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CONTRIBUTIONS TO CLINICAL MEDICINE.
33 been an accident of frequent occurrence in these cases, when theattacked, simultaneously, with acute rheumatism and with extreme -soft parts were so much compressed; but such did not happen, dyspncea, and a very acute pain in the region of the heart. He arid therefore they afford a very favourable contrast to the cases was bled at the onset, by Mr. Davey, to twenty-four ounces, withdelivered by the forceps in nearly similar circumstances. The out syncope following. The blood was buffed and cupped. At intelligent practitioner would therefore hesitate to expose his pa- present, various joints are swelled, red, and intensely painful; skin tient to the risk of vesico-vaginal fistula, for the mere gratifica- hot; profuse sour sweats; face pale, pinched, and very anxious ; considerable dyspnoea, but not orthopnaea; decubitus dorsal; tion of shortening the severities of labour. We have been reluctantly compelled to dwell longer upon the little or no cough ; sharp pain in the cardiac region, (but less management of this degree of disproportion than we desired. The than it has been,) increased on inspiring deeply; heart’s action difficulty of the question it involves, and the contradictions among very rapid, rather tumultuous; impulse felt over too large a surthe most experienced writers, must be our apology. In the case face, and too strong, but the stroke of the heart is not free and that we are considering, that in which the second stage of labour distinct; dulness on percussion over too great an extent, but is protracted, and the head of the child advancing very slowly, we ceases superiorly at the third rib ; natural sounds of the heart have shown you that there is no increased danger to the mother diminished ; no morbid sound ; pulse very frequent, soft, not very or child by leaving the case to nature in place of delivering by full, slightly jerking; auscultation detects nothing morbid in the the forceps; that if there be any difference in the ratios of mor- lungs anteriorly; posterior surface of the chest not examined. Has tality, it is in favour of non-interference, and rather against the just had a considerable number of leeches over the region of the forceps. We have pointed out, as far as imperfectly detailed heart. Ordered, three grains of calomel every three hours. facts would enable us, that the post-partum accidents of labour Nov. 29th.-I did not see the patient again until to-day. I learnt follow operations with the forceps more frequently than cases from Mr. Davey that his gums had been affected by the calomel; which are left to themselves, and, consequently, the conclusion he had so far improved as to be able to sit up, and his pulse had at which we must arrive, is hostile to the use of that instru- got down to 70 or 80. On the 26th he became worse; had some ment, under the circumstances stated. But recollect, that there is pain in the chest, and considerable dyspncea. On the 28th the mo general rule without an exception, and you will sometimes dyspnoea was extreme, and the pulse 120, and nine leeches were meet with cases so feeble in their habits that they will not endure applied over the region of the heart. At present, face pale ; features sharp and very anxious; slight cough ; no expectoration; a protracted labour without great risk of exhaustion ; you may be called to patients where you dare not temporise, whom you a little pain in the left side; some dyspnoea; lies on his back, with must deliver although the head is making a tardy progress. We the trunk moderately elevated by a bed-chair; impulse of the only ask you to consider these as the exceptions, not often met heart too strong and extended, visible, elevating a considerable with, but still necessary to be studied and understood. It is for extent of the thoracic walls ; a very soft double morbid sound, this reason we have brought before your notice the symptoms of (believed to be a friction sound,) loudest over the body of the exhaustion, and those which precede it; the same desire to direct ventricle, scarcely heard at the apex, and not at all at the top of your attention to the study of individual cases, which may be the sternum or over the neck. Natural sounds feeble over the body exceptions to the general principle we would wish to govern you, of the ventricle, but distinct at the top of the sternum; cardiac leads me to bring before you the varieties, not only in the forma- region rather more prominent than the corresponding part of the tion, but in the resistance of the pelvis, so that you may know right side; dull sound on percussion, too extensive transversely, where an operation might be undertaken and where it cannot be but ceases superiorly at the third rib; pulse 108, very soft, attempted. If we have placed this subject before you with sum" moderately full, rather jerking, and unequal in force.-Lungs: cient clearness, we shall conclude by directing your attention to Dull sound on percussion over a great part of the left lung that opposition in the practice of experienced authorities which behind, and over the lower two-thirds of the lateral surface ; a most has rendered its discussion so necessary. perfect bronchial respiration over the greater part of the lower two-thirds of left side posteriorly; over the middle portion it has quite a tubular character ; it is audible to the very bottom of the chest, but in the lower part has a different character, such as to suggest the notion that it has its seat in tubes of smaller size. No crepitation or other rhonchus; right lung yields a dull sound behind, over the lower third, but much less completely dull than the left; some large crepitation and some bronchial respiration, but this also is much less perfect than on the left side. Vocal vibration much less distinct to the touch on the left side, posteriorly and laterally, (indeed, it is scarcely to be felt at all,) than on the right side. Has still some rheumatism, and considerable sour
CONTRIBUTIONS TO CLINICAL MEDICINE. BY JOHN TAYLOR, M.D., PROFESSOR OF CLINICAL MEDICINE IN UNIVERSITY COLLEGE, AND PHYSICIAN TO UNIVERSITY COLLEGE HOSPITAL, LONDON.
