MEDTCINE.

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MEDICINE.

RESULTS OF EXPERIENCE IN THE TREATMENT OF CHILDREN. BY DR BIERBAUM, DORSTEN.

Growths from the Gum.?The author relates two cases of epulis. One, occur- ring in a female child of five years old, situated on the left lower jaw, close to the first molar, was as large as a good-sized hazel nut, of the same colour as the rest of the ?um, with a broad base, and a tense, hard feel; it was painless to the touch, and was removed by a circular sweep of the knife. The other, like- wise in a girl, grew from the posterior portion of the lower jaw, near the velum palati, and was a pedunculated fungus, of a bright red colour, and very vascular. It was removed by the knife, and the root cauterized with lapis infernalis ; it however speedily returned, and was only cured by repeated cauterization.

These two distinct forms of epulis are considered by Heyfelder to arise from different causes. The one is a vascular growth arising from an alveolus, fre- quently passing between two teeth, separating them, and throwing them out of their sockets, forming sometimes a double swelling, one before, and the other behind the teeth ; the other, the firm wart-like growth, with a broad base, he considers to be generally connected with a carious condition of the alveolar process. Epulis may be of any size, from a hazel nut to a hen's egg, and sometimes involves the whole jaw, having then a malignant appearance, and secreting a quantity of stinking ichor. Angina Faucium.?The author considers the reason why sore throat is so

often found to relapse in adults, and so seldom in children, is, that in the former it is frequently accompanied by, and to a certain degree dependent on, disease of the abdominal organs, particularly of. the liver ; and as the patients never remain long enough under treatment to have the source of the angina put right, hence the cause of the frequent relapse, (and hence also the importance of at once attacking the cause. Guaiac and jalap, two parts of the former to one of the latter, in repeated doses till free purgation is produced, is a certain cure for sore throat, and equally certain preventive of relapse. The only other treatment to be a hot poultice and steaming, or a gargle of tannin and nitre.? Trans.)

Diphtheritis is either primary or secondary. Primary form is much rarer than the secondary. It runs its course in about

eight days, and is characterized by the occurrence of a pseudo-membranous exudation on the tonsils, uvula, soft palate or fauces, which assumes the form of patches or layers of a whitish, yellowish-white, or bacony and semi-transpa- rent appearance, and with no disagreeable odour, being rarely of an ash-grey appearance at first. They occur in larger or smaller patches, are thrown off, and again developed, sometimes slowly, and at others quicker. The disease sometimes extends over other organs, and has its peculiar seat in the mucous membrane, which is bared of its epithelium. It is chiefly dangerous when it extends to the nares and larynx.

Secondary form occurs simply as a concomitant of other diseases, particularly the exanthemata ; and of these, it most frequently accompanies scarlatina, it may occur in any stage of the exanthem ; never, however, in the primary stage of the angina; and the usual foetid odour of that is generally at once de-

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stvoyed on the occurrence of the diphtheritic exudation. The exudation seldom covers all the fauces, but is commonly confined to one or other tonsil, or the uvula, and appears as a white, yellowish, or grey patch, sometimes easily re- moved, and at others firmly adherent. The mucous membrane is soft'ened, thickened, and covered with purulent exudation, which is also infiltrated into the tonsils; the mucous membrane is also frequently more or less deeply ulcer- ated ; the ulcers are covered with pseudo-membranous exudation, and some- times extend to the submucous or muscular tissues. In the primary or idio- pathic form, the mucous membrane suffers no important anatomical change, and is very rarely ulcerated. The two affections seem perfectly distinct in their nature.

The primary or idiopathic form is seldom dangerous. The treatment con-

sists in the local application of caustics, more or less powerful, to check the spread of the disease, and alter the specific character of the inflammation. Emetics are of much less use, but they promote the loosening and expectora- tion of the exudation, besides checking the spread of the disease, particularly where it threatens the larynx. Mustard poultices are also exceedingly useful applications. Blisters must be avoided, from their tendency to form unhealthy sores. Leeching may be sometimes called for, but is generally contra-indicated by the adynamic character of the disease. The internal use of nitrate of potass is frequently beneficial, where the febrile reaction tends to the inflammatory. Calomel is of little use, except where the disease threatens the larynx; but the, doses must be much smaller, and the leechings, if any, much fewer, than in ordinary croup. Where the diphtheritis is typhoid, and gangrene threatens, quinine and serpentaria are of much use, with stimulating gargles of quinine, myrrh, and spir. cochlear. Borax is the best application for the ulcerations. The treatment of the secondary form must of course be chiefly directed to

the disease with which it is associated. Any direct treatment required must be similar to that already described.?Journal fur KinderlcranJcheiten, Juli and August 1857.

A NRAV CASE OF LEUKILiEMIA. BY DR N. FRIEDRICH, WURZBUUG.

