페이지 이미지



remedy with many, but there is no practitioner who practice, and with great success. The following cases has had recourse to them who does not know, even in will show how effectually it acts in arresting the inflamcases where they have been most beneficial, how matory process in the different stages of the disease :inconvenient their application always must be. In

CASE I. cases of orchitis the great wish of the patient is to | December 16th. J. T. contracted gonorrhea about keep secret the cause of his illness, and this can a month since; he has never had orchitis before. He scarcely be done where leeches are used. If a few are yesterday found the testis becoming painful, and it applied they seldom do much good, and the expense of

soon swelled to a large size. It has within the last many often proves an objection to their use.

twenty-four hours become of the size of a hen's egg, is

extremely painful and tender, and the scrotum is red Purgatives of course are useful in this disease, but ex

and inflamed. There is also pain along the cord, they are not of themselves sufficient to effect a cure.

general febrile disturbance, and the gonorrhea conThe same may also be said of narcotics, and especially

tinues. Strips of adhesive plaster were firmaly applied of opium.

round the affected testis, and for the first five minutes Mercury is frequently administered in large quan-caused an increase of pain. He soon, however, became tities, and we find ptyalism often occurs before any easier, and remained so. impression is made on the disease. Excepting in very | 18th. The straps having become very loose from severe cases this remedy is almost as bad as the disease, the diminished size of the testis, they were removed, and it may do harm when gonorrhea is present, as and fresh ones firmly applied. of course it often is in cases of orchitis.

20th. The straps came off; the testis has almost Emetic tartar is the remedy most commonly em- |

returned to its natural size, and there is but little

| induration remaining. ployed, and in many cases it subdues the inflammation. Unpleasent as this medicine is when taken in the

CASE II. Dauseating doses requisite, it doubtless does a great July 4th. R. T., aged 22, has had gonorrhoa eleven deal of good in many cases.

days. Six days ago the discharge lessened, and four The local application of cold lotions or warm fomen

days ago the right testis became inflamed. Has had

gonorrhrea, but not orchitis, before. The testis was tations, will be found beneficial, more especially the

| strapped with soap plaster, and cubebs given internally. latter, with or without the addition of laudanum or

6th. The testis smaller and less painful. Restrapped. aconite. A warm bran poultice with hydrochlorate of Ilth. The testis has regained almost its usual size, ammonia in it is also useful.

and there is but little hardness remaining, With all these, however, one thing is needful,-entire

Case III. rest, either in bed or on a couch, and it often proves

I June 26th. H. W., aged 20. Gonorrhea two very inconvenient to the patient to be obliged to sub

months. Four days ago the right testis began to mit to this necessary restriction.

swell, and is now the size of a hen's egg; not very Suppose then, that the patient after some days treat-tender except when pressed. Never had orchitis ment with either of the above remedies, is better, and before. Strapped with soap plaster, and to have one the inflammation has subsided, -is he well? Certainly | drachm of cubebs three times a day. not. The testis remains enlarged, bard, painful from 30th. Gonorrhoea cured ; testis much smaller, and its weight, and liable on the slightest injury to take | bardness less. on inflammation, and render the patient incapable of July 4th. Cured. attending to his employment for some days more.

CASE IV. If it goes on ever so favourably, a long period must July 15th. E. M., aged 19. Gonorrhæa fourteen elapse before all the enlargeinent which remains will days. Orchitis of both sides. Twelve days ago the gield, either to the employment of mercury or iodine,

right testis became swelled, and has gradually increased however diligently applied.

in size, and is now as large as a goose egg, tender and

painful; there is also tenderness and swelling of the I have thought it best to notice the merits and

cord. The testicle has been large since an attack of demerits of the remedies usually employed before

orchitis six months ago. Straps of adhesive plaster speaking of the advantages which result from the use

were applied.. of compression. Some time ago Fricke, of Hamburgh,

16th. Much smaller and less painful. Restrapped. proposed compression of the testicle when the acute 24th. Almost well. The left is now swelled and stage of orchitis bad subsided; and in sub-acute cases painful. of the disease, Ricord, in France, used it also to a 25th. The left being larger, was strapped. great extent, and I believe still continues it. The 26th. Left testis better. practice has now found its advocates in many of our 31st. Both well except slight induration of the right. hospitals, although it has not come into general use.

