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there are no distinctive signs proving these as resulting from a stricture or strangulation of the intestine ; but that, when they do not yield to antiphlogistic treatment, it is to be presumed that they depend upon one or other of these causes. “ I have observed some of these cases of stricture," says Velpeau, “but it seems to me that their nature has been mistaken. There is nothing permanent or organic about them. They may be dissipated in a few seconds with the fingers and a purgative usually easily triumphs over them after the operation; and it would be a piece of barbarism to stretch the organ below, as has been proposed.” M. Maisonneuve, in his Memoir upon the "Enterotomie of the Small Intestines” (Archives Generales, 1845), enumerates the causes which may stricture the intestine, states that the most frequent of all is the firm constriction of the intestinal tunics at the hernial orifice. M. Vidal, in his “ Pathologie Externe," likewise admits this cause of stricture of the intestine, observing that this is more complete and persistent in proportion as the strangulation has been of long continuance.
The case already related proves that M. Velpeau's opinions upon the subject will not always hold good, although a temporary obstruction is in all probability the general circumstance. The constriction could not have been induced here by a truss, as suggested by Cruveilhier, inasmuch as the woman had worn none; and it is most probable that it resulted from organization of plastic lymph, as stated by Hunter.
During the operation the surgeon should very carefully examine the condition of the intestine, and it is from neglecting to do this that so many see their patients die afterwards. “I perceive,” says Ritsch, "in these cases, how important it is not to proceed to reduce the intestine after the division of the ring, until a portion of it has been previously drawn out, and the effect of the constriction at the seat of strangulation examined; and, if I found any obliteration of the canal which would render the passage of the fæcal matters impossible, I would take great care not to make the reduction, which would only be to devote the patient to a certain death.” MM. Velpeau, Tessier, and others recommend the speedy recourse to purgatives after operations for hernia. This was warmly opposed by Sanson in 1833, who was a partisan of the physiological medicine ; and certainly injections or very mild laxatives would seem to be preferable to purgatives of a drastic nature.
Supposing the surgeon has recognised the stricture, his line of conduct is still a difficult one: but the facts brought forward by Louis, in his Memoir upon the cure of hernias affected with gangrene, should lead the surgeon to endeavour to form an artificial anus. If the intestine was returned in spite of the endeavours of the operator, or if he had not remarked its condition, and symptoms of strangulation still continued, he should imitate M. Maisonneuve, who determined upon searching for the intestine two days after he had operated upon a lady 64 years of age, and whose life, by this bold procedure, he had the happiness to save.-Revue Medico-Chirurgicale, Tom. 1, p. 329.
RESEARCHES ON THE NORMAL AND ANORMAL CAPACITY OF THE
CAVITIES OF THE HEART. By Dr. BEAU. This paper is intended by its author as an Appendix to the one on Arterial Murmurs noticed at length in our Number for October 1846. In that, be sought to establish that arterial murmurs, and especially the carotidean, are produced whenever the wave of blood, rendered too large by reason of the dilatation of the cavities of the heart, exercises too great a degree of friction upon the arterial parietes. In support of this proposition he advanced that post-mortem examinations exhibited to us dilatation of the heart as a lesion connected with those
1847] Beau on the Capacity of the Cavities of the Heart. 535
diseases which are characterised by these murmurs. On the present occasion his object is to state the confirmation of this proposition he has derived from actual mensuration. His mode of mensuration is a great improvement upon that usually adopted; for, instead of attempting to give the absolute capacity of the cavities, which may normally vary much, he furnishes the comparative capacity as derived from its comparison with that of the arterial orifices--which, from their fibrous character, are preserved nearly invariable during the changes the muscular structures of the heart are liable to. He has, however, confined himself to the comparative mensuration of the left ventricle and aortic orifice ; since with most observers he has found the cavity of the auricle very irregular and difficult of appreciation, while the right ventricle and its auricie are found of varying capacity according to the quantity of blood that may have accumulated there during the last movements of life. Nevertheless, although exact mensuration has not been attempted of these, the right cavities were always found to possess a greater capacity than the left, and the left auricle exhibited the same variations of capacity as did the ventricle of the same side. So that, in fact, the comparative mensuration of the left ventricle and the aortic orifice supplies a statement of the capacity of the entire heart.