PERICARDITIS.
after living in a new and damp house, began to suffer from rheumatic pains in the limbs,followed, in a fortnight, by a simultaneous attack of acute rheumatism and acute pain in the region of the heart, increased and tumultuous action, 4spneea and anxietysubsequently a double friction-sound over the heart; next, pleura-pneumonia of lower lobe of left lung, and pneumonia of lower third of right lung; strong tubular and diffused bronchial respiration;pleuralfriction-sound;resolution of pneumonia;loud murmur and purring tremor at the apex of the heart; the former extending to the left side and to both infrascapular regions, but not to the upper part of the sternum. Pericarditis curedhypertrophy of the left ventricle and disease e/’ the mitral valve, with enlargement of the liver and spleen,
CASE 4.-A young
man,
remain.
Charles E-,aged twenty-four, of good conformation, middle &bgr;tatnre, sanguine-bilious temperament, a draper, was attacked with acute rheumatism a few days before I first visited him, with Mr.
Davey,
of Great
Nov. 12th, 1842.
Ormond-street, which
was on
Saturday,
My examination of the patient was necessarily at this time a very hurried one, but I ascertained the following particulars :-In consequence of living in a new and damp house, he had been suffering from pains in his limbs for about a fortnight, but was not confined to bed. A few days ago he was
perspirations. Ordered, venesection to ten ounces, to resume
the calomel, and to take a grain of tartarized antimony every three hours. Dec. 4th.-Countenance free from anxiety; no cough, pain in the chest, or dyspnoea; pulse 76 ; respiration audible over a great part of the left lung behind, but less vesicular and more bronchial than natural; friction sound over the lower part ; no rhonchi; very considerable resonance on percussion, but less than on the right side; no crepitation on the right side; impulse of the heart too extended, but not very strong; some morbid sound, but it cannot be determined whether it is a friction or a bellows sound. Blood was much buffed and cupped. Has been taking the medicine regularly, but the mouth is not affected. Has now a blister between the seaputse. April 4th, 1843.-Has had rheumatic pains in the limbs at intervals, since the last report; no pain elsewhere till the beginning of April, when, the weather being cold and damp, he had pains in the arms and chest, but not fixed. Has now occasional chilliness, but generally increased heat of the skin ; has perspired much during the whole illness, and continues to do so; has never regained his strength; is unable to walk far, from feeling exhausted. No headach, but frequent giddiness; this is produced by noise, by walking far, and by going too long without food. Has not regained his usual amount of flesh. Face pale, and free from anxiety; lips florid, but not at all livid; dyspnoea upon any exertion ; no cough or expectoration; no oedema, of the feet, and has never had any. Never feels his heart, except on lying down ; palpitations only after exertion. Physical siges :--Cardiac region rather more prominent than the corresponding part of the right side; impulse visible, elevates the thoracic walls moderately at the apex; on percussion there is a dull sound from the fourth rib down to the liver, and transversely to the extent of two inches and a
34 at the left border of the sternum; a distinct a remarkable degree, all the ordinary characters of those origibellows-murmur with the first sound, loudest at the nating in the mitral, as distinguished from those produced in the apex, loud thence to the left lateral surface of the chest, very dis- aortic valves. The pulse had now lost its jerking character, tinct below the left scapula, and well heard over the lower third partly perhaps because the heart’s action had become calmer, and of the right side, behind and near to the spine; not audible at the partly perhaps from the disease in the mitral valve allowing a base of the heart ; but in this situation a different and very faint portion of the blood to regurgitate at each ventricular systole. murmur is just audible with first sound, and is prolonged into the 5. The slight murmur at the same time heard over the aortic neck. Pulse 96, rather small, soft, and regular, not jerking. valves probably arose from ansemia, for it no longer existed when Lungs.-A clear sound, on percussion, in front and behind, ex- the patient was last examined. cept between the scaputso, where it seems too dull, especially on JMn.—1. When I first saw the patient there was no evidence of the right side; respiration everywhere audible, but feeble compared pulmonic disease. Fourteen days later, when the pericarditis with the clear sound on percussion ; slightly bronchial between the was rapidly disappearing, a distinct acute disease supervened, scapulae, especially on the right side. Over the region of the liver which was clearly pleuro-pneumonia. the resonance is dull as low as the umbilicus, nearly as high as Nov. 29th, three days after the disease began, the condensation the end of the sternum, and as far as the left hypochondrium ; a of all the lower and probably of part of the upper lobe of the clear sound is elicited between the left lobe of the liver and the left lung was most perfect. This was shown by the characters of spleen. In the splenic region it is again dull over too great an the bronchial respiration, which was much stronger and more extent. Appetite bad, and has been so except at the commence- diffused than in pleurisy with serous effusion. About the root ment of his convalescence from the acute attack, when it was of the lung, near the large bronchi, the respiration was quite voracious. Tongue rather furred; bowels confined; urine deposits tubular; at the lowest part of the chest the bronchial respiration a reddish sediment after standing, and has done so during the was diffused, and seemed as if produced in a large number of whole illness. Ordered, iodide of potassium, four grains; iodide small tubes. To the complete solidification of the lung, and imof iron, three grains; infusion of quassia, an ounce and a half. permeability of its vesicular structure, we may perhaps ascribe to be taken three times a day. Also, every night, or every other the total absence of every species of rhonchus, and also of expecnight, to take five grains of a pill, mass composed of equal parts toration. Is the absence of vocal fremitus on the left side to be. of blue pill, compound extract of colocynth, and soap. ascribed to the perfect solidification simply, or to the possible 10th.