- Email: [email protected]
CONTRIBUTIONS TO CLINICAL MEDICINE.
61 We have now concluded the consideration of difficult labours, once daily.-Evening: only six or seven ounces of blood were far as their causes, symptoms, and general treatment, are con- obtained by cupping, and it was buffy; pain continues on the cerned. We have directed your attention to cases where the aid left side; friction-sound over the cardiac region increased; pulse of the vectis, the forceps, or the perforator, is called for. It re- 130, rather full; countenance very anxious; joints swelled and mains to us, therefore, to consider the mode of applying these painfuL Ordered venesection to twenty-four ounces, which did instruments. The application of instruments shall be the next not produce fainting ; to take three-quarters of a grain of muriate of morphia immediately, two more doses of calomel in the course subject of our attention. of the night, and to have a blister upon the left side of the chest, Erratum.-In p. 31, note, at foot of second column, for Ramsbotham’s Obstetric Midwifery and Surgery, read Ramsbotham’s Obstetric liledicine and another over the heart. and Surgery. October 1 st.- The blisters have acted well; friction-sound continues ; face very pale; pulse still rather full. Has had three doses of calomel, and the mouth is very sore. At noon, Dr. CONTRIBUTIONS TO CLINICAL MEDICINE. Thomson saw her, and ordered one grain of calomel and two BY JOHN TAYLOR, M.D., grains of tartarized antimony, in a pill, to be taken every four still some pain; pulse 120, rather hard and hours.-Evening: PROFESSOR OF CLINICAL MEDICINE IN UNIVERSITY COLLEGE, AND full; the sogophony behind approaches nearer to bronchophony; PHYSICIAN TO UNIVERSITY COLLEGE HOSPITAL, LONDON. none but bronchial respiration audible. 2nd.-The pulse has fallen much in force and volume, but not PERICARDITIS. in frequency. This change took place last night, soon after the CASE 5.-Rheumatismus sub-acutus-Acute pericarditis, without tartar emetic was taken. Has been very sick and a good deal metastasis-Feeble impulse and sounds-Friction-sound-Exface anxious ; has had no sleep; friction-sound not dimipurged; tended and variable dulness-Subsequently, pleurisy and pneumonia nished. To have three-quarters of a grain of muriate of morphia both sides-Endocarditis about mitral the of valve-Enlargement at bedtime. of the heart-Pneumonia in the right lung preceded by signs of 3rd.-Passed a good night and feels better ; pulse 120; double congestion.-Treatment :Copious bleeding, general and local, rubbing sound much rougher, being quite rasping, about the base mercury, tartarized antimony, and blisters-Cure-Remarks- of the heart, but not about the apex; bronchophony; bronchial Direction of the pel’icardial dulness-Effusion of serum into the respiration and crepitant rhonchus over the posterior part of the pericardium may exist with a friction-sound and without any or- left lung, and friction-sound over the posterior part of’ the right. thopnaea- Respiratory murmur may co-exist with effusion of serum Had pain in the right side yesterday, for which ten leeches were into the p7eura-Physical conditions in pleurisy producing cegoapplied. It is now better. To have two grains of tartarized phony and bronchophony-Complications of the pericarditis and antimony and one grain of blue pill every six hours, and threetheir causes-Long duration of the friction-sound-Pneumonia quarters of a grain of muriate of morphia at bedtime. and pleurisy may supervene whilst the system is under the influence fluence 4th.-Feels better; pulse 120, not full, easily compressed; a of mercury. little sharp rough sound about the base of the heart undiminished, ELLEN P-, aged twenty-six, admitted September 28th, 1838. and in the rest of the cardiac region much rougher and louder Servant of all-work, of ordinary conformation and lymphatic tem- than yesterday. No murmur in the arteries of the neck; no perament ; has never been ill, except with occasional headach; bruit de diable; external jugular vein of each side very large, but never had rheumatism-*oefore; has had a hard situation, and lived no distinct pulsation.- Lungs : left, posteriorly bronchophony in a damp kitchen with a stone floor. A fortnight ago began to and crepitation; right, posteriorly bronchophony, bronchial rehave pains and swelling in the joints ; has had pain in the region spiration, and crepitation; friction-sound with expiration, but no of the heart the whole time, but more particularly during the longer any with inspiration. Mouth and throat very sore; no last seven days. Has had no medicine, except a dose of Epsom sickness or purging; tongue pale, and furred; countenance less salts. anxious; rheumatism better. On admission, pains in most joints, with swelling and redness5th.