“ I divided the heart across and perpendicularly to its axis in the middle of the space comprised between the apex of the organ and the origin of the arterial orifices. I took the diameter of the circumference formed by the ventricular walls of the left side upon the section belonging to the base of the heart, having first gently compressed it to dispel the cadaveric rigidity when this existed, and taking care to maintain the ventricular walls as rounded as possible. I then measured exactly the diameter of the cavity, without comprehending its walls, and in avoiding the columnæ attached to the bicuspid valves. Having taken the diameter of the ventricle, I divided the aorta at the level of the free border of the semilunar valves, and measured the diameter of the circumference of the vessel upon the section attached to the base of the heart, taking care to maintain its calibre rounded, and not including the arterial walls in the admeasurement.”
The hearts measured belonged to three categories of patients. 1. Those who had died of diseases in which no arterial murmurs were heard. 2. Those who had manifested such murmurs until the period of their deaths. 3. Those in whom the arterial murmurs having existed, disappeared during the latter period of their respective diseases. The reproduction of the figures
would demand more space than we have at command; and, as the real point of importance is the comparative size of the parts measured, the general results arrived at will suffice. In the first category then, in which, as far as regards the murmurs, the heart and vessels may be considered as normal, the diameter of the left ventricle equalled the aortic, or was a little larger than it. And although in different individuals the size of the ventricular diameter varied, yet, on comparing this with that of the aortic, the same relation was found to be maintained. In the second category, in which the murmurs were persistent, the ventricular diameter was found to be about double that of the aortic; sometimes a little more, sometimes a little less. It is on account of this relatively narrow calibre of the large vessels, that the blood entering these from the dilated ventricle exerts the degree of friction which induces the murmurs. In respect to the generation of this and some other symptoms, this relative dilatation of the ventricle is a matter of far higher importance than its absolute dilatation. In the third category, in which murmurs once heard disappeared prior to death, the capacity of the ventricle was found in a very slight degree larger than in the first category, and less considerably than in those of the second. This dilatation of the heart depending on its atony is not a fixed, unchangeable, condition, like that which is connected with lesion of the orifices, and it diminishes or disappears with the sounds which it gives rise toma diminution of the volume of the pulse, and of the extent of dulness on percussion in the præcordial region, being coincident events.
Phthisis is the disease in which a disappearance of the sounds and dilatation most commonly takes place as the patient becomes exhausted by the disease. In like manner, in certain cachexiæ, as the cancerous, the same thing occurs-a permanent diminution of the mass of the blood taking place, and a corresponding gradual retractation of the cavities to near their normal size.
The mode of relative admeasurements here advocated, may also be employed advantageously for the determination of the different degrees of thickness of the cardiac walls and the ascertaining whether this is normal or not: for, if Nature accommodates the cardiac cavities to the extent of the aperture of the arterial orifices, it is but reasonable to suppose she would establish a relation between the size of this orifice and the thickness of the muscular substance which propels the wave of blood through it. As in the normal state, these orifices being Darrow, and the cardiac cavities likewise small, the wave of blood, then of little volume, does not require such strong and thick muscular walls for its propulsion as in individuals in whom this capacity is larger. To ascertain the thickness of the walls of the ventricle precisely the extent of the capacity of its cavity must be taken into consideration : for by this alone can we clear up the questions of passive dilatation and concentric hypertrophy: This subject being, however, only secondary to the one whose illustration he had in view, M. Beau has as yet made none of the necessary measurements, and we need not therefore follow bim in the interesting speculations he enters into respecting it.