—Fee)s much better; urine clear; much less pain in the presence of a thin layer of liquid in the pleura in addition? of causes would suffice also to account for the ablimbs; feels stronger; appetite better; bowels open. 24th.-Feels stronger; has more colour; less dyspnoea ; no this time of pleural friction-sound which was heard a pain; appetite good; urine clear. Continue the medicines, in- few days later. There was also inflammation of the right lung,. butto a less extent, and less advanced. creasing the iodide of iron to four grains. 2. Five days from the date of the signs just enumerated a 31st.-Has no pain whatever; has quite regained his strength; can walk any distance without unusual fatigue, and without pain advance had been made towards the restoration of the or palpitations; no perspirations; appetite good; sleeps well; healthy condition of the lungs. On the left side the dulness on has taken no medicine for a fortnight. percussion and bronchial respiration were exceedingly dimiThere is now a slight bulging in the cardiac region, but none nished, and a friction-sound had supervened in the pleura. elsewhere. Resonance, on percussion, equally clear on both however, none of the rhonchus crepitans redux which sides behind, and also in front. Respiratory murmur abundant, is sometimes heard as hepatization disappears. and vesicular behind; less loud in front, but equal on both sides. 3. I did not see the patient again until four months later, when Heart’s impulse too strong, and felt over too large a space. A I found the lungs as resonant as usual, except at one spot, but the murmur with the first sound is heard at the apex only. Dulness respiratory murmur remained feebler than natural. The last on percussion over too large a space in the region of the spleen. time I saw the patient was two months afterwards, (May 31st.) The liver ascends to the lower border of the sixth rib, and The resonance, on percussion, was then quite natural behind and descends considerably below the false ribs. in front. The respiratory murmur was healthy also in the former Remarks.-Among the signs of pericarditis, at first, we may situation, but still rather feeble in the latter. note(.’auses.-1. The rheumatism appears to have been developed 1. The rapid tumultuous action of the heart ; the impulse too under the influence of the continued application of cold and. strong, and felt over too large a space, yet not distinctly defined. moisture. These circumstances gradually produced considerable 2. There was no rubbing sound in the pericardium, and the constitutional changes, which were again the source at once of natural cardiac sounds were diminished; hence I presume there rheumatism and acute pericarditis. The pericarditis must have been some serous effusion. This effusion, however, was not the effect of metastasis, for it began simultaneously with could not have been great, because the dulness on percussion and the two diseases progressed together. acute ceased superiorly at the third rib, and the impulse also continued 2. This case affords another example of the tendency of to be strongly felt. and pleurisy to supervene in the course of rheumatism 3. The pulse was jerking, probably on account of the quick and pericarditis. It seems difficult not to believe that these inflammations also were due to the same constitutional state as the jerking contractions of the left ventricle. 4. The inflammation was active and severe, occurring in a affections of the heart and limbs. That they were propagated subject previously healthy, and the local symptoms, acute pain, from the pericardium by mere contiguity, I think is not probable, dyspncea, pallid, pinched, and anxious countenance, were well for they appeared when the pericarditis was declining, and the marked. part of the left lung most affected (to say nothing of the right The following circumstances likewise deserve to be remarked :- lung) was that farthest from the pericardium. 1. There was no cough, nor any sign of disease in the lungs or 3. The endocarditis, which appeared later, (when is uncertain,) must be referred to the same source. pleurae. 2. Seventeen days after I first saw him there was a soft 4. These considerations serve to show how much these affecdouble friction sound, differing from almost all mitral murmurs, tions are due to constitutional, and how little to mere local, causes in being double, and from aortic valvular murmurs, in not being Under the influence of certain external agencies, the condition of audible over the upper part of the sternum, and in the neck. the whole body (or rather, I conceive, of the blood) becomes About five days later there was a slight morbid sound, probably changed. This change leads to the development of local ina remnant of the above, but not distinguishable, by its quality, flammation in one or more organs, and that either with or withfrom a valvular murmur. The whole duration of the rubbing i out the intervention of any additional or exciting cause. In sound was probably, therefore, about three weeks. such a case, the constitutional state, or, as it is called, predispos3. A comparison of the physical signs of the heart on Nov. ing cause, is everything; the final application of cold, or other 29th, and on the 4th of April succeeding, will show that the exciting cause, when such can be discovered, (which it often space, yielding a dull sound on percussion, was greater at the cannot be,) is comparatively nothing. Without the previous exformer period than at the latter. This may have been due to a istence of the former, the latter would, in ordinary circumstances, moderate amount of serous effusion, which in that case co-existed prove inoperative. The same observations, I suspect, are, in a with a double friction-sound, or to the pericarditis producing a considerable degree, applicable to the greater part of internal intemporary increase in the bulk of the heart, perhaps by sangui- flammations. The constitutional state, whose existence for the The former was pro- present has been rather assumed than proved, continued in this neous engorgement of its muscular tissue. case for a considerable period of time, for some weeks in a high bably the chief cause. 4. At the examination made April 4th, 1843, I first found evidegree, and to a less degree for months, as was shown by the dence of valvular disease, and consequently of the previous ex- symptoms detailed. (Vide infra.) It is most important, then, to istence of endocarditis. This inflammation arose and pro- combat this by all the means in our power, and most important gressed insidiously, as it frequently does: it was marked by no likewise to avoid exposure to all exciting causes of disease whilst severe pain or other local symptom. The murmur possessed, in this state persists.