-Dr. Thomson omitted the antimony and blue pill, and in some; countenance rather anxious; headach ; throat rather ordered solution of potash with tincture of hyoscyamus; also a sore; tongue white and furred ; bowels opened daily; respirationspint of beef-tea daily. short and frequent; a sharp pain in the region of the heart on 8th.-To have eight leeches on the right side of the chest. inspiring deeply; pain also on pressure about the left breast, much10th.-Rubbing sound over the heart undiminished; crepitant more under the left hypochondrium, and some on the left side ofrhonchus and bronchophony posteriorly on the left side, and the abdomen; can lie on either side. slight friction-sound on the right. Pulse 120; some pain in the Physical signs.-Heart: impulse scarcely if at all perceptible, back on respiration. Venesection to eight ounces; tartarized either by the eye, hand, or ear; natural sounds very feeble; a antimony, two grains, and calomel, one grain, every six hours. double friction-sound over the greater part of the cardiac region; Omit the beef-tea. that with the systole the louder and more prolonged of the two. lith.-Blood much buffed and more cupped; pulse 120; has They are most distinct upon the sternum, but do not vary much been sick. in intensity over different parts of the heart; no bellows-murmur 15th.-To omit the tartarized antimony, and resume the beefat the apex, top of the sternum, or in the neck. tea. Lungs.-Respiratory murmur rather feeble, but otherwise i 20th.-Cardiac double friction-sound is now almost confined to healthy ; no cagophony. Percussion : dulness in the cardiac a point on the sternum, opposite to the second rib. No murmur region much too extended, being vertically four inches and a in the arteries of the neck; crepitation in both sides behind. half, commencing superiorly at the third rib, and transversely Pulse 108, smaller and weaker. 22nd.-Cardiac friction-sound now very faint and limited. No four inches from the middle line of the sternum. Pulse 116, not very full or strong; no irregularity. Ordered, venesection to murmur in the neck; a faint deep-seated bellows-murmur with sixteen ounces; to take five grains of calomel and ten grains of the first sound at the apex of the heart. Pulse 112. November 12th.-Over the second rib a slight double sound of Dover’s powder immediately, and four grains of calomel every three hours ; low diet. roughish character, heard less distinctly in receding from that 29th.-The sharp pain on deep inspiration has diminished, but point, and not heard in the neck; at the apex a deep-seated not ceased, since the bleeding; pulse 116, not less full, slightly bellows-sound. Impulse too strong and too extended; no crepijerking ; impulse and natural sounds as before; friction-sound tation ; no pleural friction-sound. feebler; dulness on percussion now reaches as high as the second 25th.-Slight sound, as before, about the second rib; soft faint rib, but is not increased in extent transversely. Venesection to murmur at the apex; nothing morbid in the lungs or pleura. Is twelve ounces.-Evening: blood much buffed and cupped; has much improved in strength. now acute pain further towards the left side, just below the Discharged about this time, having pains in the abdomen, axilla ; respiration audible, but feeble ; percussion duller; sego- thought to be rheumatic. phony about the lower angle of the left scapula; cardiac frictionRemarks.-Synaptoms and Diagnosis.-Nothing could be clearer sound less, but still distinct; pulse 120, rather full. Repeat vene- than the proof of acute pericarditis in this case, and at first it was section to twelve ounces. probably uncomplicated with pleurisy,although this is not a 30th.-The blood last taken is much less buffed; rather less matter of certainty. The general symptoms indicated the existpain in the chest, but the joints are even more painful ; sleeps ence of pericarditis or of pleuritis of the left side, but were quite none; friction-sound rather increased; no bellows-murmur; useless as a means of distinguishing between the two. The respiration still too feeble on the left side, and there is some habitually short and frequent inspirations, and sharp pain on inbronchial respiration ; segophony ; dulness on percussion. Right spiring deeply, would be supposed, a priori, more likely to arise side: percussion less clear posteriorly than it was; respiratory from pleurisy than from pericarditis; and the absence of palpitamurmur unchanged; ptyalism has supervened. To be cupped on tions and of all irregularity in the pulse would be calculated to the left side to ten ounces, and to have four grains of calomel confirm this view. The diagnosis, therefore, rested almost exso