A woman, aged 46, previously of healthy appearance, and tolerably well nourished, though in destitute circumstances, and living in a miserable un- healthy dwelling, was seized about Christmas time, 1856, with a severe bron- chitis, without fever, which lasted till the middle of January 1857, yielding then somewhat to treatment with Tart, emet., etc. As, however, for a short time previously, the patient had begun rapidly to fail, becoming remarkably pale and emaciated, she was put on tonics, without any result. A ten days' hemor- rhage, of menstrual or pseudo-menstrual origin, which took place about the beginning of January, had probably something to do with the acuteness of the origin of the ansemia. About the middle of January, the patient began to complain of a slightly painful feeling of abdoniinal distension, which Dr Mill- berger, her then physician, found to depend on enlargement of the spleen. In the end of January, oedematous swelling of the feet came on ; and on the 1st of February, the patient came into the Julius Hospital, complaining of violent perspirations and constant diarrhoea, which both continued till her death. She also complained of a great feeling of weakness and faintness. Her appearance was excessively pale ; her skin and muscles flabby ; bodily temperature no- where increased; the pulse small and frequent, about 120 ; the heart's shock weak ; considerable enlargement of both liver and spleen ; slight sugil- lation in the right eye. A disagreeable smell came from her mouth, caused by a ragged gangrenous sore of the mucous membrane of the left lower jaw and adjoining portion of the lip. She constantly complained of great thirst, want of appetite, sleeplessness, and constant bronchial catarrh, but without dyspnoea; frequent complaints of pain in the left side of abdomen ; the urine, generally small in quantity, almost constantly deposited urates on cooling. The patient was treated with astringents and opiates to quiet the diarrhoea; the sore in the

MEDICINE. 935

mouth was cauterized with muriatic acid. On the 5th of February she fell

unexpectedly into a state of seeming syncope, and died in an hour and a half. The section took place next day. The external lymphatic stands but little

affected ; one or two in the inguinal region were the size of a hazel nut, infil- trated with a soft, reddish-grey, marrow-like substance. Thorax.?Both lungs cedeinatous; the left adherent to the sides of the thorax

both at its apex and in front; the upper and lower lobes also united by nume- rous bands. The anterior portion of the lower half of the right lung was covered with numerous more or less extensive patches, of a whitish colour, which partly passed gradually into the sound pleura, and were partly sur- rounded by a vascular area ; these patches were sometimes more or less red- dened by a fine and close network of filled vessels which traversed them ; they were formed by a soft, marrow-like, homogeneous thickening of the pleura; they were in many places above a line in thickness, arid here and there a simi- lar exudation passed for a short distance from them, along the interlobular cellular tissue; they were at once recognised as different from any of the hitherto known affections of the pleura ; the costal pleura was unaffected ; and

at these spots no adhesions existed ; no fluid in the pleural cavities. The bronchi were full of frothy fluid ; the mucous membrane strongly injected ; a small quantity of fluid in the pericardium ; the heart small ; the left ven- tricle firmly contracted ; the right remarkably lax. On the anterior portion of the right ventricle, and towards the external edge of the left, several indu- rated patches. The left heart contained a small quantity of blood, chiefly fluid, containing a few dark-red pieces of clots, showing here and there white points of separated colourless elements ; in the right heart also fluid blood, with scanty buffy coat formation. The substance of the left ventricle very pale ; valves normal, except a few small vegetations upon one of the aorta valves ; circumscribed yellow thickening of the lining membrane of the com- mencement of the aorta; the thyroid gland slightly enlarged, colloid dege- neration. Abdomen.?The peritoneal cavity contained about a gallon of fluid. The entire

mass of the mesenteric glands, particularly those belonging to the lower portion of the ileum, presented the appearance of white glistening tumours, from the size of a hazel nut to that of a hen's egg. The cut surface of these tumours

showed them to be formed by a soft white substance exactly similar to that found on the pleura?a few exhibited here and there, amidst the mass, a blood- vessel, or a patch of recent exudation?all the internal lymphatic glands were similarly affected. The intestines were filled with a thin grey stuff free from bile, which, when diluted with water, bore the greatest resemblance to rice water stools; it was more homogeneous in character in the colon than in the small intestines, where it was mixed with shreds of epithelium. The intestinal mucous membrane was pale and of a slaty colour, with here and there a few strongly injected venous twigs; from the coecal valve upwards it was studded with prominent swellings, bearing the greatest possible resemblance in appear- ance and anatomical characters to the ordinary typhus infiltrations previous to ulceration, and, like them, partly confined to the peyerian glands, but also in

part perfectly distinct from them ; they contained the same soft white matter already referred to. The colon was entirely free from these swollen patches; the rectum contained one of them. About the junction of the ileum with the jeju- num two or three varicose lymphatics, about the thickness of crow quills, were seen to run between one of these leukhamian tumoursanda swollen mesenteric

gland, but none could be observed to leave the gland, nor could the like be found in any other part of the mesentery ; the vessels were filled with a thick white fluid ; similar tumours were found in the stomach, particularly in its pyloric half. The spleen was very much enlarged?paris. inches long, 5 broad, and thick, weighing 1 pound 9? ounces Bayr.; felt remarkably soft and flabby, its substance pultaceous and full of blood; the malpighian bodies swollen and scattered through it as white granules, here and there aggregated in small grape-like