half, beginning
prolonged
,
Either these sence at very great
There was,
the acute the
rheumatism, pneumonia
35 Treatment.-l. The pericarditis and acute rheumatism were snbdued by one free bleeding, and by the exhibition of calomel, so as to affect the mouth. The patient might be considered convalescent from both affections in from fourteen to eighteen days. 2. The pleuro-pneumonia yielded with unusual rapidity to one free application of leeches, and one venesection to the amount of ten ounces, and to the free administration of tartarized antimony and calomel. All these measures were had recourse to on the third day of the attack, and consequently within the period to which the power of venesection to shorten the duration of pneumonia has been proved by M. Louis to be chiefly or altogether limited.* A blister was subsequently applied. Ptyalism was not produced. The patient was again convalescent in nine days. 3. Four months later, no acute inflammation remained, but the general health continued to suffer much. The patient was pallid, thin, weak, and giddy ; the appetite was bad, and the tongue furred; the perspiration continued to be abundant; the urine still deposited a reddish sediment, and the rheumatic pains continued to recur. It was now, therefore, of consequence to remove this condition. For this purpose the patient was ordered quassia, steel, and iodide of potassium. This treatment was continued for about six weeks, during the whole of which time there was a progressive and rapid improvement, and at the end of it the patient appeared in very good health, and equal to any ordinary exertion. There remain, however, some permanent disease of the mitral valve, and, the usual legacy of cardiac inflammations, some hypertrophy of the left ventricle, besides enlargement of the liver
tive examination of the causes, the symptoms, and the progress of insanity does not enable us to recognise the characters of insanity in acute or chronic inflammation of the brain. Children and young people are very frequently attacked with inflammatory affections of the brain, but are not insane. Insanity is nearly exclusively experienced by persons of a nervous, irritable temperament. The lesions of the intellect do not require for their manifestation, inflammation, softening, hardening, or any other material lesion. Hereditary predisposition, a bad education, moral commotions, alone sufiice to give rise to them. M. RocHoux was ready to admit that it is impossible to attribute insanity to acute or chronic meningo-cerebritis; but, on the other side, he could not allow that lesions of the intellect could take place without a material alteration of the brain. There was no eft’ect without cause. Insanity must depend on a lesion of the brain, or of the mind, and no one had ever attempted to establish the existence of diseases of the mind distinct from the brain. Every functional disturbance presupposes the disturbTo assert that a lesion of the ance of the corresponding organ. functions of the mind can exist independently of a lesion of the brain, is to assert that the same sounds may be obtained from a violin, whether the strings are tight or slack. The views of M. Belhomme, thus supported by M. Rochoux, were also defended by M. Ferrers in an animated discussion, whilst MM. Gerdy, Prus, and Castell, joined with M. Jolly in strenuously denying the possibility of connecting functional disorders of the brain with material lesions.
and spleen.
FISTULA OF THE URETHRA CURED BY AUTOPLASTY.
M. JOBERT has again succeeded in curing by autoplasty an urethral fistula. The fistula was situated at the root of the penis, FOREIGN DEPARTMENT. in front of the scrotum, was two centimetres and a half in length, and the result of retention of urine. Two unsuccessful attempts ACADEMIE DE MEDICINE, PARIS. were made, which M. Jobert attributed to the patient’s labouring under chronic syphilis. He was treated for this disease, and then (MARCH, APRIL, MAY, JUNE.) he proceeded to operate as follows :-After refreshing the margin AUTOPLASTIC OPERATIONS IN CANCEROUS DISEASE. of the solution of and excising the skin around the M. BLANDIN presented to the Academy a woman on whom he fistulous orifice to acontinuity, width of several lines, two incisions, parallel had extirpated an inferior eyelid affected with cancer. The loss to the axis of the penis, were made on a level with the inferior of substance thus occasioned was then remedied by a flap taken orifice of the fistula, and prolonged on to the scrotum, so as to from the forehead. This operation he considered calculated a cutaneous flap as wide as the denuded surfaces on each to prevent the return of the cancerous disease. The operation comprise side the fistula. This flap was then dissected off, dragged up, was successful. The views of M. Blandin, with reference to on the fistulous orifice and the denuded surfaces, and carethe influence exercised by autoplasty in preventing the return of applied fully attached by means of interrupted sutures to the surrounding cancer, were supported by M. Roux and M. Berard. A sound of middle caliber had been previously placed in M. GERDY stated that he was not a great friend to autoplastic parts. the urethra, and slight compression was exercised on the flap, in operations, the result of which was seldom or ever satisfactory. order to maintain it in its place. The adhesion was complete in In the case of M. Blandin, he thought the operation would have the five-sixths of the extent of the fistula. There remained, howbeen more successful if the flap had been taken from the cheek. a small lateral orifice, which gave considerable trouble. ever, that the healthy flap would so modify the The twisted suture was resorted to He did not believe several times, the edges parts as to prevent the return of the cancerous affection. CancerI having been freshened with the bistoury, but without success. returns either from some of the tissues affected having been left This method of treatment, followed by cauterization with the in the wound, or in virtue of a general predisposition, the essential nitrate of at length successful, and the fistula became silver, proved nature of which is unknown, and which autoplasty does not completely cicatrized.
remedy.
RELATION BETWEEN THE EXTENT OF THE BRAIN AND
ON THE CAUSES OF INSANITY.
