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PROVINCIAL MEDICAL & SURGICAL JOURNAL.
A COURSE OF LECTURES ON CLINICAL gurgling of large bubbles ; impulse of the heart much MEDICINE.
increased, the head being sensibly raised by the By W. R. BASHAM, M.D., Physician to the Westminster upheaved stethoscope ; the systolic murmur is not proHospital.
longed, but the diastolic sound is confounded someLECTURE X.
what with it, it is not clear and distinct; the pulse is Case of Hypertrophy of the Heart with Dilatation : sbarp and full, regular and equal on both sides; no pul
the accompanying symptoms illustrative of this form sation noticed in the neck; the cough is frequent; sputa of cardiac disease; cough; dyspnea; peculiar and muco-glutinous, and stained by the hæmapbæin of the special form of expectoration ; anasarca and general blood; some slight tenderness on pressure in the lum. dropsy: stethoscopic signs.--Hepatic derangement ; bar region of the kidneys; the liver appears to occupy state of the excretions ; condition of the urine a larger space than usual, but there is no tenderness albuminous; deficient in urea; analysis of the blood, in the right bypochondriac region. He was cupped over detection of urea in.-General indications of treat the region of the heart, and directed to take the blue ment ; advantages of venesection.-Singular character pill, in three-grain doses, night and morning, with of natter vomited from the stomach; the Sarcina infusion of diosma and tincture of digitalis. ventricali, of Goodsir, observed in the yeasty mass
During the next twenty-four hours the anasarca ejected from the stomach.
sensibly diminished, but the heart's action continuing Gentlemen,-The case to which I wish to engage very violent and impetuous, it was thought desirable your attention to-day, is one that I have had frequent to take blood from the arm to sixteen ounces. The opportunities of making passing observations upon blood drawn did not separate into its constituent pore during our visits to the wards; but as it has presented tions of coagulum and serum, but remained a firm many symptoms of complication and difficulty to the uniform coberent red clot, easily broken up, but which student in clinical medicine, I propose to take a general did not yield up any serous fluid on being so disturbed. review of the symptoms as recorded in the ward-book, The urine was this day examined. He passed not more and to give you such explanations as may be necessary than a pint in the twenty-four hours; it was cloudy, to interpret either its pathology or treatment
of an orange-brown colour, with numerous flocculi G. F- , aged 38, carpenter, has been addicted to appearing in it, faintly acid, cleared by heat, with drinking ; his general health has been good till within copious erolution of gas-bubbles; on reaching the the last five weeks. He was admitted into Burdett boiling point it agaio became cloudy, and on the addiward on December 24th, and was then suffering tion of nitric acid, a flaky albuminous deposit in from frequent urgent dyspnea, with suffocative cough, ininute quantity, was thrown down. Microscopically and copious expectoration, of a very dirty-coloured, glu- examined, amorphous urate of ammonia, with contipons, jelly-like fluid. He states that his health began siderable amount of epetbelial matter, was observed. to give way abou: five weeks since, first complaining | As he obtained no sleep, being much disturbed by the of severe attacks of gastrodynia and tenderness at epi- cough, he was ordered Extr. Conii, gr. x., hora somni. gastrium, augmented after eating ; cough and dyspnea The impulse from the beart continuing but little followed, and then the legs began to swell, and he diminished, and the pulse being still full and sharp, it noticed that the face became puffed and ædematous in was thought desirable on the 31st to take a farther the morning. There was, on adinission, general ana- quantity of blood from the arm, and eight ounces were sarca, the scrotum being distended with Auid ; face abstracted; and now the separation into serum and cedematous, especially in the morning; aspect of the clot took place, but there was no separation of the red patient not unhealthy, as there is a remarkable injection particles from the fibrin. The effect of this bleeding of the vessels of the cheeks, which gives a florid appear was most beneficial upon the secreting organs; the ance of health; the conjunctiva bas a slight icteritic hue; | kidneys now formed two pints and half of urine in the the surface of the chest is cedematous, the stethoscope twenty-four hours, of a lighter colour and clearer, leaving an impression by its pressure. The chest is with less deposit of urates. The fæces became of a equally resonant throughout; no dulness in the pre- brighter bilious bue, and the expectoration was more cordial region ; resicular murmur not clearly heard; copious and easier of excretion, but still presented a breacbial respiration in each region, with deep mucous dirty bue, the colouring matter of the blood being still
No. 12, June 16, 1847.