’
’
62
elusively upon the ph3-sical signs, the indications of which, how- part of the right lung, shown by dull sound on percussion, without appreciable change in the respiration. Did this arise from ever, were quite unequivocal. 1. The enfeebled impulse and natural sounds of the heart, and congestion, which subsequently passed into inflammation ? On the extent and direction of the dull sound on percussion, especially the sixth day, also, we have pleurisy on the right side, announced considered in connexion with the other signs and symptoms, by friction-sound and pain in the right side; and on the seventh proved the presence of a rather considerable amount of liquid day, bronchial respiration, bronchophony, and crepitation, indieffusion into the pericardium. The dull sound alone, reaching up cating the addition of pneumonia. On the fourteenth day the to the third rib, (probably its upper margin,) would have war- pneumonia and pleurisy of both sides had ceased. Causes and complications.-The rheumatism was complicated ranted a strong’ suspicion, if no more, of the existence of this effusion, and on the next day, when found to have extended to the with pericarditis at the time of the patient’s admission. The second rib, it was of itself perfectly distinctive. In this case, as rheumatic affection neither ceased nor diminished, as far as the effusion increased, we find the dulness extended upwards could be learnt, when disease of the heart appeared. In fact, the pain in the left side had existed from the first. The next only, and not transversely. 2. The double morbid sound had all the characters of the fric- complication was with pleuritis of the left side. This may have tion-sound of pericarditis. It was almost equally distinct in every been caused in the same way as the pericarditis, or it may have part of the cardiac region, and was not limited to the situation of originated in an extension of the inflammation by the contiguity any of the valves. There was no sign of valvular disease co- of the two membranes. From the subsequent occurrence of existing ; no murmur at the apex, at the top of the sternum, or in pneumonia and pleurisy on the right side, however, it seems more the neck. 3. This case proves, beyond all doubt, that’a double rubbing sound in the pericardium may co-exist with a considerable amount of serous effusion. The report on Sept. 29th proves the presence of both, but the friction-sound had decreased as the effusion of serum had increased. 4. Tracing the progress. of the cardiac disease, we find, on the 30th, the friction-sound increased again, probably from a diminution in the quantity of effused serum; but this was not ascertained by percussion. Oct. 3rd.-Probably a further diminution of serum, for the rubbing sound was increased, and was much rougher at the base but not about the apex. On the 4th, a still further absorption of serum was indicated by the increase of the rubbing sound over the body of the ventricle. On the 20th, we find evidence of adhesion of a great part of the pericardium, or of absorption of the coagulable lymph previously effused; the morbid sound was now limited to a very small space on the sternum, opposite to the second rib. On the 22nd, the morbid sound at the base of the heart was still less, but now there was evidence of disease in the mitral valve having supervened-viz., a deepseated systolic bellows-murmur at the apex of the heart, not heard at the base or in the neck, and not existing on the 20th. 5. On November 12th and 25th the characters of the sound at the base of the heart were such that it might have arisen either from some slight remains of the pericarditis, or from a trifling amount of inflammation supervening in the aortic valves. If the cause last named were the true one, then it is worthy of remark that the sound was not (probably on account of its feeble intensity) propagated into the arteries of the neck. 6. Although there was considerable effusion into the pericardium, no mention is made of any orthopnoea. 7. When the patient was discharged, there remained a murmur in the mitral valve, a trifling morbid sound at the base of the heart, and some hypertrophy, with dilatation of the left ventricle, indicated by the increased force and extent of the
impulse.
