« 이전계속 »
His mother states that the bodies expectorated have always the form of a trunk and branches, and they are generally an inch and a half long. They have a white colour, and he has never brought up any blood with them. His voice has never been affected, but he is habitually short breathed. He was directed to take an expectorant and anodyne mixture, containing small doses of the potassiotartrate of antimony, ipecacuanha wine, and compound tincture of camphor, with an alterative of hydrarg, c. cretâ, soda, and rhubarb.
April 3.—He has continued to expectorate the membranous bodies every second or third day; sometimes they are brought
Fig. 1. up with a cough ; at others, they rise in the throat and are expelled with a feeling of sickness, either by the mouth or through the nostrils. He has brought up a considerable mass about two hours ago, portions of which are here figured. They have the usual form; the largest piece (fig. 1) is about two inches in length, the trunk is as thick as a writing-quill, and the subdivisions decrease in size till they become very minute. His mother thinks the masses grow larger; of various portions which I have seen, all have been unmixed with other secretions, and free from any appearance of blood. Upon the whole, his general health continues much as before, but his mother thinks that he is losing flesh. The left side of the chest is altogether somewhat less resonant than the right, and the difference is most marked at the left supra-scapular region. A slight irregular subcrepitant rhonchus is heard in every part, but is most distinct at the upper portions, and especially at the left side posteriorly. When last examined, a distinct valvular clicking sound was heard in the left supra-scapular region, but this does not now exist. He was directed to take the oleum jecoris with quinine and iron, and an anodyne and expectorant. From this time he gradually improved, and was dismissed cured July 17th.
The case which I have related will be observed to belong to the chronic form of the disease, the patient hav.
Fir, 3. ing had several attacks before that in which he fell under my notice. Like many of the similar cases, he was a very delicate person, and inherited a predisposition to pulmonary disease. The inflammatory symptoms had probably never been very severe, and had already nearly subsided. The casts appear to have been at first moulded in the smaller bronchial tubes of the upper lobe of the left lung, but, as the disease advanced, the fibrin was either effused from the original seat of disease, in larger quantity, or the disease itself extended, so that the masses expectorated had the form of the main bronchus of that lobe. When first ex
pelled, the solid matter formed oblong or rounded bodies, about the size of a filbert, and these, when macerated for a short time in water, gradually unfolded themselves, till their peculiar branched form became apparent; but for the complete separation and exposure of the smaller divisions, much careful manipulation was required. The largest pieces expectorated had an extreme length of about three inches, and at the trunk were three to four lines in diameter. In some I was able to trace ten distinct subdivisions, and the terminal portions were most minute, as in those represented in figs. 2 and 3. Two or three masses were generally expectorated on the same day, or within two or three days, and he then usually did not bring up any more for a period of a week or ten days; but, occasionally, they were expelled more frequently, and in a day he once expectorated not less than seventeen pieces. When first observed, the membranous material was only expelled after a severe fit of coughing, but latterly they were brought up with little effort. The physical signs which were observed in the case were those of slight capillary bronchitis, with obstruction in the tubes of the upper part of the left lung, and consolidation of the corresponding pulmonary substance. There was slight sibilant rhonchus, with more or less crepitation, heard in different parts of the chest; some dulness on percussion at the upper part of the left side, especially posteriorly; and slight bronchial respiration, with mucous sounds, occasionally having the clicking or valvular character, more frequently the usual subcrepitation, in the same regions.