diseolved in it. The anasarcous condition of the frequent, 120, but had lost its jerking character, and system had much diminisbed; there was much less the general appearance of the patient was that of a cedema of the chest; no swelling of the scrotum; and healthy man, from the before-noticed state of the scarcely any of the lower extremities. On the 2nd of capillaries of the cheeks. The sputa bad become mucha January, the quantity of urine excreted is stated as diminislied in quantity, and frothy, and colourless, three pints; natural in colour and general appearance; presenting only a few masses of yellow mucus. He no indication of albumen; normal amount of uric was now placed upon an improved diet, three ounces acid ; tongue clean ; pulse, however, still continued full, of meat for dinner, with extra bread allowance. Two sharp, cordy, and jerking. Up to this period the patient days after, however, the symptoms again retrograded. had been confined to a fish diet, carefully avoiding all The ædematous condition of the legs, scrotum, and stimuli. The mercurials were repeated only at intervals; . entire surface, even of the cheeks, again returned. digitalis being solely trusted to bring down the impetu. The urine two pints daily, of a dark orange-colour, with osity of the heart's action after the plenitudo ad molem copious deposit; bowels open, dejections natural; had been to a certain extent relieved by venesection, appetite craving ; pulse 110, full and tumultuous. .
The report of the 4th of January states that the urine The symptoms continued without any material altera. had again diminished to a pint aud a half, of a brown tion to the 21st of January. During this interval he bad orange colour, and much loaded with urates. The taken nitric acid, and subsequently for a few days, heart's impulse still continues augmented; sounds quinine, but without any change for the better. somewhat obscure; an aortic bruit accompanies the On the 21st, after breakfast, he was seized with systolic murmur, increased and becoming more distinct nausea and vomiting of a peculiar yeasty-looking fluid. as the stethoscope is raised to the position of the arch The urine during the last few days had become very. of the aorta. On the 6th of January the urine became dark coloured, of a specific gravity of 1.022, and the again higbly loaded with urates; albumen in small amount of albumen had very much increased. At the quantity still present; bowels continue to act freely, afternoon visit on this day, a rough murmur was heard. but the dejections are offensive and dark coloured ; continuous with the systolic sound, and much obscured pulse 120, full and incompressible; cough frequent by the moist iuucous crepitation, heard more particu- , and distressing; sputa as before, but without any trace larly in the mammary region of each side. A good deal of blood; heart's impulse inuch increased ; action of restlessness occurred, and morpbia was administered impetuous. Blood was again taken from the arın to at night. eight ounces, a portion of which was analysed by the On the 22nd, vomiting again occurred, of the same following process, to ascertain if urea existed in the frothy yeasty fluid. Tuis, when exainined by the blood. As soon as drawn, three ounces were agitated microscope, presented many fat globules, epithelial well with pure alcohol, and allowed to stand at rest scales in abundance, frequent tufts of margaric acid, for four hours; the inass was then filtered, and the and several beautiful speciinens of the Sarcina dentriculi residue on the filter again treated with alcohol, and of Goodsir. Ammoniated draughts, in a state of the solution filtered. An orange-coloured alcoholic effervescence, with citric acid, were given; and arrowsolution was obtained, which was evaporated to dryness root, and small quantities of wine, with morphia at night. in tbe water bath, after three fourths of the alcohol The ammoniated draught seemed to check tbe vomiting, had been recovered by distillation at a low temperature. for it did not return after the first two doses. During The dry residue had a yellow orange colour, and a the next three days the ædematous state increased; faint crystalline appearance; a few drops of distilled the heart's action increased in tumultuous iin peliiosity; water were added, and then a sınall quantity of pure the sounds in the præcordial region became mufiled ; nitric acid; on setting this aside in a watch-glass in a the cough and dyspnea returned in frequency and cool place, after an hour's rest, crystals of the nitrate urgency; the urine diminished in quantity ; the bowels of urea were distinguished with the half-inch glass, were freely moved; the appetite craving ; no thirst, under the microscope.