CASE V. Mr. Curling, Mr. Acton, and Mr. Langston Parker, March 28th. J. M., aged 18, fell across an iron bave also used it with success; and at the Seaman's bar and injured the left testis, which has been swelled Hospital Mr. Bask almost uniformly follows the for a week. It is now about the size of a large hea's

erg, aot very hard, and of a more oval form than in The above is the most severe case of the kind which · gonorrbceal orchitis. Strapped with adhesive plaster. will generally be met with; and I have adduced it to

29th. Much better; straps very loose ; re-applied. show what is the dark side of this mode of treatment.

31st. The testis is become quite soft, and of its I do not, however, consider the symptoms to bare been Datural size.

more serere than in some cases of orebitis where I would here observe, that this kind of orchitis

other treatment than strapping has been used ; and (from injury,) gets well more speedily than when con

often a blow on the testicle will cause the same nected with gonorrbæal inflammation.

symptoms. CASE VI.

At the time Case 1 applied to me, a neighbour J. D., aged 25, has had more or less gonorrhea for

of his came with the same disease; and, thinking it two years, but no orchitis. Fourteen days ago the

would be a good opportuniiy to test the different right testis became painful and swelled. Straps of adhesive plaster were tightly applied. In three days modes of treatment, I ordered him tartar emetic and it was re-strapped, the scrotum, which was previously

calomel, with warm fomentations to the part. He got tense and inflamed, being now flaccid and free from better in about ten days, but was obliged to use the tenderness. The testis after one more application Linimentum Hydrargyri cum Camphora, for some time returned to its usual size.

before the induration and enlargement of the testis CASE VII.

gave way. June 16th. S. C., aged 30. Gonorrhea one week. A brother practitioner called me to see a case of Never had orchitis before. Last evening the testis orchitis, arising from a blow. The testis was very became tender and swelled, after using violent exercise.

soft but of large size. Here leeches, calomel, and The urethral discharge is diminished; there is much

| tartar emetic, were put in requisition, and after a pain along the cord, which is swelled. Straps of

week the patient was allowed to get up; and in a few weeks adhesive plaster were applied, and one drachm of cubebs given every six hours.

after the testis slowly diminished to nearly its natural 18th. Better; testis much smaller. Re-strapped: 1 size. In this case the probability is, that if strapping and after this, being quite easy, he walked a good deal. had been applied, the cure would have taken not Pain then came on, and the strapping was immediately more than a week, as iu Case 5; but my friend removed. Hot fomentations were constantly applied, thought the old mode of treatment better than the As the pain became very violent. A little tincture of new. Since then he, as well as others, has been opium gave speedy relief.

persuaded of the efficacy of compression in such cases. 19th. The testis less painful. To be supported by

supported by Having already taken up far more space than

Having already taken op far more spac a suspensory. 28th. The testis almost well, but some degree of

I intended, I will finish these remarks by a few

observations on the mode of treatment. It will be enlargement and hardness remains. This case shows that if the compression gives pain se

seen from the above cases, that we may apply the and is immediately removed, the case goes on well. strapping at any time, from a few hours after the

The next case is one where I was not called in to disease has appeared, to a fortnight, or even longer. see the patient for some time after he was seized with It generally speedily relieves the pain, but some cases the severe symptoms which supervened; but I do not there are where, from violent exercise, or, perhaps, doubt that if I had seen him at once, and had imme- idiosyncrasy, the patient cannot bear the pressure. diately removed the strapping, the patient would have As a general rule, I should say, that if after the first done as well as Case 7.

quarter of an hour of the application, the patient. CASE VIII.

should have much pain, and increasing in violeace, June 10th. J. F., aged 24. Gonorrhæa fourteen

the strapping should be temporarily removed. If the days. Orchitis six days. Testis the size of a duck's

straps be applied uniformly, and tolerably firm, this egg, very hard and painful; the cord very tender and swelled. Strapped with adhesive plaster.