In the categories already described, the diameters of the orifices of both the aorta and the ventricle were found to be more considerable in proportion to the age of the subject ; confirming as far as they go the law laid down by M. Bizot, that the calibre of the heart and arteries, and the thickness of the cardiac and arterial parietes indefinitely increase with age, so as to be found at their beight in old persons. M. Bizot employs this conclusion as a means of attack against à priori reasoning, by exposing the powerlessness of theory in reconciling this excess of material energy of the heart and arteries in the aged with the physical and moral debility which is their attribute: but the difficulty is not perhaps so inexplicable as M. Bizot deems it ; for a dilated state of the heart and arteries may easily be conceived to be connected with general debility of the entire organism. Thus in old age we find the veins, especially of the extremities, the sphincters, and the aponeurotic rings lose their elasticity, or rather tone, and yield to forces tending to increase their diameter; and this same atony leads to an augmented capacity of the heart and arteries. The simultaneous increase of the thickness of the heart and arteries, takes place as admitted by M. Bizot in the intestines, stomach, or any organ submitted to dilatation; and did not the heart and vessels acquire from this cause some additional force, they would be powerless for the movement of the increased mass of blood their dilated condition admits the entrance of. This increase of substance is, however, in its nature, a morbid phenomenon, and not to be likened to that which occurs at an early period of life. In the latter, the normal increase of substance takes place alike in all the constituent parts of the heart, and especially at the semi-lunar valves. But, in the aged, these valves do not increase in extent simultaneously with the arterial orifices, and are not consequently sufficiently large to prevent some reflux of blood into the heart. There is, in relation to the cause, the greatest possible analogy between the amplification of the heart as a consequence of old age, and that which is developed in diseases characterized by the presence of arterial murmurs; since in both cases it depends upon atony arising from a relaxed condition of the muscles of animal life. There are these differences however--the amplification taking place in the aged very slowly, the hypertrophy resulting is far more con siderable than in the pathological amplification; and, as in old age, the dilatation of the heart comes on so very gradually, the arteries have time to become propor: tionally enlarged: so that the normal relative capacity of the respective cavities
maintained. Consequently, though the wave of blood sent through the orifices
1847) Eschars of Sacrum-Crepitation of Tendons. 537 is larger, the violence of the pulse of old persons fuller, and the dulness over the præcordial region greater, there is no production of the anormal murmurs, which manifest themselves in that pathological dilatation of the heart, which creates a disproportion between its cavity and that of the aorta. Nevertheless, in the aged, any increase of dilatation due to a morbid cause may induce such murmurs, by destroying the relation; but the defective proportion necessary for their production exists less often in the aged than in the adult or adolescent, notwithstanding their greater liability to adynamic diseases.--Archives Generales, T. xiv., pp. 133–161.
(We consider the above a very interesting communication, and forming a worthy complement to the elaborate series of papers referred to. The mode of comparative admeasurement suggested is the only one that can convey any precise idea of the capacity of the heart in relation to the functions it has to execute. -Rev.]
EschARS OVER THE SACRUM,
From the earliest period of his medical career M. Blandin has always entertained most serious fears for patients in whom sloughing over the sacrum occurs; and in his Anatomie Chirurgicale, published in 1826, drew the attention of the profession to the almost sudden manner in which they often prove fatal. He believes he has discovered the explanation of this in the following circumstances. The point which suffers most from pressure in dorsal decubitus corresponds to where the sacrum is joined to the coccyx--exactly there, where the vertebral canal is only formed by the posterior sacro-coccygean ligament. Sphacelus in this way may easily reach the termination of the arachnoid membrane, and air, pus, or sanies gain admission into its cavity, producing a violent inflammation, which at first attacks the nerves of the cauda equina. Necrosis, too, may open a way into the vertebral canal with the same results; and in both cases the phlegmasia which results induces the phenomena of paralysis of the rectum, the bladder, and the lower extremities. When I made my earliest observations I was in the medical wards, and the accident is of no unfrequent occurrence in typhoid fevers. You have observed in the patient who has given rise to these remarks (a case of amputation of the thigh otherwise proceeding favourably) retention of urine and paraplegia.”—Gazette des Hôpitaux, No. 71.