no voiniting. The dyspnea became more urgent on It was now thought advisable to allow the system to the afternoon of the 26th of January, and in the evening rest for a time without any interference by medicinal of that day he died. agents, for the last abstraction of blood bad materially | Sectio Cadaveris twenty-four honrs after death. relieved the more urgent symptoms; the heart's The whole surface of the body was anasarcous, the impulse was diminished; the pulse was reduced to subcutaneous tissues being much infiltrated with clear 90, softer in character; and the cough was less fre- serum ; soine also was present in the abdominal cavity. quent, and the expectoration free from bæmaphæin Firin adhesions between the pleural surfaces. The and more purely mucnus in its appearance. The urine, bronchial glands situated at the fork of the dirision of though still bigh in specific gravity, (1.021,) was clear, the bronchi were very much enlarged, as were also those yet dark coloured. No urea could be detected, and which lay beneath, and followed the direction of the the presence of albumen was still indicated by the left bronchus. The mucous membrane of the trachea ordinary re-agents.
was finely injected, and of a bright red colour, but at On the 9th of January a great improvement became the bifurcation this colour had become of a dusky manifest. The anasarcous condition of the surface brown, with marked evidence of passive venous hyperbad disappeared, and the legs only became edematous æmia; all the tubes were filled with a tenacious towards night, and after be had walked much about fawn-coloured inucus. The heart was very much the ward; the pulse, however, had become unnaturally enlarged, its cavities dilated, and its walks thickened;
it weighed after being cleaned seventeen and a ball matory attack, or anything analogous to an attack of ounces; the tricuspid valve was opaque and thickened bronchitis. The patient declared that the cough came at its edges; the semilunar valves of the pulmonary on gradually, and becanie aggravated day by day, artery were natural; the aortic valves, however, were in an imperceptible manner, and that up to a certain rigid, and stood out pouch-like from the parietes of the period, though occasionally troublesome, it did not vessel, and their edges thickened and covered with stop bim from his usual avocations. The dyspncea wart-like fibrinous growtbs. The aorta for five inches became subsequently very urgent, and compelled him in its extent, was covered with a semi-cartilaginous to seek medical relief. Cough and dyspođa thus deposit that presented the walls as wrinkled or corru- gradually coming on, without any previous wellgated, and with evident enlargement of its capacity by defined inflaminatory attack, may generally be condilatation. The liver on the superior surface of the sidered as indicative of some deranged condition of right lobe presented a copious exudation of plastic the pulmonary circulation, originating in irregular lymph, causing firm adhesion to the diaphragm; the cardiac action. The mucous membrane in these substance of the organ was highly granular, and exli cases is in a state of venous hyperæmia, sometimes bited the features of incipient cirrhosis, the appearance called passive congestion; it is livid in colour, turgid, being myristicate,-a purplish reining, surrounding and ædematous, and a dirty-coloured brownish viscid isolated yellow granules. The organ weighed fifty secretion lines the bronchial tubes, and is the main nine ounces. The kidneys were not enlarged; the right cause of the cough and respiratory distress. When weighed four ounces and three quarters, the left five raised and expectorated, the sputa are specially ounces. The tubuli uriniferi were clearly marked out characteristic of the above-described condition of the by a deep purple injection, and the cortical part was mucous meinbrane, differing remarkably from any granular, plainly deinonstrated when the peritoneal tunic form of excretion that usually follows inflammatory was removed ; some granular deposit was also observed states of the bronchial tubes. The expectorated matter dipping between the tubular processes. The veins of is glutinous-similar to glue, both in consistence and the stomach both of the lesser and greater curvature, colour, of a dirty dusky ochre, or fawn colour, somewere so gorged with blood as to present a reirarkable times even still darker, as if the bæmaphæin of the feature. The mucous surface of the viscus was of a blood were dissolved in it. This form of expectoration purple madder colour throughout, and the greater may be considered very characteristic of venous part of the mucous membrane of the small intestines hyperæmia of the bronchial mucous membrane, arising presented the same appearance. The mesenteric veins from beart-disease. The cougla commencing imwere much distended. The bladder exhibited, as to its perfectly, the dyspnrea and this peculiar glue-like mucous membrane, similar conditions to that of the expectoration may be taken as one series of the stomach.