THE INTELLECT. communication addressed to the Academy, M. BAILLARGER, in a paper ’on the above subject, states that endeavoured to prove that insanity is always, and necessarily, connected with acute or chronic phlegmasia of the brain, or of its he has been able to unfold the cerebral substance by a process membranes. Chronic encephalitis, characterized by the harden- different from that of Gall. He takes away gradually, and by a and minute dissection, all the white substance, and when ing of the cephalic substance, coincides with chronic insanity, long and with dementia, accompanied by paralysis, whilst acute in- the brain has been thus reduced to a very slight thickness, the flammation, with softening, gives rise to acute insanity, or to peripheric membrane developes itself as it were. Operating as mania with delirium. M. Belhomme supported his views by we have stated, he has been able to model with plaster the fifteen cases. The report of the lecture of M. Jolly, who was extended hemisphere, and to take its exact measure. For the of man, M. Baillarger has found a medium of one thousand Appointed by the Academy to examine the communication, gave brain seven hundred square centimetres. The measure of the extent rise to an interesting discussion. M. JoLLY maintained that the opinions of M. Belhomme were of the surface of the brain has been obtained in the same way. If we now pass to the physiological application of these inadmissible. It is possible, he stated, that physical and moral similitudes in families, or individual organization, may constitute researches, we find, in contradistinction to what has been the morbid hereditary predisposition so frequently observed in advanced, that the development of the intellect is not at all in It is also possible that anomalies in the in- relation to the extent of the brain, for the brain of dogs is smaller nervous diseases. tellectual functions may depend on some accidental molecular than that of sheep. Even in taking into consideration their modification of the cerebral fibre. Butwe are not warranted, relative size, the brain of the rabbit is found to present twice and a half as large a surface as that of man, who in this respect is at the on that account, in asserting, in the present state of science, that material lesions-lesions of texture-are necessary to produce bottom of the scale. In order for it to be otherwise, it would be reinsanity. We are not sufficiently acquainted with the normal quisite for the circonvolutions to be both more numerous and deeper. ’conditions of the intimate organization of the brain, to appreciate The brain follows this mathematical law: the volume is as the the modifications which may correspond to anomalies of motion, cubes of the diameter, whilst the surfaces are as the squares of :of sensation, of intellect. Microscopical anatomy may some day these same diameters. Thence it follows that the most volu.show us the connexion between the structure of the brain and minous brains have, relatively, a very small surface. The cereBthe acts of the mind; but until this is accomplished, fare not bellum alone, by the extent of its surface, can bear comparison .authorized to do more than simply to observe facts. The atten- with the brain of the inferior mammalia. Thus the development of the intellect, far from being in direct proportion to the relative extent of the surface of the brain, appears rather to be in an * Recherches sur les Effets de lair Indans Maladies Saignée quelques inverse proportion. Paris, 1835. :tlammatoires, &c.
M. BELHOMME, in
a
,
.
CONTRIBUTIONS TO CLINICAL MEDICINE. BY JOHN TAYLOR, M.D., PROFESSOR OF CLINICAL MEDICINE IN UNIVERSITY COLLEGE, AND PHYSICIAN TO UNIVERSITY COLLEGE HOSPITAL, LONDON.
PERICARDITIS.
after living in a new and damp house, began to suffer from rheumatic pains in the limbs,followed, in a fortnight, by a simultaneous attack of acute rheumatism and acute pain in the region of the heart, increased and tumultuous action, 4spneea and anxietysubsequently a double friction-sound over the heart; next, pleura-pneumonia of lower lobe of left lung, and pneumonia of lower third of right lung; strong tubular and diffused bronchial respiration;pleuralfriction-sound;resolution of pneumonia;loud murmur and purring tremor at the apex of the heart; the former extending to the left side and to both infrascapular regions, but not to the upper part of the sternum. Pericarditis curedhypertrophy of the left ventricle and disease e/’ the mitral valve, with enlargement of the liver and spleen,
CASE 4.-A young
man,
remain.
Charles E-,aged twenty-four, of good conformation, middle &bgr;tatnre, sanguine-bilious temperament, a draper, was attacked with acute rheumatism a few days before I first visited him, with Mr.
Davey,
of Great
Nov. 12th, 1842.
Ormond-street, which
was on
Saturday,
My examination of the patient was necessarily at this time a very hurried one, but I ascertained the following particulars :-In consequence of living in a new and damp house, he had been suffering from pains in his limbs for about a fortnight, but was not confined to bed. A few days ago he was
perspirations. Ordered, venesection to ten ounces, to resume
the calomel, and to take a grain of tartarized antimony every three hours. Dec. 4th.-Countenance free from anxiety; no cough, pain in the chest, or dyspnoea; pulse 76 ; respiration audible over a great part of the left lung behind, but less vesicular and more bronchial than natural; friction sound over the lower part ; no rhonchi; very considerable resonance on percussion, but less than on the right side; no crepitation on the right side; impulse of the heart too extended, but not very strong; some morbid sound, but it cannot be determined whether it is a friction or a bellows sound. Blood was much buffed and cupped. Has been taking the medicine regularly, but the mouth is not affected. Has now a blister between the seaputse. April 4th, 1843.-Has had rheumatic pains in the limbs at intervals, since the last report; no pain elsewhere till the beginning of April, when, the weather being cold and damp, he had pains in the arms and chest, but not fixed. Has now occasional chilliness, but generally increased heat of the skin ; has perspired much during the whole illness, and continues to do so; has never regained his strength; is unable to walk far, from feeling exhausted. No headach, but frequent giddiness; this is produced by noise, by walking far, and by going too long without food. Has not regained his usual amount of flesh. Face pale, and free from anxiety; lips florid, but not at all livid; dyspnoea upon any exertion ; no cough or expectoration; no oedema, of the feet, and has never had any. Never feels his heart, except on lying down ; palpitations only after exertion. Physical siges :--Cardiac region rather more prominent than the corresponding part of the right side; impulse visible, elevates the thoracic walls moderately at the apex; on percussion there is a dull sound from the fourth rib down to the liver, and transversely to the extent of two inches and a