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groups. The trabecular substance scanty and scarce to be recognised. Reaction of the pulp and splenic blood intensely acid. Liver also much enlarged, weighing 4 pounds ounces Bayr. Parenchyma anremic, soft, and flabby; near the lower border of the small lobe, a soft greyish white tumour, the size of a pea, could be seen shining through the capsule on both sides of the liver?its con- tents were similar to those of the other tumours, it was not sharply defined, but gradually lost itself in the surrounding parenchyma; only a little fluid blood was found in the portal and true venous system. The gall bladder was full of brown stringy bile. Pancreas remarkably firm and granular?its connecting cellular tissue abundant and thickened. The kidneys of normal size, but soft consistence; the left kidney had also a

small tumour similar in size, form, and appearance to the one in liver; in the left ovary a recent corpus rubrum, the right in a state of cystic degene- ration, etc. These are the more important portions of the copiously detailed description

of the dissection, which is followed by an equally careful and detailed micro- scopic examination, in which the author shows, that the soft white tumours were composed of numerous colourless elements, both nuclei and cells. At the

edge of the pleural patches, where the milky discoloration commenced, it was particularly easy distinctly to make out that the pre-existing corpuscles of the pleural connecting tissue were the points of origin of the new formation, begin- ning with the endogenous growth of two or three nuclei, and speedily increas- ing till the peculiar connective tissue could scarce be seen, and even then only sufficed to combine the numerous cells and nuclei into the soft white mass of the tumour. The intestinal tumours arose in the same manner. The mucous follicles seemed to have nothing to do with them, and could in fact be often seen distinctly atrophied in the midst of the white mass. The splenic tumour was a quite recent hyperplasie, not only of the elements of the pulp, but also of the follicles. The white follicles consisted of numerous small colourless cells, some of them holding a few oil globules, many free nuclei, and fat and cell detritus; here and there, also, large cells with several endogenous nuclei. The

microscope showed the vessels of the pulp uncommonly full of blood, enormous masses of spindle-formed splenic corpuscles, and also a great quantity of large and small colourless cells, some of them in a state of fatty degeneration, others contained numerous nuclei; finally, an unusual number of large cells containing blood corpuscles. The enlargement of the liver was caused by an enormous increase of its cell elements (parenchymatous hepatitis); both liver and spleen, particularly the latter, had an intense acid reaction. The leukhamie swelling, both of the liver and spleen, consisted of the same colourless elements already described; the renal tumour consisting chiefly of nuclei; the hepatic containing cells, both apparently arising from the corpuscles of the renal or hepatic stroma, this connection not being quite so clearly made out in the kidney as in the other organs. The colourless elements of the blood, though increased, were re- latively but triflingly so, compared with the extensive organic disease existing; they were chiefly recognisable in the splenic vein; free nuclei were not found in the blood. Dr F. remarks that this is the first case of leukhamie tumour be-

ing found on a serous membrane ; directs particular attention to the important part played in the formation of these tumours by the corpuscles of the cellular tissue; and suggests the probability of their performing, to a less extent, similar functions with the spleen and lymphatic glands. He also directs particular at- tention to the recent state of the disease both in the liver and spleen, and its

character, with its obvious relation to the changes occurring in those organs in typhus, which the peculiar swellings in the intestines seemed further to confirm ; also the increase of the colourless elements in typhus?the occurrence in both of a tendency to hemorrhage, to sloughing of the skin and mucous

membranes, to diarrhoea and bronchial catarrh: besides their agreement in etio- logical causes, poverty and misery, as well as the pathological connection which may be supposed to exist between them through the connecting link of inter-

MEDICAL JURISPRUDENCE. 937

mittent fever, which has been shown on the one hand to be connected with

typhus, and on the other to be often the starting-point of leukharaia; and sug- gests that typhus and leukhamia may yet be found to be but varieties of the same disease. Finally, he remarks, that the white masses reddened on ex- posure to the air; the pleural patches becoming a deep rose, exactly as Valentin, Virchow, Gubles, and Quevenne assure us the lymphatic fluid does when ex- posed to the air.? Virchow s Archiv., 12 Bd. Iste heft.

NEW REMEDY FOR PALPITATION.

Herr Kolliker remarks, that in a case of severe palpitation he found that deep inspiration and subsequent holding of the breath sufficed, after a few- times, to cut short this most unpleasant symptom.?Verhandlungen d. Phys. Med. Gesellschaft.