symptoms indicative of hypertrophy with dilatation. The history of this case presents us with all the The second series embraces the anasarcous condition most characteristic features of hypertrophy and dilata- of the surface of the body, the edematous condition tion of the heart; it exhibits also many circumstances of the face in the morning, or after sleep, and the illustrating the effects of mal-assimilation, and the general dropsical state of the system generally, the consequent diseased condition of the blood. The swollen legs, and distended scrotum. The third series position these several morbid conditions bear towards of symptoms comprises the altered state of the secreeach other, it is impossible, with certainty, to define. tions; the high coloured, orange-tinted, and albumiWhether the heart disease be the cause, and the other nous urine, deficient in urea, abundant in uric acid and morbid conditions but the effect of the disturbed circu- | its compounds, diminished in quantity, and of bigh Jation; or whether reversely, the organic alterations specific gravity; the dry, acid skin, the icteritic in the heart's structure, be produced by an imperfectly aspect, and the offensive mud-coloured, imperfectly formed circulating fluid, deficient informative elements, formed fæces. This category of symptoms suggests or redundant with morbid material, and capable of the heart to be, in a corresponding degree, deranged in exciting the heart to irregular action, it is not possible function, and probably altered in structure; and though to deterınine. It is my wish on all occasions of our we cannot prove that all these symptoms are severally meeting for clinical study, to avoid mere speculative dependent on the diseased heart as their morbid cause, or hypothetical points, and to confine myself strictly yet experience teaches us that they for the inost part to an explanation of the symptoms that are capable co exist, and that the presence of the above-enumerated of illustrating the nature and progress of diseased series would be presumptive evidence of disease of the action. Laying aside therefore the speculatire matters heart. The stethoscope amply confirmed this suspicion just hinted at, let me turn your attention, first, to of cardiac disease, and enabled us to define, to a certain tbe more prominent and most characteristic symptoms extent, the special form of disease affecting this organ; of hypertrophy, with dilatation; and secondly, to the the impulse of the heart was increased to such an more complicated condition of deranged secretion and extent as sensibly to raise the head when applied to the diseased blood.
cbest ; the rhythin of the beart's sound was not per The earliest symptoms recorded in the case book fect; the systolic and diastolic murmurs were conare those of cough and dyspnea, accompanied by a founded, the latter merging into the systole, and not peculiar form of expectoration. In searching for the to be distinguished clearly from it. There was an cause or origin of these pulmonary symptoms, we fail aortic bruit beard over the aortic region, continuous to detect any specific commencement from an infam. I with the systolic sound; hypertrophy, with dilatatio
and some organic defect in the aortic valves, were thus quantity, quickly induces relief to the more urgent detected; but the stethoscope not only indicated these and distressing symptoms, the permanency of which alterations in the structural condition of the heart, upon is proportioned in a great measure to the extent of the the admission of the patient, but it enabled us to deter- 1 disease. Internal remedies are feeble in their effects, mine the progressive mischief and changes that were and uncertain in their operation, till the congested state proceeding, unchecked by any of the remedies of the venous system has been relieved by blood-letting. employed. Notwithstanding that at one time a Mercury produces no appreciable effect on the secrefavourable change appeared to take place, the worst tions,--digitalis is useless as an internal agent, till the symptoms being suspended, the anasarcous condition plethoric condition of the systein has been diminished. having disappeared, the cough and dyspnea abated, and So soon as that has been effected, then these remedies, this consentaneous with a general improvement in the either separately or combined, oftentimes operate several secerning functions, yet, nevertheless, the with marked success. You cannot bave failed to stethoscope revealed, even at this period, a peculiar notice in this case the immediate and sensible relief aortic bruit, and on the 21st of January this bad obtained from the more distressing symptoms, as soon increased to a rough murmur, heard most plainly over as blood was taken from the arm. The cupping over the aortic valves, and which irregular sound clearly the region of the heart obtained the effect desired, indicated some defective formation of, or adventitious as far as the threatened or suspected indications of growth upon, the membranous fold. The post-mortem pericarditis were concerned; but it was not till after examination explained this aortic murmur, and shewed the bleeding from the arın, that the most evident it to have been caused by the fibrinous vegetations benefit to the general symptoms was observed, and found appended to these valves.