34 at the left border of the sternum; a distinct a remarkable degree, all the ordinary characters of those origibellows-murmur with the first sound, loudest at the nating in the mitral, as distinguished from those produced in the apex, loud thence to the left lateral surface of the chest, very dis- aortic valves. The pulse had now lost its jerking character, tinct below the left scapula, and well heard over the lower third partly perhaps because the heart’s action had become calmer, and of the right side, behind and near to the spine; not audible at the partly perhaps from the disease in the mitral valve allowing a base of the heart ; but in this situation a different and very faint portion of the blood to regurgitate at each ventricular systole. murmur is just audible with first sound, and is prolonged into the 5. The slight murmur at the same time heard over the aortic neck. Pulse 96, rather small, soft, and regular, not jerking. valves probably arose from ansemia, for it no longer existed when Lungs.-A clear sound, on percussion, in front and behind, ex- the patient was last examined. cept between the scaputso, where it seems too dull, especially on JMn.—1. When I first saw the patient there was no evidence of the right side; respiration everywhere audible, but feeble compared pulmonic disease. Fourteen days later, when the pericarditis with the clear sound on percussion ; slightly bronchial between the was rapidly disappearing, a distinct acute disease supervened, scapulae, especially on the right side. Over the region of the liver which was clearly pleuro-pneumonia. the resonance is dull as low as the umbilicus, nearly as high as Nov. 29th, three days after the disease began, the condensation the end of the sternum, and as far as the left hypochondrium ; a of all the lower and probably of part of the upper lobe of the clear sound is elicited between the left lobe of the liver and the left lung was most perfect. This was shown by the characters of spleen. In the splenic region it is again dull over too great an the bronchial respiration, which was much stronger and more extent. Appetite bad, and has been so except at the commence- diffused than in pleurisy with serous effusion. About the root ment of his convalescence from the acute attack, when it was of the lung, near the large bronchi, the respiration was quite voracious. Tongue rather furred; bowels confined; urine deposits tubular; at the lowest part of the chest the bronchial respiration a reddish sediment after standing, and has done so during the was diffused, and seemed as if produced in a large number of whole illness. Ordered, iodide of potassium, four grains; iodide small tubes. To the complete solidification of the lung, and imof iron, three grains; infusion of quassia, an ounce and a half. permeability of its vesicular structure, we may perhaps ascribe to be taken three times a day. Also, every night, or every other the total absence of every species of rhonchus, and also of expecnight, to take five grains of a pill, mass composed of equal parts toration. Is the absence of vocal fremitus on the left side to be. of blue pill, compound extract of colocynth, and soap. ascribed to the perfect solidification simply, or to the possible 10th.—Fee)s much better; urine clear; much less pain in the presence of a thin layer of liquid in the pleura in addition? of causes would suffice also to account for the ablimbs; feels stronger; appetite better; bowels open. 24th.-Feels stronger; has more colour; less dyspnoea ; no this time of pleural friction-sound which was heard a pain; appetite good; urine clear. Continue the medicines, in- few days later. There was also inflammation of the right lung,. butto a less extent, and less advanced. creasing the iodide of iron to four grains. 2. Five days from the date of the signs just enumerated a 31st.-Has no pain whatever; has quite regained his strength; can walk any distance without unusual fatigue, and without pain advance had been made towards the restoration of the or palpitations; no perspirations; appetite good; sleeps well; healthy condition of the lungs. On the left side the dulness on has taken no medicine for a fortnight. percussion and bronchial respiration were exceedingly dimiThere is now a slight bulging in the cardiac region, but none nished, and a friction-sound had supervened in the pleura. elsewhere. Resonance, on percussion, equally clear on both however, none of the rhonchus crepitans redux which sides behind, and also in front. Respiratory murmur abundant, is sometimes heard as hepatization disappears. and vesicular behind; less loud in front, but equal on both sides. 3. I did not see the patient again until four months later, when Heart’s impulse too strong, and felt over too large a space. A I found the lungs as resonant as usual, except at one spot, but the murmur with the first sound is heard at the apex only. Dulness respiratory murmur remained feebler than natural. The last on percussion over too large a space in the region of the spleen. time I saw the patient was two months afterwards, (May 31st.) The liver ascends to the lower border of the sixth rib, and The resonance, on percussion, was then quite natural behind and descends considerably below the false ribs. in front. The respiratory murmur was healthy also in the former Remarks.-Among the signs of pericarditis, at first, we may situation, but still rather feeble in the latter. note(.’auses.-1. The rheumatism appears to have been developed 1. The rapid tumultuous action of the heart ; the impulse too under the influence of the continued application of cold and. strong, and felt over too large a space, yet not distinctly defined. moisture. These circumstances gradually produced considerable 2. There was no rubbing sound in the pericardium, and the constitutional changes, which were again the source at once of natural cardiac sounds were diminished; hence I presume there rheumatism and acute pericarditis. The pericarditis must have been some serous effusion. This effusion, however, was not the effect of metastasis, for it began simultaneously with could not have been great, because the dulness on percussion and the two diseases progressed together. acute ceased superiorly at the third rib, and the impulse also continued 2. This case affords another example of the tendency of to be strongly felt. and pleurisy to supervene in the course of rheumatism 3. The pulse was jerking, probably on account of the quick and pericarditis. It seems difficult not to believe that these inflammations also were due to the same constitutional state as the jerking contractions of the left ventricle. 