PAINFUL CREPITATION OF THE TENDONS. By M. VELPEAU. The man whom you have just seen is a dyer by trade, æt. 49, and his case deserves a moment's notice. A week since he endeavoured to raise a load, having kis left hand applied to his hip. He felt a violent pain in this arm, and now we may perceive a slight swelling at the lower and external part of the forearm, unaccompanied by any change of colour or fluctuation. Of a regular and elongated shape, it is only painful during motion, while on applying the hand over it we may perceive a fine, characteristic crepitation; and it is an example of the painful crepitation of the tendons which was vaguely indicated by Boyer and Desault, described by me first in 1825, and has since formed the subject of the special writings of several authors. I first met with it in a case in the hospital of Tours, where it was suspected to be a fracture of the radius. The affection is especially observed among washerwomen, mowers, blacksmiths, locksmiths, and joiners, and when it is seated in the foot, among soldiers, huntsmen, &c. Excessive frietion is the condition necessary for its production. In the forearm and wrist,
where it is especially met with, its recognition is very easy, the crepitation it gives rise to being quite pathognomic, being neither like that felt in fractures, that of cartilage or emphysema : but which has been compared to the crepitation of starch or of hoar-frost-such as is produced by walking on the snow. Its seat is evidently the sheath of the tendons, and it is probably due to a slight inflammation, first causing too great a dryness of the mucous membrane, and afterwards giving rise to effusion. It is generally in no-wise serious, disappearing in a few days by rest alone: but it must not be absolutely neglected, for I have seen it in some cases give rise to a fungous transformation of the sheaths; and indeed there is no reason why all the changes which occur in diseases of the joints should not take place here. If there is much pain we apply leeches and poultices, and the resolvent lotions and compression : but rest is indispensable.Gazette des Hôpitaux, No. 82.
M. ROYER-COLLARD ON THE Statistics of INSANITY. In a Report to the Academy of Medicine upon an Essay by M. Baillarger, entitled “Statistical Researches upon the Hereditariness of Insanity,” M. RoyerCollard made some interesting remarks upon the undue importance given to this description of statement, a few of which, as having a far more general bearing than upon the case eliciting them, we here quote.
M. Baillarger's figures are as follow: they relate to 600 patients. Of 453 attacked by insanity in the direct line, the disease was transmitted 271 times by the mother, 182 by the father. Of the 271 families, in which it was transmitted by the mother, it occurred 70 times in inore than one child, i. e. in more than a fourth : while of the 182, in which it was transmitted by the father, this was the case only in 30 instances, i. e. in one-sixth. In 346 cases in which the mother was mad, 197 girls and 149 boys were affected; and in 215, in which the father was mad, 128 boys and 87 girls were so. M. Baillarger arrives at the following conclusions:-1. Insanity of the mother, in relation to hereditariness, is more serious than that of the father, not only because it is more frequent, but also because it is transmitted to a greater number of children. 2. The transmission from the mother is more to be feared for the girls than the boys, and, on the contrary, that proceeding from the father is more to be feared for the boys. 3. The transmission from the mother is generally to be more feared for the boys than that from the father : but it is to be much more feared for the girls.”
“ If the choice of the subject merits nothing but praise," observes RoyerCollard, " I must be allowed to express some objections to the method by which M. Baillarger has pursued it. These objections he has indeed foreseen, declaring that his observations are as yet but insufficient, and stand in need of completion. But I do not hesitate to say that it is Statistics which is guilty of this imperfection. In the eyes of many, Statistics, which it has been so improperly attempted to raise into a science, is of all our methods of scientific investigation the most positive and certain. So much have what are called facts been of late abused, that their very images have been elevated into a worship, or rather an idolatry. Figures for some, and even enlightened, men, are an irrefragible expression of the truth. But, let us not be deceived here : in the sciences, as elsewhere, figures, as well as words, have only a representative value. Statistics, which assembles them together and manœuvres them, is, of itself, blind and unreasoning ; so that, to reach that truth which it promises us, we must absolutely penetrate all this drapery, and proceed straight to the things represented through the signs representing them.” After alluding to the well established general facts of the hereditary character
physiological and pathological condition of the economy, and of insanity