then also the effects of the mercury and digitalis The cardiac disease must be accepted as the cause quickly developed themselves in augmented and imof the dropsy, combined, perhaps, with a morbid proved secretions, and a gradual abatement of the condition of the liver, by which the freedom of the general dropsy. This favourable condition, however, portal circulation was cliecked. The heart endowed did not continue, as is but too often the case ; for by its increased volume of muscular fibre, with an it is but temporary relief that can be expected, when augmented power, forces the arterial current through this form of heart-disease has made any progress. the aorta and the arterial trunks, with a force dis- The urine again diminished in quantity, became proportionate to the power of the venous capillaries more highly albuminous than before; anasarca of the to carry it onward in its return to the right side. The lower extremities returned, but the cough and dy dilated condition of the auricles, especially the right, were not so distressing as on his admission. He was dininishes the suction power by which the venous again bled, and the blood was reserved for analysis, blood is in some measure inoved towards the heart; to ascertain if urea could be detected in the blood, the venous current is thus retarded, and general that element being deficient in the urine, and my venous hyperæmia produced. Hence the anasarcous object was to gain some additional evidence of the state of the whole surface of the body, face, chest, possible existence in the kidneys of that granular arms, trunk, and lower extremities; and hence also degeneration known as the morbus Brightii. At the the venous congestion of internal organs, kidneys, time this analysis was made, I explained to you the liver, mucous surface of lungs, stomach, and intestines, method of conducting it. It is a process requiring much and the consequent alteration in the integrity of their analytic skill. The presence of urea in the blood was several functions. The distressing state of the respira- determined, and you had an opportunity of seeing the tory organs, the urgent dyspnea, is in like manner minute crystals of the nitrate of urea under the field of caused by the heart disease. The increased power the microscope. I bad now no hesitation in believing of the right ventricle drives a voluine of blood upon that a granular state of the kidneys had to be added the lungs, with a force incommensurate with the to the other serious morbid conditions, and with this oxygenating power of the ordinary respiratory process ; complication to pronounce a most unfavourable proge venous congestion results. An ædematous state of) nosis; and as the prospect of any ultimate relief was tbe bronchial mucous membrane is among the morbid very remote, and as injudicious efforts to obtain benefit consequences ; a mucous secretion, peculiar in its from questionable remedies, after the general therapeucharacter, forms in the bronchial tubes, and a frequent tical indications have been fully carried out, oftentimes harassing cough, vainly exhausts the patient in efforts only aggravate the symptoms and hasten the catasto clear the air-passages from this impediment to trophe, it was thought advisable to depend on a simple the respiratory functions.
diet, rest, and the occasional administration of such Such are the pathological conditions observed in remedies as the more prominent or urgent symptoms this patient, and now let me detail to you the principles might require. upon which tbe treatment of such a case should be He gradually got worse, but before his decease there conducted. Venous congestion, or retardation and occurred an irritable state of the stomach, with frequent obstruction to the venous current of blood, has been voniiting,—a state of things scarcely requiring notice pointed out as the proximate cause of the most pro- but for the remarkable character of the vomited matter, minent symptoms; and to diminish the volume of and the interesting opportunity afforded me of obserye blood moving to the right side of the heart, by venesec. ing in it specimens of the Sarcina rentriculi, of Goodsir.. tion, should be our first effort. Blood taken from The interest of this circu instance is increased by the & rein in the arm, judiciously proportioned as to 'fact that the vomited matter in this case appears to
MORPHOLOGY OF THE TEXTURES.
bare presented the same peculiar characters as were BENNET, and others, have contributed to the derelop-, observed in the case recorded by that eminent micro- ment of a physiological law or order, by which abnormal scopist, in bis first account of this species, in the changes may be rationally and scientifically tested; Edinburgh Medical and Surgical Journal. The vomited
whereas chemical philosophers have done nothing in matter in that case is described as having the appear.
