1909 BMJ (Clinical Research Edition)  
LENOBLE reports the following case (Arch. des Mal. du CueCrr, des Vaisseaux et du Sang, August, 1908): A painter, aged 16, was admitted to hospital on May 4th, 1908. About -one month previously he had fallen on to his back, and a few days later complained of pain over the region of the tlidneys. Ten days after the fall he suffered from violent pains in the abdomen and legs, and the following day vomiting and severe diarrhoea set in, the stools containing {blood. Repeated attacks of epistaxis
more » ... urred, together with bleeding from the gums. The patient was feverish -and delirious. Red spots then appeared on the arms and legs, and the abdomen became distended and painfal to palpation. On the fifteenth day following the accident rthe patient passed bloody urine. When admitted to hospital he was found to be a well-developed man; the mucous membranes were of a good colour and the skin slightly icteric; the abdomen was distended and painful; ,there was no oedema of the limbs. On percussion, there was slight dullness found in the flanks, the rest of the -abdomen being tympanitic. The tongue was pale, the -appetite very bad; vomiting had stopped, but diarrhoea 5till persisted, although no blood was seen in the stools. Heart and lungs were healthy. The urine was of a deep red colour. On rectal examination there was to be felt behind the bladder a hard mass. Slight attacks of -epistaxis occurred from time to time. On May 20th a .confluent purpuric eruption appeared on both forearms and both legs. From this time the abdomen ceased to be painful, but signs of ascites appeared. Diarrhoea ceased And the stools became of a putty colour. Signs of fluid in ,each pleural cavity at this time occurred. By June lst the ,purpuric eruption was clearing up, but the ascites was increasing and oedema of the legs and scrotum appeared. -On June 5th a fresh attack of purpura occurred; this, however, had completely disappeared by the llth; the jurine contained a large quantity of albumen and, on -centrifugalization, red cells. The examination of the blood on May 29th showed well-coloured red cells and numerous haematoblasts; the white cells were abundant. The coagulation time of the serum was ten minutes. The serum was alkaline in reaction and did not give a positive --melin reaction. A differential count of white cells showed th-e following: Polynuclears, 71.2 per cent.; 4lymphocytes, 23.3 per cent.; mononuclears, 3.3 per cent.; -eosinophiles, 0.4 per cent.; mast cells, 0.1 per cent.; ,transitional forms, 1.7 per cent.; no myelocytes. The red -cells exhibited neither poikilocytosis nor polychromatophilia, and no nucleated red cells were seen. On June Sth the red cells numbered 3,162,000, the white 10,380, and large numbers of haematoblasts were present. There were no nucleated reds. The differential count of white cells -gave much the same result as on the first occasion. 127. Muscular Rheumatism. LEMIL SCHWARZ (Zentralbl.f. die gesamte Therap., October, D908) deals with the subject of muscular pains under three Jheadings: (1) Muscular pain due to affections of the muscles which are preceded by some pathological process in the nervous system, as, for example, the pain of the -cramps which are an expression of the alcoholic diathesis; *2) muscle pain accompanied by anatomical changes in the .muscles, as in purulent or haemorrhagic acute poly--myositis, or in the acute simple or rheumatic polymyositis, -the symptoms of which are high fever and severe mus-.cularl pain.; (3) pain not accompanied by any obvious pathological anatomical change in the muscles. Cases belonging to the third group are those frequently met with, and, since within the group are included many -different conditions whose common characteristic is the muscular pain, the author would prefer to give to them the name " myalgia " rather than the more pretentious ordinary name of "I muscular rheumatism." The diagnosis of myalgia needs considerable care: it is not enough that spots painful on pressure should be found on the muscle, but the body of the muscle must be painful in its whole extent. Where the muscles of the trunk are in question it is not always easy to differen. tiate hyperaesthesia of the skin from myalgia. In connexion with rheumatic torticollis and. lumbago, Schwarz puts forward the views of Erben. Erben finds that in rtLematie torticollis the pain is on the convrex, not on the concave, side of the neck, and he considers it to be caused by the distortion of the cervical spine, and tbhus a joint affection rather than true myalgia; sJxilarly lumbago, according to Erben, is either a neuralgia or caused by an acute distortion of the joints; the author is unable to. agree with this explanation of lumbago in all cases, because of the permanent benefit which he bas often seen result in lumbago from the application of strong faradic currents. Abdominal myalgia is often the cause of a mistalke in diagnosis; in one case which came under the author's notice myalgia was diagnosed as cholelithiasis, while in another the patient was treated for myalgia, but died of perforation of an ulcus ventriculi. In testing for abdominal myalgia the author's practice is to ;put his hand upon the rectu-s muscle while the patient is.lying down; the patient then sits up, the muscle contracts almost against the investigating hand, and in cases of myalgia there is acute pain. Errors may still arise, either because the muscular contraction has an irritating action upon the deeper lying muscles, as is perhaps the case in abdominal colic, or because hyperaesthesia of the skin may occur, as in appendicitis or cholelithiasis. The diagnosis of other forms of muscular rheumatism is also considered. Finally, Schwarz points out that the pain of myalgia is not always most severe after movement, but is very often worse at night in bed. Women at the time of the climacteric are very subject to nightly exacerbations of myalgia, often accompanied by acroparaesthesias of the fingers and legs; the association of symptoms suggests the possibilty that the seat of the disease is not in the muscles, but that the muscular pain depends upon an abnormal nervous and vasomotor condition. 128. The Ophthalmo-reaction to Tuberculin.
doi:10.1136/bmj.1.2515.e41 fatcat:szzllra4z5dzbmzptcqpq5cfgi