’
probable that all the internal inflammations were due to one cause-.viz., the rheumatic diathesis ; and the case affords an additional illustration of the tendency of pericarditis to become complicated with endocarditis, pleurisy, and pneumonia. Duration.-The duration of the rubbing sound in the pericardium was at least two months, and probably from one to two weeks longer. Rheumatism existed fourteen days before, and six days after admission. Pleurisy of the left side continued about a fortnight; and pleurisy of the right side, with pneumonia of both, about seven or eight days.
Treatment.-I. Eighty-four ounces of blood were taken by bleeding and cupping, besides the application of eighteen leeches,. yet the patient was lymphatic, and not remarkable for strength. No fainting was produced, nor bruit de diable, but considerable
paleness of the face. The mouth was made sore by calomel, yet the rheumatism,. and pleuritis, continued after ptyalism came on;.y, and pneumonia of both sides, with pleurisy of the right, first appeared, whilst the mouth was sore. Aboutthe time the gums became tender, however, (Sept. 30th,) and for two or three days> after, (Oct. 3rd and 4th,) the quantity of serum in the pericardium decreased. 3. A considerable quantity of tartarized antimony was taken in two-grain doses. It was prescribed October 1st, and the following day there was a marked change in the force and volume, but not in the frequency of the pulse. The first day it: produced a good deal of sickness and purging: a dose of muriate. of morphia was given, and these symptoms ceased. 2.
pericarditis,
FOREIGN DEPARTMENT. ACADEMIE DE MEDECINE, PARIS. (MARCH, APRIL, MAY, JUNE.) (Concluded from our last number.)
8. A bellows-murmur in the mitral valve, which must have arisen from endocarditis, first appeared October 22nd. This was A NEw MODE OF TREATING SPERMATORRIHEA. long after the mouth had been made sore. There was no other M. of in the of the this inflammation interior heart. BRACHET, of Lyons, stated that he had been induced, accisymptom Lungs and .PMy
’
’
62
elusively upon the ph3-sical signs, the indications of which, how- part of the right lung, shown by dull sound on percussion, without appreciable change in the respiration. Did this arise from ever, were quite unequivocal. 1. The enfeebled impulse and natural sounds of the heart, and congestion, which subsequently passed into inflammation ? On the extent and direction of the dull sound on percussion, especially the sixth day, also, we have pleurisy on the right side, announced considered in connexion with the other signs and symptoms, by friction-sound and pain in the right side; and on the seventh proved the presence of a rather considerable amount of liquid day, bronchial respiration, bronchophony, and crepitation, indieffusion into the pericardium. The dull sound alone, reaching up cating the addition of pneumonia. On the fourteenth day the to the third rib, (probably its upper margin,) would have war- pneumonia and pleurisy of both sides had ceased. Causes and complications.-The rheumatism was complicated ranted a strong’ suspicion, if no more, of the existence of this effusion, and on the next day, when found to have extended to the with pericarditis at the time of the patient’s admission. The second rib, it was of itself perfectly distinctive. In this case, as rheumatic affection neither ceased nor diminished, as far as the effusion increased, we find the dulness extended upwards could be learnt, when disease of the heart appeared. In fact, the pain in the left side had existed from the first. The next only, and not transversely. 2. The double morbid sound had all the characters of the fric- complication was with pleuritis of the left side. This may have tion-sound of pericarditis. It was almost equally distinct in every been caused in the same way as the pericarditis, or it may have part of the cardiac region, and was not limited to the situation of originated in an extension of the inflammation by the contiguity any of the valves. There was no sign of valvular disease co- of the two membranes. From the subsequent occurrence of existing ; no murmur at the apex, at the top of the sternum, or in pneumonia and pleurisy on the right side, however, it seems more the neck. 3. This case proves, beyond all doubt, that’a double rubbing sound in the pericardium may co-exist with a considerable amount of serous effusion. The report on Sept. 29th proves the presence of both, but the friction-sound had decreased as the effusion of serum had increased. 