will seldom be-required. Much, of course, depends 12th. Better. Re-strapped.

on the mode in which the operation is performed, 15th. Better. Re-strapped. Walked a great deal. for it is not so easily done as may be imagined ; and Some hours after the strapping had been applied, great it would be worth while for a surgeon to go some way pain came on, with considerable swelling of the cord, to see it properly performed, which be will, most protenderness over the lower part of the abdomen, and bably, at any large hospital. Care should be taken to-pain in the loins. Vomiting, a quick feeble pulse, and place the first strip tightly round the cord, immediately cold extremities, were the severe symptoms which above the testicle, and to continue the strips tightly followed. Stimuli were given, æther and opium; the downwards, with perpendicular ones also to give plenty strapping removed, and hot fomentations constantly

of support. Soap or adhesive plaster is generally used applied. He soon became easier, and progressed

at first; but in more chronic cases, the Emn strum favourably. 27th. The testis very hard, but free from pain; in

Hydrargyri cum Ammoniaco may be sube uted.. other respects well. (This state of the testis has ! It will generally be found that a few nutes after the become permanent.)

| strapping is properly applied the pain is relieved. In. ON INFLAMMATION OF THE BRAIN IN INFANTS.


a day or two the testis is so much diminished in size! This description evidently refers to acute meningitis ibat the straps are very loose; they may then be re- but the author has committed an error in stating that applied once, twice, or thrice, according to the state of vomiting is absent, and that the pulse is feeble and the case. I have seen a patient in the greatest agony

slow; on the contrary, vomiting is very generally before the application, and in an hour after the straps

present, and the pulso though feeble, is not slow.

Coindet, while he admits that hydrocephalus is the have beeu put on he has been able to walk about

result of a peculiar inflammation of the lining mem. almost without pain.

brane of the ventricles, establishes a distinction between The earlier the remedy is applied the less will be

phrenitis and dropsy of the ventricles. the induration remaining after the inflammatory stage Matthey also separates the disease which he terms has subsided.

hydro-meningitis, from the water on the brain which Lastly, (and that not of the least consequence to follows scarlatina, and also from sub-acute hydrothe surgeon,) the patient will be delighted with the cephalus. This latter variety is that described by Whyrt sale, speedy, and almost painless recovery from a very and corresponds to the tubercular meningitis of recent onpleasant disease, and will be grateful for the means writers. The hydro-meningitis of Matthey offers on of relief being used without discovering to his friends

the contrary a close analogy with the disease in question the nature of bis malady. More especially will he

Its characters as stated by Matthey are as follows:

“More or less headache, sickness, spasmodic movements value this simple and easy niode of treatment if he

of the limbs, brilliancy of the eyes, quiet delirium, con. bas unfortunately been the subject of the same disease

traction of the pupils, quick and small pulse, coma. before, and bas bad to submit to the nausea consequent After death.

After death, gelatinous effusion on the surface of the on the use of emetic lartar, or the salivation caused by brain, seldom in the ventricles.” the calomel he has taken, as well as to the troublesome Jahn (Analeklen über Kinderkrankheiten, 1835,) application of leeches and fomentations, to say nothing describes a foran of disease similar to our acute menin. of the loss of time from being obliged to remain in bed gitis under the denomination of idiopathic encephalitis. or on a couch for days or even weeks.

It is characterized by intense fever, with quick breathing, Crewkerne, January 29, 1847.

thirst, great susceptibility to light and noise, brilliancy of the eyes, frequent vomiting, obstinate costiveness, &c. The anatomical characters, as stated by the


1. Injection of the brain and its membranes. MEMBRANES OF THE BRAIN IN INFANTS.

2. Induration of the cerebral substance. By Dr. Rillier, of Geneva.

3. Effusion of a greenish lymph in the anfractuosities

of the brain, and along the course of the vessels. (Translated for the Provincial Medical and Surgical Journal.)