Dr Peacock, from extensive literary research, observes, that ist, The plastic bronchitis, bronchite pseudo-membraneuse, or bronchitis crouposa, as the disease has been termed by different modern writers, is of more frequent occurrence in males than in females. 2d, While the affection is not limited to any period of life, but occurs both in the young, in persons of middle age, and in the old, it is most frequent between the ages of 20 and 50. 3d, It may attack persons who have enjoyed robust health, but generally occurs in those who have been previ. ously suffering from some chronic pulmonary disease, or who have been exhausted
by other debilitating causes. 4th, The affection is characterised by the ordinary • phenomena of bronchitis, aggravated, however, by the difficulty in expectorating
the solid material ; and it may either be acute, rapidly terminating in recovery or in death; or chronic, the peculiar sputa continuing to be expectorated, at longer or shorter intervals, for weeks, months, or even years; or it may repeatedly occur on any exacerbation of the bronchitic symptoms. 5th, Hæmoptysis, at least to any considerable extent, is by no means a frequent or even a common symptom; but, on the contrary, the membranous material is most generally expectorated, either almost alone, or mixed with the ordinary bronchitic sputa, usually with the white, glairy, adhesive mucus which first occurs during a bronchitic attack. 6th, The membranous material is most generally of a dull white colour; more rarely of a brownish hue, or slightly discoloured by blood. Chemically and microscopically, it presents the usual characters of fibrin. In form, it may either be moulded into the shape of a bronchial tube and its ramifications, or it may constitute a thin shred of membrane. When assuming the branched or dendritic form, it may be hollow or solid, and is found to be comprised of a number of delicate laminæ, arranged concentrically. The trunk of the branched cast generally has a diameter of from one line to two or three lines, or varies from the size of a small crow-quill to that of a large goose-quill. The branches subdivide till they become very minute. It would thus appear, that the casts are generally moulded in bronchial tubes of the third or fourth size ; but cases are recorded in which the masses expectorated had a much larger diameter, and in which, after death, the main bronchi have been found obstructed; and others in which the false membrane extended from the smallest tubes to the trachea. 7th, The ultimate result of cases of fibrinous expectoration depends upon the circumstances under which the formation of the solid matter took place. When, as is not unfrequently the case, the membranous effusion occurs as a complication of phthisis, or of some other fatal disease, it necessarily follows the course, and may but little affect the result of that disease. When, on the contrary, it is
an idiopathic and acute affection, though the symptoms by which it is attended are ordinarily urgent and alarming, it usually soon subsides, under appropriate treatment, and the patient quickly regains his usual health. In other cases, however, the acute symptoms may subside, but the false membrane may continue to be formed, at intervals, for a long period.-Medical Times and Gazette, DR PEDDIE ON THE SUPPOSED EFFECTS OF THE SUSPENSION OF ACCUSTOMED
STIMULANTS IN THE PRODUCTION OF DELIRIUM TREMENS. In order to obtain some additional evidence on this disputed point, I submitted some queries to Drs Simson and Gibson, the medical officers of the large prison establishments of this city and of Glasgow, and to Mr Page and Dr Scott, surgeons to the county gaols of Carlisle and Dumfries; and the following information has been kindly furnished by them, as to the effect of the sudden withdrawal of all stimulants from civil and criminal prisoners known or presumed to be of intemperate habits, and the immediate substitution of prison fare, which is well known not to be of the most generous description.
As regards the prison of Carlisle, it appears that, although the annual number of commitments during the last fifteen years has been about 600; and that, although three-fourths of these are considered to have been, in one way or another, the consequence of drunkenness, Mr Page states emphatically he has never yet seen any ill “ result from the sudden abstraction of stimulants from habitual drunkards, who had been drinking to excess up to the time of being placed on prison fare." Mr Page had also, during nine years' experience in connection with the Carlisle County Pauper Lunatic Asylum, observed the same impunity with which all stimulants could be at once withdrawn. (Letters, 9th and 21st June 1854.)
Of the gaol of Dumfries, it is stated by Dr Scott (Letters, 12th and 21st June 1854) that, during the last fifteen years, the number of civil and criminal prisoners have amounted to 5539; that of this number he supposes about two-thirds were committed for crimes resulting from intemperate habits; that he believes a very large number to have been habitual drunkards; and that, although all of these, of course, were deprived of their usual libations, and at once put on prison allowance, only five cases of delirium tremens are found on the register of disease, and that all of these patients but one were admitted to the prison with the disease on them ; and that in regard to that one, although entered as under de lirium tremens on the day after admission, there is every probability for believing that she had had the disease on her when admitted, although not reported to be ill. Dr Scott also notices, as an important fact, that during the time the railways were being constructed in the county of Dumfries, a very large number of navvies were committed to prison, who had led a very dissipated life for many months, and although deprived of liquor from the moment of apprehension, not a single case of delirium tremens occurred.