4. The inflammation was active and severe, occurring in a affections of the heart and limbs. That they were propagated subject previously healthy, and the local symptoms, acute pain, from the pericardium by mere contiguity, I think is not probable, dyspncea, pallid, pinched, and anxious countenance, were well for they appeared when the pericarditis was declining, and the marked. part of the left lung most affected (to say nothing of the right The following circumstances likewise deserve to be remarked :- lung) was that farthest from the pericardium. 1. There was no cough, nor any sign of disease in the lungs or 3. The endocarditis, which appeared later, (when is uncertain,) must be referred to the same source. pleurae. 2. Seventeen days after I first saw him there was a soft 4. These considerations serve to show how much these affecdouble friction sound, differing from almost all mitral murmurs, tions are due to constitutional, and how little to mere local, causes in being double, and from aortic valvular murmurs, in not being Under the influence of certain external agencies, the condition of audible over the upper part of the sternum, and in the neck. the whole body (or rather, I conceive, of the blood) becomes About five days later there was a slight morbid sound, probably changed. This change leads to the development of local ina remnant of the above, but not distinguishable, by its quality, flammation in one or more organs, and that either with or withfrom a valvular murmur. The whole duration of the rubbing i out the intervention of any additional or exciting cause. In sound was probably, therefore, about three weeks. such a case, the constitutional state, or, as it is called, predispos3. A comparison of the physical signs of the heart on Nov. ing cause, is everything; the final application of cold, or other 29th, and on the 4th of April succeeding, will show that the exciting cause, when such can be discovered, (which it often space, yielding a dull sound on percussion, was greater at the cannot be,) is comparatively nothing. Without the previous exformer period than at the latter. This may have been due to a istence of the former, the latter would, in ordinary circumstances, moderate amount of serous effusion, which in that case co-existed prove inoperative. The same observations, I suspect, are, in a with a double friction-sound, or to the pericarditis producing a considerable degree, applicable to the greater part of internal intemporary increase in the bulk of the heart, perhaps by sangui- flammations. The constitutional state, whose existence for the The former was pro- present has been rather assumed than proved, continued in this neous engorgement of its muscular tissue. case for a considerable period of time, for some weeks in a high bably the chief cause. 4. At the examination made April 4th, 1843, I first found evidegree, and to a less degree for months, as was shown by the dence of valvular disease, and consequently of the previous ex- symptoms detailed. (Vide infra.) It is most important, then, to istence of endocarditis. This inflammation arose and pro- combat this by all the means in our power, and most important gressed insidiously, as it frequently does: it was marked by no likewise to avoid exposure to all exciting causes of disease whilst severe pain or other local symptom. The murmur possessed, in this state persists.
half, beginning
prolonged
,
Either these sence at very great
There was,
the acute the
rheumatism, pneumonia
35 Treatment.-l. The pericarditis and acute rheumatism were snbdued by one free bleeding, and by the exhibition of calomel, so as to affect the mouth. The patient might be considered convalescent from both affections in from fourteen to eighteen days. 2. The pleuro-pneumonia yielded with unusual rapidity to one free application of leeches, and one venesection to the amount of ten ounces, and to the free administration of tartarized antimony and calomel. All these measures were had recourse to on the third day of the attack, and consequently within the period to which the power of venesection to shorten the duration of pneumonia has been proved by M. Louis to be chiefly or altogether limited.* A blister was subsequently applied. Ptyalism was not produced. The patient was again convalescent in nine days. 3. Four months later, no acute inflammation remained, but the general health continued to suffer much. The patient was pallid, thin, weak, and giddy ; the appetite was bad, and the tongue furred; the perspiration continued to be abundant; the urine still deposited a reddish sediment, and the rheumatic pains continued to recur. It was now, therefore, of consequence to remove this condition. For this purpose the patient was ordered quassia, steel, and iodide of potassium. This treatment was continued for about six weeks, during the whole of which time there was a progressive and rapid improvement, and at the end of it the patient appeared in very good health, and equal to any ordinary exertion. There remain, however, some permanent disease of the mitral valve, and, the usual legacy of cardiac inflammations, some hypertrophy of the left ventricle, besides enlargement of the liver
tive examination of the causes, the symptoms, and the progress of insanity does not enable us to recognise the characters of insanity in acute or chronic inflammation of the brain. Children and young people are very frequently attacked with inflammatory affections of the brain, but are not insane. Insanity is nearly exclusively experienced by persons of a nervous, irritable temperament. The lesions of the intellect do not require for their manifestation, inflammation, softening, hardening, or any other material lesion. Hereditary predisposition, a bad education, moral commotions, alone sufiice to give rise to them. M. RocHoux was ready to admit that it is impossible to attribute insanity to acute or chronic meningo-cerebritis; but, on the other side, he could not allow that lesions of the intellect could take place without a material alteration of the brain. There was no eft’ect without cause. Insanity must depend on a lesion of the brain, or of the mind, and no one had ever attempted to establish the existence of diseases of the mind distinct from the brain. Every functional disturbance presupposes the disturbTo assert that a lesion of the ance of the corresponding organ. functions of the mind can exist independently of a lesion of the brain, is to assert that the same sounds may be obtained from a violin, whether the strings are tight or slack. The views of M. Belhomme, thus supported by M. Rochoux, were also defended by M. Ferrers in an animated discussion, whilst MM. Gerdy, Prus, and Castell, joined with M. Jolly in strenuously denying the possibility of connecting functional disorders of the brain with material lesions.
and spleen.