4. Absence of serous effusion in the ventricles. I. PRELIMINARY OBSERVATIONS.

Evanson and Maunsel hare also distinguished arach. A great number of practitioners, even in the present vitis of the convexity of the brain, from inflammation day, confound all the acute cerebral affections of of the membranes at the base, and hydrocephalus. ipfancy under the term acute hydrocephalus, or tuber. They observe :-" Infants are not exempt from arach. cular meningitis ; and the error has continued, although vitis of the convexity of the brain, although ths form many attempts to introduce, a more strict pathology of inflammation is less common than the preceding, bave been made, even as long since as the end of the hydrocephalus and inflammation of the base.)" But last century

we need not multiply quotations; those already adduced Thus Hopfengartner, who wrote in 1802, has distin. suffice to demonstrate that several writers have enguished meningitis from acute hydrocephalus, and it is dearoured to distinguish hydrocephalus from acute evident from the tenor of his observations, that under inflammation of the nervous centres. the former term he alludes to the same form of the From the time that the term hydrocephalus was disease which it is our object to illustrate in the pre-exchanged for that of meningilis, confusion was resent communication. “From the very onset of the established,-& confusion wbich was increased by the disease," he obserres, “ and without any precursory terminology. It was rational enough to distinguish symptoms, the children complain of pains in the head hydrocephalus from meningitis; but what good could and abdomen ; on the second day they keep their bed, arise from making two forms of meningitis ! Those and the disease proceeds without those remissions which who had written of the disease under this term, as we notice in acute bydrocephalus. The patients are dull, Golis, Senn, Charpentier, &c., confounded both forms the eyelids close convulsively; the teeth are fixed, under the same description; but others, as Parent and and deglutition is difficult. Constipation is not so Martinet, at once separated inflammation of the base obstinate as in hydrocepbalus. There is in general from that of the convexity of the brain, and recognized little or no vomiting and the pulse is small and slow. the fact, that in infants the former was a far more Coma superrenes much more rapidly than in hydro- common affection than the latter, cephalus. The patient usually dies about the fifth or From the period at which the writings of MM. sixth day. After death the membranes are found to be Papavoine and Rufz contributed so much to the elucida. indamed throughout their whole extent.”

|tion of the true nature of acute hydrocephalus, the

epithet tubercular was added to the designation menin- 3. Both are accompanied by effusion into the contrigilis; it was thought that more precision was thus cles, and frequently co-exist with cerebral tubercles. introduced into the diagnosis of the disease; but it 4. Both co-exist with tubercular deposits in other was not so in truth, for MM. Piet, Green, &c., hare organs. almost entirely omitted the mention of simple menin On the contrary, in true meningitis, it is the pia gitis. Rufz, however, does not deny the existence mater and arachnoid of the convexity, or of the of this latter affection, though he admits its great compa- ventricles, which are ipdamed and iufiltrated ; serous rative rarity; and before him M. Guersent (Dict. de effusion into the ventricles is the exception, and the Méd., tom. xix., p. 410,) had distinguished the simple affection does not coincide with tubercles or granulations, from the tubercular form of meningitis, although be either in the brain or other organs. These differences referred to the former, as it appeared in adults, and in are so marked, that if the brain of an infant be an epidemic form.

presented to us, with the fissure of Sylvius filled with The first description of simple acule meningitis based adhesive exudation, and the base covered by memupon clinical obserration is undoubtedly due to the

branous and purulent deposit, the convexity at the same past labours of M. Barthez and myself. But it is

time being free from inflammation, we do not hesitato strange, that even subsequently to the appearance of

to predict that there are most probably also granulations our memoir, MM. Deleseur, Barrier, and other talented in the membranes and serous effusion into the ventricles. writers on the diseases of early infancy, hare entirely

have entirely and that tubercles will certainly be found either in the omitted to mention this variety of the disease. M.

| lungs or bronchial glands. Deleseur has collected all the acute or subacute cerebral

Again, we are able to tell from the nature and affections of childhood, under the generic term men.

number of the tubercles present in the chest or abdomen, ingo-encephalitis, and scarcely even endeavours to dis.

what has been the character of the cerebral affection. tinguish between simple and tubercular peningitis.