Then, as regards the prison of Glasgow, in which the annual commitments amount to upwards of 4000, the experience of the year 1850 is adduced by Dr Gibson (Letter of 16th June 1854), as affording an approximation to the facts wished to be elicited. A calculation made in that year showed that, while 4122 were imprisoned, the number of assaults, with few exceptions, committed under the influence of liquor, and “the drunk and disorderly," amounted to 1519; and of this number only three cases of delirium tremens occurred-a very small proportion indeed, especially when it is considered that the debtors, who are almost all habitual drunkards, and drinking up to the moment of incarceration, are not included in this list. Many hundreds more, therefore, may be considered to have belonged to the drunken population of the gaol. The average of the last ten years, however, is greater (5:7), there having been fifty-seven cases altogether during that period, but, after all, this is a very small proportion to the number of dissipated and drunken characters gathered together there, and at once broken ofl' from intemperate habits. Dr Gibson, however, states that he does not altogether enter into my views as to the proximate cause of delirium tremens, although he admits that "it does not so frequently occur as the advocates of the theory, which attributes it to the total withdrawal of accustomed stimuli, such as Blake and others are inclined to suppose;" and he mentions, in proof of his objection, that he had never seen it occur in less than twenty-four or beyond seventy-two hours after apprehension, which necessarily put a stop to dramdrinking. As I have already explained, however, and as the cases given at the conclusion of this paper will show, there is always, whether the individual is drinking much or little, more or less of a premonitory stage present in this affec. tion, distinguished by digestive derangement, nervous irritability, restlessness, and sleeplessness, before much tremor is displayed, or any illusions manifested ; and it is easy to suppose that these might not be brought immediately under the notice of the medical officer of a large criminal establishment, such as the Glasgow prison. But even granting that no incipient symptoms of the disease were observed, and that this proportion of the habitual drunkards were not quite on the verge of being affected with it, it is quite in accordance with the views already advanced to suppose that, when there was a certain amount of alcoholization existing, the disease might be hurried on more speedily than otherwise would have been the case in individuals of a nervous and excitable temperament, by the agitation or shock of apprehension, and the deprivation of liberty. But, further, I should suppose it a very just, nay moderate calculation, to assume that out of a population of 2000 confirmed drunkards belonging to any class of society, although enjoying unrestrained liberty and uninterrupted opportunities for indulgence to excess, at least from three to six instances of delirium tremens would annually occur.
But, in fine, on this point, the evidence communicated by Dr Simson, the medical officer to the prison board of this city (Letler, 4th July 1854), is sufficiently satisfactory; for while the number of civil and criminal prisoners, committed during the last year, was 5864 (which may be assumed as a sample of the previous fourteen years, over which Dr Simson's experience extends), only four cases of delirium tremens occurred within the last eighteen months. The average number of cases during former years, Dr S. states as from 2 to 3 per annum. Dr S. considers that, at least one-half of the whole prisoners may be assumed as dissipated characters, and that at the very lowest computation, 500 must have been regular systematic drunkards, from whom all drink was suddenly abstracted ; and he goes on to state as his decided opinion, that “the sudden taking away of spirits, etc., does not produce delirium tremens. In every case, the prisoner had symptoms of the disease on him when admitted that is, they were all restless, irritable, etc. ; and I have no doubt, but that in many instances the crimes committed were the effects of this disease. I do not remember a single case of delirium tremens occurring when the prisoner was quite well when received into prison. There is not the least doubt that a peculiarity of constitution predisposes to delirium tremens,” etc.