4. Tracing the progress. of the cardiac disease, we find, on the 30th, the friction-sound increased again, probably from a diminution in the quantity of effused serum; but this was not ascertained by percussion. Oct. 3rd.-Probably a further diminution of serum, for the rubbing sound was increased, and was much rougher at the base but not about the apex. On the 4th, a still further absorption of serum was indicated by the increase of the rubbing sound over the body of the ventricle. On the 20th, we find evidence of adhesion of a great part of the pericardium, or of absorption of the coagulable lymph previously effused; the morbid sound was now limited to a very small space on the sternum, opposite to the second rib. On the 22nd, the morbid sound at the base of the heart was still less, but now there was evidence of disease in the mitral valve having supervened-viz., a deepseated systolic bellows-murmur at the apex of the heart, not heard at the base or in the neck, and not existing on the 20th. 5. On November 12th and 25th the characters of the sound at the base of the heart were such that it might have arisen either from some slight remains of the pericarditis, or from a trifling amount of inflammation supervening in the aortic valves. If the cause last named were the true one, then it is worthy of remark that the sound was not (probably on account of its feeble intensity) propagated into the arteries of the neck. 6. Although there was considerable effusion into the pericardium, no mention is made of any orthopnoea. 7. When the patient was discharged, there remained a murmur in the mitral valve, a trifling morbid sound at the base of the heart, and some hypertrophy, with dilatation of the left ventricle, indicated by the increased force and extent of the
impulse.
’
probable that all the internal inflammations were due to one cause-.viz., the rheumatic diathesis ; and the case affords an additional illustration of the tendency of pericarditis to become complicated with endocarditis, pleurisy, and pneumonia. Duration.-The duration of the rubbing sound in the pericardium was at least two months, and probably from one to two weeks longer. Rheumatism existed fourteen days before, and six days after admission. Pleurisy of the left side continued about a fortnight; and pleurisy of the right side, with pneumonia of both, about seven or eight days.
Treatment.-I. Eighty-four ounces of blood were taken by bleeding and cupping, besides the application of eighteen leeches,. yet the patient was lymphatic, and not remarkable for strength. No fainting was produced, nor bruit de diable, but considerable
paleness of the face. The mouth was made sore by calomel, yet the rheumatism,. and pleuritis, continued after ptyalism came on;.y, and pneumonia of both sides, with pleurisy of the right, first appeared, whilst the mouth was sore. Aboutthe time the gums became tender, however, (Sept. 30th,) and for two or three days> after, (Oct. 3rd and 4th,) the quantity of serum in the pericardium decreased. 3. A considerable quantity of tartarized antimony was taken in two-grain doses. It was prescribed October 1st, and the following day there was a marked change in the force and volume, but not in the frequency of the pulse. The first day it: produced a good deal of sickness and purging: a dose of muriate. of morphia was given, and these symptoms ceased. 2.
pericarditis,
FOREIGN DEPARTMENT. ACADEMIE DE MEDECINE, PARIS. (MARCH, APRIL, MAY, JUNE.) (Concluded from our last number.)
8. A bellows-murmur in the mitral valve, which must have arisen from endocarditis, first appeared October 22nd. This was A NEw MODE OF TREATING SPERMATORRIHEA. long after the mouth had been made sore. There was no other M. of in the of the this inflammation interior heart. BRACHET, of Lyons, stated that he had been induced, accisymptom Lungs and .PMy