Thus if we learu that miliary granulations have been Trousseau gives the name of cerebral serer to all

found in considerable abundance in the lungs and cerebral inflammations indiscriminately. Bouchut and

other organs, we can affirm that the acute symptoms of Barrier refer the reader to the tubercular form of the

the head affection have been preceded by precursory disease, apparently believing that no advantage is to

symptoms, that the onset of the disease has been be derived by separating it from simple meningitis.

insidious, that the inflammation of the membraves was We do not hesitate to differ entirely from the authors

ushered in by vomiting, that there was constipation above cited, and to express our belief that their doctrines

mrith but little fever, and that the malady has lasted have been the cause of the greatest confusion. We

two or three weeks. On the other hand, if the brain are far from insisting upon frivolous distinctions, but

of an infant be exhibited to as, the conrexity of which there are, nerertheless, certain laws which the patholo.

is covered with false membranes or purulent exudation, gist cannot transgress, without the risk of falling into

we do not hesitate to assert that no tubercles will be error and confusion.

found either in the membranes of the brain or elseWe have already shewn, (Traité des Maladies des

where ; that the disease has set in suddenly and with Enfans tom. iii. p. 518.) and shall again satisfactorily

violence, with convulsions perhaps, if the infant be prove, that simple (franche) meningitis, and tubercular

very young; with violent headache, constipations, and meningitis differ essentially. Their causes are not

vomitings if it is of more adranced age; that delirium alike. They attack children under different circum

has been violent, and that the duration of the disease stances; they have neither the same modes of origin,

has not been longer than three, four, or six days. progress, or termination; their anatomical characters

We shall revert to this subject in our article on are different, and the treatment likewise is to a certain

diagnosis, and shall then enter further into details res. extent different. If these points are not sufficient to

pecting the differences between the two forms of the establish their distinction, there is no use in nosological


II. MORBID ANATOMY. arrangements; our own opinion is that true meningitis

Great familiarity with pathological anatomy is is as distinct from tubercular meningitis, as pneumonia

necessary for the appreciation of the slight lesions is from pbihisis pulmunalis.

which frequently constitute the morbid appearances Before we enter into the more immediate subject

| left by tubercular meningitis; but it is far more easy of our present commovication, it will be useful to make

to recognize the results of true meningitis of the con. a few observations upon a point upon which we fear

vexity. Scarcely, in fact, is the ivjected dura mater that we hare been misapprehended in our former

divided, than a greater or less extent of the couvexity writings. In our opinion, meningitis developing itself

of the two hemispheres is seen to be covered with in a tubercular subject, is always tubercular meningitis,

a layer of yellow or yelloirish green exudation, whether we find granulations in the pia mater, or

The deposit extends also to the internal aspect of the whether we do not. Tubercalar meningitis, therefore,

hemispheres, the upper surface of the cerebellum, and and the meningitis of the tuberculous, are, to us, one

sometimes to the base of the brain. A slight examine and the same malady, and for these reasons:

tion is sufficient to demonstrate that the deposit con1. In both, the seat of disease is at the base of the

sists of liquid pus, and that its seat is always the pia brain.

matæ, and sometimss also the arachnoid cavity. The 2. Both consist of a thickening of the pia mater

products of inflammation deserve to be separa tely with salse membranes or purulent exudation.

studied in these two situations.



1. In the arachnoid. This membrane, although it con. 1. In cases which prove fatal before the fifth day, tains the products of inflammation, may itself not we find the pus fluid or semi-fluid, or false membranes exhibit any trace of that process; but in general retains in the arachnoid and pia mater, the latter being vividly its smooth and polished appearance. If life has been injected, but not adherent to the surface of the brain. prolonged to the sixth or seventh day, the pus loses its Later we in general discover only concrete pus or gaidity, and acquires such consistence as to resemble false membranes; the pia mater is less injected, and & false membrane ; in other cases true false membranes the surface of the convolutions is sometimes soft and are formed in addition to the fluid products. These reddened. In some instances the ventricular portion partake of the yellow colour of the pus,-are thin, soft, of the arachnoid is inflamed, and the cavity contains and seldom very extensive; they are always easily a small quantity of purulent serosity, but never pure detached from the serous membrane, unless as is serum. occasionally seen, organization has commenced.