Here, then, it has been shown, that hundreds of individuals among the public at large, and of the criminals committed to our gaols, leave off or are suddenly deprived of the stimulants to which they had been previously addicted, without being seized with delirium tremens, or anything approaching to it. On the other hand, also, it is unquestionable that numerous instances of the disease do occur in which there has been no suspension either voluntarily or by compulsion of the amount of liquor consumed, nay, even an increased excess in drinking up to the very moment of seizure. The assumption, consequently, that this disease is produced invariably, or chiefly, or even occasionally, by the diminution or abstraction of an accustomed stimulus, is not supported by facts. Any cases, therefore, noticed as occurring under these circumstances, are simply of an exceptional character, but which, in my apprehension, fall quite short of proof from the considerations already so fully explained.-Peddie on Delirium Tremens.
DR STOKES ON AUSCULTATION OF THE HEART. If you take works upon disease of the heart, you find that it is assumed by
almost every writer, that the first sound of the heart and the second sound of the heart are to be easily distinguished from each other. There are some persons who, if you were to say to them, in any given case, “I think that I have had considerable difficulty in saying which was the first and which the second sound of the heart,” would set you down as very deficient indeed, as one that had not been properly taught, and did not know his business. But the fact is, gentlemen, that there are inany cases in which at first it is very difficult indeed to say which is the first and which the second sound of the heart. There are cases in which the most experienced man will require repeated observation before he can make up his mind on the point.
It has happened to me over and over again, that after I thought I had made up my mind by examining at one part of the heart, when I changed the stethoscope an inch or two I was again thrown into doubt.
I mention this to show you how diffident we should be in our opinions upon these subjects, how slow we should be to condemn men because they do not come up to the mark laid down in books. The truth, in fact is, that they go beyond it—that they are wiser than the authors of such books.
Can we distinguish by acoustic signs alone, the inorganic from the organic murmur? The answer to that question is simply,—that in the present state of our knowledge, there are many cases in which we cannot do so ; that there is no special acoustic character by which you can distinguish one of these phenomena from the other. This looks like a depreciating statement, as far as diagnosis is concerned ; but the cause of diagnosis would be much more injured by attributing to it powers which it does not possess, than by confessing its deficiencies. The diagnosis, in the case in question, is to be drawn from other circumstances.
The great mistake, gentlemen, that was made-I am happy to say that it is now going out very fast,-in connection with auscultation generally, was this, it was supposed that every disease had its special acoustic sign, and consequently the attention of students and physicians was directed to the study of those signs in a purely mechanical point of view, merely to the observation of their acoustic characters.
There can be no doubt that it is of the greatest possible importance to study carefully every thing connected with a diseased organ, both its physical and its vital phenomena ; but what you have to learn specially is this, not so much how to detect the sign or how to recognize it, as to know how to reason upon a particular sign when you have discovered it.
Bear this in mind always, that there is no pathognomic physical sign of any disease whatsoever. This cannot be too strongly stated ; and I believe that we might go further, and say, that there is no combination of mere physical signs which, excluding the history and vital symptoms, can be justly considered to be pathognomic; at all events, if there be such a combination, it is one of extreme rarity indeed. We hear of certain murmurs being pathognomic signs of this and that disease of the heart,-of friction sounds being pathognomic of pleurisy-of crepitating râles being pathognomic of pneumonia-of amphoric sounds being pathognomic of effusion into the pleura. All this is wrong; it is based upon error; and you must expunge it altogether from your minds, if you wish to be accomplished physicians, investigators of truth, and faithful observers of disease as it is found at the bedside.—Medical Times.
[There is one observation by Dr Stokes with which we would beg leave to differ, viz., that, when he tells students that they have not so much to learn how to detect and recognise signs, as how to reason upon them. While granting the full importance of reasoning correctly, the great difficulty we have experienced in teaching clinically, is undoubtedly causing the students accurately to make out the signs and symptoms. We need scarcely say that unless the facts are ascertained with exactitude in the first instance, all subsequent reasoning must be erroneous.]