FISTULA OF THE URETHRA CURED BY AUTOPLASTY.
M. JOBERT has again succeeded in curing by autoplasty an urethral fistula. The fistula was situated at the root of the penis, FOREIGN DEPARTMENT. in front of the scrotum, was two centimetres and a half in length, and the result of retention of urine. Two unsuccessful attempts ACADEMIE DE MEDICINE, PARIS. were made, which M. Jobert attributed to the patient’s labouring under chronic syphilis. He was treated for this disease, and then (MARCH, APRIL, MAY, JUNE.) he proceeded to operate as follows :-After refreshing the margin AUTOPLASTIC OPERATIONS IN CANCEROUS DISEASE. of the solution of and excising the skin around the M. BLANDIN presented to the Academy a woman on whom he fistulous orifice to acontinuity, width of several lines, two incisions, parallel had extirpated an inferior eyelid affected with cancer. The loss to the axis of the penis, were made on a level with the inferior of substance thus occasioned was then remedied by a flap taken orifice of the fistula, and prolonged on to the scrotum, so as to from the forehead. This operation he considered calculated a cutaneous flap as wide as the denuded surfaces on each to prevent the return of the cancerous disease. The operation comprise side the fistula. This flap was then dissected off, dragged up, was successful. The views of M. Blandin, with reference to on the fistulous orifice and the denuded surfaces, and carethe influence exercised by autoplasty in preventing the return of applied fully attached by means of interrupted sutures to the surrounding cancer, were supported by M. Roux and M. Berard. A sound of middle caliber had been previously placed in M. GERDY stated that he was not a great friend to autoplastic parts. the urethra, and slight compression was exercised on the flap, in operations, the result of which was seldom or ever satisfactory. order to maintain it in its place. The adhesion was complete in In the case of M. Blandin, he thought the operation would have the five-sixths of the extent of the fistula. There remained, howbeen more successful if the flap had been taken from the cheek. a small lateral orifice, which gave considerable trouble. ever, that the healthy flap would so modify the The twisted suture was resorted to He did not believe several times, the edges parts as to prevent the return of the cancerous affection. CancerI having been freshened with the bistoury, but without success. returns either from some of the tissues affected having been left This method of treatment, followed by cauterization with the in the wound, or in virtue of a general predisposition, the essential nitrate of at length successful, and the fistula became silver, proved nature of which is unknown, and which autoplasty does not completely cicatrized.
remedy.
RELATION BETWEEN THE EXTENT OF THE BRAIN AND
ON THE CAUSES OF INSANITY.
THE INTELLECT. communication addressed to the Academy, M. BAILLARGER, in a paper ’on the above subject, states that endeavoured to prove that insanity is always, and necessarily, connected with acute or chronic phlegmasia of the brain, or of its he has been able to unfold the cerebral substance by a process membranes. Chronic encephalitis, characterized by the harden- different from that of Gall. He takes away gradually, and by a and minute dissection, all the white substance, and when ing of the cephalic substance, coincides with chronic insanity, long and with dementia, accompanied by paralysis, whilst acute in- the brain has been thus reduced to a very slight thickness, the flammation, with softening, gives rise to acute insanity, or to peripheric membrane developes itself as it were. Operating as mania with delirium. M. Belhomme supported his views by we have stated, he has been able to model with plaster the fifteen cases. The report of the lecture of M. Jolly, who was extended hemisphere, and to take its exact measure. For the of man, M. Baillarger has found a medium of one thousand Appointed by the Academy to examine the communication, gave brain seven hundred square centimetres. The measure of the extent rise to an interesting discussion. M. JoLLY maintained that the opinions of M. Belhomme were of the surface of the brain has been obtained in the same way. If we now pass to the physiological application of these inadmissible. It is possible, he stated, that physical and moral similitudes in families, or individual organization, may constitute researches, we find, in contradistinction to what has been the morbid hereditary predisposition so frequently observed in advanced, that the development of the intellect is not at all in It is also possible that anomalies in the in- relation to the extent of the brain, for the brain of dogs is smaller nervous diseases. tellectual functions may depend on some accidental molecular than that of sheep. Even in taking into consideration their modification of the cerebral fibre. Butwe are not warranted, relative size, the brain of the rabbit is found to present twice and a half as large a surface as that of man, who in this respect is at the on that account, in asserting, in the present state of science, that material lesions-lesions of texture-are necessary to produce bottom of the scale. In order for it to be otherwise, it would be reinsanity. We are not sufficiently acquainted with the normal quisite for the circonvolutions to be both more numerous and deeper. ’conditions of the intimate organization of the brain, to appreciate The brain follows this mathematical law: the volume is as the the modifications which may correspond to anomalies of motion, cubes of the diameter, whilst the surfaces are as the squares of :of sensation, of intellect. Microscopical anatomy may some day these same diameters. Thence it follows that the most volu.show us the connexion between the structure of the brain and minous brains have, relatively, a very small surface. The cereBthe acts of the mind; but until this is accomplished, fare not bellum alone, by the extent of its surface, can bear comparison .authorized to do more than simply to observe facts. The atten- with the brain of the inferior mammalia. Thus the development of the intellect, far from being in direct proportion to the relative extent of the surface of the brain, appears rather to be in an * Recherches sur les Effets de lair Indans Maladies Saignée quelques inverse proportion. Paris, 1835. :tlammatoires, &c.
M. BELHOMME, in
a
,
.