this respect. Secondly, microscopical analysis reveals , ance of yeast, and the report in Burdett ward-book
elements and forms, as nearly as possible as they of tbe vomiting of this patient was that it looked like yeast. It was not till the following day that I
exist in the living structure,—nay, in the living body bad an opportunity of seeing this singular yeasty,
itself; whereas, a chemical analysis furnishes only the pulps mass, which I witnessed being ejected from the result of complex wanipulations, in which unnatural stomach. Its appearance was 80 peculiar that I at agents are employed, unnatural changes produced, and once placed it under the microscope, and then I unpatural products evolved. Thirdly, the materials immediately recognized those singular cubic and bale- for the growtb and nutrition of living bodies are prelike masses of vegetable development, minutely and pared or elaborated in the interior of closed vesicles or regularly marked into sections of quadrupled subdi- cells, so that when the cell-wall ruptures, and the visions. There were also many tufts of margaric acid,
interior matter is thereby exposed to new agents, new with epithelial cells in abundance. There is much interest in the coincidence of the presence of the
changes occur; and alterations of form and quality Sarcina ventriculi io vomited matter of the same
therefore anticipate a chemical investigation. Lastly, physical characters, and it certainly gives force to the vegetable morphology, as a branch of scientific research, opinion of Goodsir, that in special cases the contents owes everything to the microscope, and nothing to of the stomach suffer certain spontaneous or intestine the filtering paper, the test-tube, or the crucible; it changes, analogous to fermentation, and consequently is therefore reasonable to expect that the normal opposed to the true digestve function, which must for order of animal morphology may be equally as well the time be in abeyance, and that as the consequence of illustrated by the same means. Not that microscopical this fermentative process, certain vegetable structures
and chemical investigations are to be considered as in are developed, of which the Sarcina ventriculi is an
any way opposed to each other; on the contrary, the example.
question is, which, in the present state of our koow-..
ledge, affurds the most useful and trustworthy informa. THE LAW OF THE MORPHOLOGY OR META tion. Chemical facts in their relation to the structure MORPHOSIS OF THE TEXTURES OF THE and functions of living beings, appear to me, at present, HUMAN BODY.
as loose and isolated materials, which may hereafter (Fourth Series of Experimental Researches,)
find their useful applications; but to the microscope
will, if I mistake not, belong the credit of enabling us , By WILLIAM Addison, M.D., F.R.S., Malvern.
to establish physiological and really practical pinciples. (Continued from page 263.)
In applying the law of morphology in explanation XIV. INFLAMMATION CONSIDERED MORPHO- J of the phenomena of inflammation, the distinctions: LOGICALLY.
between organs, textures, and elements, must be : Vague generalizations with respect to the nature
insisted on. of the elements entering into the normal composition | In vegetable structures, - leaves, sepals, petals, , of the textures, and a neglect of the order of their stamens, and carpets are organs. appearance in the embryo, may be enumerated as
It has been shown (I., p. 33) that leaves are comobstacles to a knowledge of the real nature of inflam
ure of inflam- posed of two distinct cellular textures, (the coherent mation and of the import of pathological facts. Among respiratory, and the incoherent secretory,) of a supthe mucous membranes or textures many microscopical
es many microscopical porting fibrous texture, spiral vessels, and stomata. distinctions exist; and the same may be said also of The same kind of demonstration may be extended to the serous membranes. The outer covering or tunica all vegetables organs. conjunctiva of the eye-ball, differs from the intestinal It has also been shown, (I. and II., pp. 33 and 61,)* tilli ; the pia-mater, from the plexus choroides, and the that the elements contained within the secretory cells synovial membrane of the joints.
are either a viscous protoplasma mixed with molecules, In researches directed to the attainment of a know
green granules of chlorophylle, with sundry properties ledge of the morphology of the elements of normal
and qualities; or (as in petals,) a coloured Auid with textures, for the purposes of practical medicine, it is
molecules. The differences in these elements being important to arrive at some conclusion with regard to
due to an elaborating process effected within the closed the relative values of a microscopical and chemical
cells in obedience to a fixed morphological law. analysis; and the following considerations have prompted
The same kind of demonstration may be extended me to trust to the former as the surer and safer guide. to animal structures. In the human body, for example,
First, the microscopical investigations of SCHLEIDEN, the liver, the lung, the brain, the kidney, and a bone, SCHWANN, HENLE, BARRY, WHARTON JONEs, are organs : each organ being composed of various