell. The morbid changes relate to quantity as well as quality. The blood is often deficient or superabundant-as in anemia and plethora. In various diseases, Dr. M. contends that the qualities of the blood are deteriorated, and seems inclined to infer, that these deteriorations are the cause, rather than the effect of disease. Much may be said on both sides of this question.
"Considerable changes are induced in the blood in inflammation. It is well known that the blood drawn in inflammation of the serous membranes is apt to be cupped and buffed; that is, the cruor is firm and contracted, and its edges are much raised above the central part of its surface; and its upper portion consists in a substance nearly deprived of colouring matter. This buff consists of fibrine and albumen; the serum contains more albumen than natural; and the crassamentum is exceedingly firm.
Is this modification of the blood the effect, or a cause, of the inflammatory process? That the blood may be cupped and buffed independently of inflammation, is proved by the facts of the occurrence of these phenomena in cases of pregnancy.
It is true, on the other hand, that the buffed and cupped state of the blood is not so obvious on the first day as on subsequent days, in cases of inflammatory disease. It must, therefore, be concluded that inflammation, and the state of pregnancy, and other sources of excitement, and even bloodletting itself, when so conducted as to lead to reaction, induce the cupped and buffy state of the blood.
It is an interesting fact to note, that the layers and adhesions formed upon or from the surfaces of inflamed serous membranes, are of the same chemical and physical constitution as that of the buff of the blood itself.
It is important to remark that it is not every kind of inflammation which induces the cupped form and buffy coat in the blood. Inflammation of the serous membranes and parenchymatous substance has chiefly this effect. Inflammation of the mucous membranes, as bronchitis, and dysenteria, frequently occurs without any disposition to a cupped or buffed condition of the blood. Indeed, there is a greater difference between these two classes of disease than their names would lead us to suspect.
Dr. Tweedie has observed, in two instances of acute disease, the buffy coat on arterial blood. The only reason why this appearance is not so familiar to us is, probably, the less frequent performance of arteriotomy than of venesection.
But besides the marked morbid appearances of the blood in fever and in inflammation, very peculiar changes take place in chlorosis. In this disease there is a general state of bloodlessness, the crassamentum is small, the proportionate quantity of serum large; a drop of the blood observed upon white linen is seen to be extremely pale. It still remains to ascertain the exact proportions of fibrine, albumen, hæmatosine, &c. in chlorotic blood, and to observe its appearance under the microscope. It still remains to compare it with the blood of persons blanched by hemorrhagy. The morbid character of the blood in chlorosis must be ranked
amongst the most unequivocal proofs of the truth of a humoral pathology.
The next disease to be noticed in connexion with the pathology of the blood is scorbutus, the stronghold of the humoral pathologists,-the pons asinorum of the solidists. The defective cohesion and separation of the cruor, the dissolved state of the blood in scorbutus, could never be forgotten by either party; it was continually reproduced by the former, and pertinaciously neglected by the latter.
Dr. Mead gives a vivid description of the state of the blood in scorbutus. In the beginning,' he observes (Medical Works, Dublin, 1767, p. 332), as it flowed out of the orifice of the wound, it might be seen to run in different shades of light and dark streaks. When the malady was increased, it ran thin, and seemingly very black; and after standing some time in the porringer, turned thick, of a dark muddy colour, the surface in many places of a greenish hue, without any regular separation of its parts. In the third degree of the disease it came out as black as ink; and though kept stirring in the vessel many hours, its fibrous parts had only the appearance of wool or hair floating in a muddy substance.
In dissected bodies the blood in the veins was so entirely broken, that by cutting any considerable branch you might empty the part to which it be longed of its black and yellow liquor. When found extravasated, it was of the same kind. And lastly, as all other kinds of hemorrhage are frequent at the latter end of the calamity, the fluid had the same appearance as to colour and consistence, whether it was discharged from the mouth, nose, stomach, intestines, or any other part.'
There is no point in pathology more instructive than this of scorbutus. The morbid influence of salt meat, and the curative influence of acids; the baneful effects of impure air and impure diet, and the beneficial effect of a change of atmosphere and regimen; are shewn more clearly in this disease than in any other. And as subsequent links of the chain, the influence of a
'dissolved' state of the blood in inducing a 'dissolved' state of the solids, to use the ancient phraseology, is equally remarkable in this disease.
Nearly allied to scorbutus is purpura. Some singular appearances have been observed in the blood in this disease. The crassamentum has been found separated without being firm, or contracted; and buffed without being cupped; its upper surface covered to a considerable depth by a straw-coloured substance resembling ordinary jelly. This, as well as the other parts of this interesting subject, still needs further investigation.
As an improper kind of diet produces a baneful influence upon the composition of the blood, so does a disordered and loaded state of the bowels. This is apparent from the condition of the secretions; the saliva, the perspiration, the urine, are alike deranged in their obvious qualities, but especially in odour; and there is more or less of the bloodless appearance seen in chlorosis.
Icterus is another disease in which the blood is known to suffer. The colouring principle, at least, of the bile is retained in the blood. It appears to act as a narcotic upon the brain, inducing drowsiness. The serum of the blood and the secretions from the skin and kidney are in some cases alike tinged with the yellow colouring matter of the bile.
Every one knows the baneful influence of a suppressed state of another secretion-the urine. It cannot be doubted that some of the principles of this secretion are retained in the blood. Prévost and Dumas found urea in the blood of an animal in which the ureters had been tied. In the human subject, suppression of the urine, or the presence of some of its principles in the blood, produces coma and death.
M. Dance has recently renewed the idea of a former day, that the suppression of the secretion of milk may, like that of the bile or urine, affect the blood and the secretions. In one such case it is said that caseum was found in the fluid of ascites, evacuated from the abdomen.
But if the secretions become some
times suppressed, and produce a reflex alteration in the blood, there is a case in which the blood becomes morbidly affected, together with an excessive secretion, as in diabetes. The blood in this disease is more serous, and contains less fibrine than usual. It would be interesting to examine the effect upon the blood of excessive perspiration, undue lactation, and profuse or protracted menorrhagia or leucorrhoea.
The facts which result from this inquiry are these:-1. In many diseases, as fever, inflamination, chlorosis, scorbutus, there are undoubted morbid changes induced in the blood itself; 2. that other morbid changes are induced by impure atmosphere and an unwholesome diet; 3. that various miasmata in the atmosphere, and various poisonous qualities in food, produce morbid changes in the blood; 4. that suppressed secretions induce morbid changes in the blood; 5. that excessive secretions induce other morbid changes in this fluid; and, 6. that an affection of the innervation, or of the nervous system, may, as is observed on a division of the eighth pair of nerves, produce its peculiar changes in the circulating mass."
On bloodletting Dr. Hall is more at home; and his paper in the Cyclopædia is a compendium of his other publications on the same subject. We need not farther allude to them here.
The important article on Cerebral Inflammation, by Dr. Adair Crawford, is noticed separately in another part of the Periscope.
III. BRONCHITIS, by Dr. Williams, is a well-constructed paper, from which we shall make an extract on the treatment of the acute form of that dangerous and distressing disease.
Treatment of Acute Bronchitis.—1. The slighter cases of acute bronchitis are more frequently objects of domestic than of formal medical treatment. When neglected, however, a common cold may give rise to the most serious complaints; and we are far from subscribing to a prevalent opinion to which even Laennec seems to lean, that it must al