2. In very young infants, the brain is often softened 2. Pia mater.- Alterations similar to the above are universally; the ventricles contain a large quantity of discovered also in the pia mater, especially in patients serosity, and there is also occasionally a sub-arachnoid who bave died on the fourth or fifth day. The pus, serous effusion. when liquid, may be made to pass over the surface of 3. General meningitis is the most common form of the membrane by pressure with the finger, but it sub- the disease ; next, meningitis of the convexity; that sequently becomes concrete, forming a flat broad lager | of the base and rentricles, is much more rare. of variable thickness, and which passes down into the

(To be continued.) solci. The membrane appears to be puffed up by the secretion, and is increased both in thickness and tenacity. The deposit of pus is always more copious

Wospital Reports. along the sides of the blood vessels, and in the in. terstices of the convolutions, than elsewhere. At the QUEEN'S HOSPITAL, BIRMINGHAM. base the pia mater is often quite healthy. Over the surface occupied by the pus, the membrane is finely CLINICAL REPORTS OF SURGICAL CASES injected, and is readily detached from the surface of UNDER THE TREATMENT OF WILLIAM the brain.

SANDS COX, ESQ. 3. Cerebral substance.-The brain is firm, sometimes By Peter HINCKES BIRD, one of the Resident preternaturally so. The grey substance is of a normal

Medical Officers. colour is death bas occurred before the fifth day; later it

- (Continued from page 128.) may also be nearly analtered, but it is more generally of

CASE XXV. & vivid rose colour, and the medullary portion exhibits

FISTULA IN ANO. numerous bloody points. The most superficial layer of the convolutions is sometimes softened, so that

William Wilson, aged 38, shoemaker, of full ple. portions of it are removed along with the pia mater.

thoric habit, admitted into the Queen's Hospital, under In very young infants, the brain is sometimes softened

the care of Mr. Sands Cox, on July 21st, 1846. He throughout, an appearance which is probably due to

states that in June, 1845, he first perceived a small odema of its tissues. The condition of the brain in

swelling, with circumscribed hardness, on the verge of so bjects who have speedily succumbed, shows plainly

the anus, it caused him much pain and inconvenience, that inflammation of the membranes is the initiatory

which gradually increased, so that in September follesion, and the cerebral pulp becomes involved sub.

lowing he was unable to sit down. In December this sequently.

small swelling " came to a bead," wbich broke and dis4. Ventricles. -As a general rule, the ventricles are

charged a thin matter; it kept getting worse until found empty, or containing only a teaspoonful or two

January, 1846, when it was about an inch and a half of purulent serosity. The exception to this occurs in

deep; it was then laid open by the medical man very young ipfapts. In some cases the lining mem.

attending him. Another formed by the side of it, and brane and the plexus choroides exhibit traces of inflam.

it was again laid open, but witbout success. He states. mation, beinginjected and softened, or subsequently pale,

that these openings have bled at times. His health has bat thickened and opaque. The central portions of the

always been good; no tendeney to phthisis can be brain in some cases, preserve their consistence; in others

traced in the family; his father died of apoplexy; his they are softened, or converted into a diffluent pulp.

mother is alive and well; bis occupation is a sedentary The latter case chiefly occurs in young infants, in

one; in bis early life he was rather " a free liver;" his connection with copions serous effusion into the ven.

bowels have always been exceedingly regular ; is tricles; but it is occasionally seen without this, and

seldom troubled with congh ; has never been subject mast then be attributed to inflammatory action, and

to hæmorrhoids. not to maceration, as may be the case when the effusion

Present state. There are two fistulous openings, is in large quantity.

one on the left side, the other on the right side of the To recapitulate : -The anatomical characters vary

anus. The one on the right side bas but lately appeared, according to - 1st, the duration of the malady; 2nd,

it is about an inch and a balf deep, situated about half the age of the patient; 3rd, the seat of the inflamma.

an inch from the anus, and communicates with the tion.

rectum; the other, which has been present since last September, is situated on the verge of the anus, and is

« 이전계속 »